Plastic & Reconstructive

Surgery
October 2007, Volume 120, Issue 5,Pg(1095-1441)

BREAST
ORIGINAL ARTICLES

Breast Reduction: Modified "Lejour Technique" in 500 Large Breasts.

Albert K. Hofmann, M.D.; Margot C. Wuestner-Hofmann, M.D.; Franco Bassetto, M.D.;
1095
Carlotta Scarpa, M.D.; Francesco Mazzoleni, M.D.

BREAST
ORIGINAL ARTICLES: Discussion

Discussion.
Elizabeth J. Hall-Findlay, M.D.
1105

BREAST
ORIGINAL ARTICLES

Validation of a Questionnaire for Measuring Morbidity in Breast

1108 Hypertrophy.
Leif Sigurdson, M.D., M.Sc., M.B.A.; Susan A. Kirkland, Ph.D.; Eric Mykhalovskiy, Ph.D.
Supplemental Digital Content is available in the text.
Immediate Nipple Reconstruction on a Free TRAM Flap Breast
1115 Reconstruction.
Eric H. Williams, M.D.; Lawrence Z. Rosenberg, M.D.; Paul Kolm, Ph.D.; Jorge I. de la
Torre, M.D.; R Jobe Fix, M.D.
Surveillance Mammography following the Treatment of Primary
1125 Breast Cancer with Breast Reconstruction: A Systematic Review.
G Philip Barnsley, M.D.; Eva Grunfeld, M.D., D.Phil.; Douglas Coyle, Ph.D.; Lawrence
Paszat, M.D., M.Sc.

BREAST
IDEAS AND INNOVATIONS

Skin Banking Closure Technique in Immediate Autologous Breast

1133 Reconstruction.
Eric C. Liao, M.D., Ph.D.; Brian I. Labow, M.D.; James W. May Jr, M.D.

EXPERIMENTAL
ORIGINAL ARTICLES

Dihydrotestosterone Stimulates Proliferation and Differentiation of

1137 Fetal Calvarial Osteoblasts and Dural Cells and Induces Cranial
Suture Fusion.
Ines C. Lin, M.D.; Alison E. Slemp, M.D.; Catherine Hwang, B.S.; Miguel Sena-Esteves,
Ph.D.; Hyun-Duck Nah, D.D.S., Ph.D.; Richard E. Kirschner, M.D.
The Effect of Fibrin on the Survival of Ischemic Skin Flaps in Rats.
Zhi Qi, M.D.; Yuanjun Gu, M.D., Ph.D.; Dohoon Kim, Ph.D.; Akihito Hiura, M.D., Ph.D.;
1148
Shoichiro Sumi, M.D., Ph.D.; Kazutomo Inoue, M.D., Ph.D.
 Submucosal Injection of Micronized Acellular Dermal Matrix: Analysis
1156 of Biocompatibility and Durability.
Jeffrey B. Wise, M.D.; David Cabiling, B.S.; David Yan, M.D.; Natasha Mirza, M.D.; Richard
E. Kirschner, M.D.
Biocompatibility of Agarose Gel as a Dermal Filler: Histologic
1161 Evaluation of Subcutaneous Implants.
Sergio Fernández-Cossío, M.D.; Alvaro León-Mateos, M.D.; Francisco Gude Sampedro,
M.D., Ph.D.; María Teresa Castaño Oreja, M.D., Ph.D.

RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES

Optimal Use of Microvascular Free Flaps, Cartilage Grafts, and a

1171 Paramedian Forehead Flap for Aesthetic Reconstruction of the Nose
and Adjacent Facial Units.
Gary C. Burget, M.D.; Robert L. Walton, M.D.

RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES: Discussion

Discussion.
Frederick J. Menick, M.D.
1208

RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES

Aesthetic and Functional Outcome following Nasal Reconstruction.

Marc A. M. Mureau, M.D., Ph.D.; Sanne E. Moolenburgh, M.D.; Peter C. Levendag, M.D.,
1217
Ph.D.; Stefan O. P. Hofer, M.D., Ph.D.

RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES: Discussion

Discussion.
Fredrick J. Menick, M.D.
1228

RECONSTRUCTIVE
HEAD AND NECK: ORIGINAL ARTICLES

Reconstruction of the Lower Lip: Rationale to Preserve the Aesthetic

1231 Units of the Face.
J Camilo Roldán, M.D., D.M.D.; Marcus Teschke, M.D., D.M.D.; Elfriede Fritzer, M.Sc.;
Anton Dunsche, M.D., D.M.D., Ph.D.; Franz Härle, M.D., D.M.D., Ph.D.; Jörg Wiltfang,
M.D., D.M.D., Ph.D.; Hendrik Terheyden, M.D., D.M.D., Ph.D.

Incomplete Excision of Basal Cell Carcinoma: A Prospective Trial.

Shirley Y. Su, M.B.B.S.; Francesco Giorlando, M.B.B.S., B.Med.Sci.; Edmund W. Ek,
1240
M.B.B.S.; Tam Dieu, F.R.A.C.S.
Immediate, Optimal Reconstruction of Facial Lentigo Maligna and
1249 Melanoma following Total Peripheral Margin Control.
Sameer S. Jejurikar, M.D.; Gregory H. Borschel, M.D.; Timothy M. Johnson, M.D.; Lori
Lowe, M.D.; David L. Brown, M.D.

RECONSTRUCTIVE
HEAD AND NECK: CASE REPORT

Romberg's Disease Associated with Horner's Syndrome: Contour

67e Restoration by a Free Anterolateral Thigh Perforator Flap and
Ancillary Procedures.
Dogan Tuncali, M.D.; Nesrin Tan Baser, M.D.; Ahmet Terzioglu, M.D.; Gurcan Aslan, M.D.
RECONSTRUCTIVE
TRUNK: ORIGINAL ARTICLE

New Continuous Negative-Pressure and Irrigation Treatment for

1257 Infected Wounds and Intractable Ulcers.
Kensuke Kiyokawa, M.D., Ph.D.; Nagahiro Takahashi, M.D.; Hideaki Rikimaru, M.D., Ph.D.;
Toshihiko Yamauchi, M.D., Ph.D.; Yojiro Inoue, M.D., Ph.D.

RECONSTRUCTIVE
TRUNK: SPECIAL TOPIC

Mechanisms Governing the Effects of Vacuum-Assisted Closure in

1266 Cardiac Surgery.
Malin Malmsjö, M.D., Ph.D.; Richard Ingemansson, M.D., Ph.D.; Johan Sjögren, M.D.,
Ph.D.

RECONSTRUCTIVE
TRUNK: IDEAS AND INNOVATIONS

Does AlloDerm Stretch?

Maurice Y. Nahabedian, M.D.
1276

RECONSTRUCTIVE
LOWER EXTREMITY: ORIGINAL ARTICLES

Prevention of Microsurgical Anastomotic Thrombosis Using Aspirin,

1281 Heparin, and the Glycoprotein IIb/IIIa Inhibitor Tirofiban.
Thomas L. Chung, D.O.; David W. Pumplin, Ph.D.; Luther H. Holton III, M.D.; Jesse A.
Taylor, M.D.; Eduardo D. Rodriguez, D.D.S., M.D.; Ronald P. Silverman, M.D.
The Effects of Systemic Phenylephrine and Epinephrine on Pedicle
1289 Artery and Microvascular Perfusion in a Pig Model of
Myoadipocutaneous Rotational Flaps.
Marga F. Massey, M.D.; Dhanesh K. Gupta, M.D.

RECONSTRUCTIVE
LOWER EXTREMITY: IDEAS AND INNOVATIONS

Does Fascia Lata Repair Facilitate Closure and Does It Affect

1300 Compartment Pressures of the Anterolateral Thigh Flap Donor Site?
Eduardo D. Rodriguez, M.D., D.D.S.; Rachel Bluebond-Langner, M.D.; Julie Park, M.D.;
Xiaojun You, B.S.; Gedge Rosson, M.D.; Navin Singh, M.D.

HAND/PERIPHERAL NERVE
ORIGINAL ARTICLES

Preoperative Soft-Tissue Distraction for Radial Longitudinal

1305 Deficiency: An Analysis of Indications and Outcomes.
Amir H. Taghinia, M.D.; Ayman A. Al-Sheikh, M.D.; Joseph Upton, M.D.

HAND/PERIPHERAL NERVE
ORIGINAL ARTICLES: Discussion

Discussion.
Kevin C. Chung, M.D., M.S.
1313

HAND/PERIPHERAL NERVE
ORIGINAL ARTICLES

Functional Assessment of the Reconstructed Fingertips after Free

1315 Toe Pulp Transfer.
Cheng-Hung Lin, M.D.; Yu-Te Lin, M.D.; Paolo Sassu, M.D.; Chih-Hung Lin, M.D.; Fu-Chan
Wei, M.D.
HAND/PERIPHERAL NERVE
IDEAS AND INNOVATIONS

A Prefabricated, Tissue-Engineered Integra Free Flap.

John M. Houle, M.D.; Michael W. Neumeister, M.D.
1322

PEDIATRIC/CRANIOFACIAL
ORIGINAL ARTICLES

The Diagnosis and Treatment of Single-Sutural Synostoses: Are

1327 Computed Tomographic Scans Necessary?
Jeffrey A. Fearon, M.D.; Davinder J. Singh, M.D.; Stephen P. Beals, M.D.; Jack C. Yu,
D.M.D., M.D.
Use of Calcium-Based Bone Cements in the Repair of Large, Full-
1332 Thickness Cranial Defects: A Caution.
James E. Zins, M.D.; Andrea Moreira-Gonzalez, M.D.; Frank A. Papay, M.D.
Location of the Infraorbital and Mental Foramen with Reference to the
1343 Soft-Tissue Landmarks.
Wu-Chul Song, M.D.; Sun-Heum Kim, M.D., Ph.D.; Doo-Jin Paik, M.D., Ph.D.; Seung-Ho
Han, M.D., Ph.D.; Kyung-Seok Hu, D.D.S.; Hee-Jin Kim, D.D.S., Ph.D.; Ki-Seok Koh, Ph.D.

PEDIATRIC/CRANIOFACIAL
SPECIAL TOPIC

Definitive Repair of the Unilateral Cleft Lip Nasal Deformity.

H Steve Byrd, M.D.; Kusai A. El-Musa, M.D.; Arjang Yazdani, M.D.
1348
Supplemental Digital Content is available in the text.
PEDIATRIC/CRANIOFACIAL
IDEAS AND INNOVATIONS

Correction of the Unilateral Cleft Lip Nasal Deformity with a

1357 Composite Cartilage-Vestibular Lining Flap.
Michael B. Lewis, M.D.; Andrew A. Winkler, M.D.; Ronald P. Silverman, M.D.
Microdialysis: Use in the Assessment of a Buried Bone-Only Fibular
1363 Free Flap.
Constantinos Mourouzis, Ph.D., M.D., D.D.S.; Rajiv Anand, F.D.S.R.C.S., F.R.C.S.; John R.
Bowden, M.Sc., F.D.S.R.C.S., F.R.C.S.; Peter A. Brennan, F.R.C.S., F.R.C.S.I., F.D.S.

COSMETIC
ORIGINAL ARTICLES

Observations on Periorbital and Midface Aging.

Val Lambros, M.D.
1367
Supplemental Digital Content is available in the text.
COSMETIC
ORIGINAL ARTICLES: Discussion

Discussion.
Joel E. Pessa, M.D.
1377

COSMETIC
ORIGINAL ARTICLES

Chin Surgery VII: The Textured Secured Implant-A Recipe for

1378 Success.
Stephen M. Warren, M.D.; Jason A. Spector, M.D.; Barry M. Zide, D.M.D., M.D.
 Patient-Reported Benefit and Satisfaction with Botulinum Toxin Type
1386
A Treatment of Moderate to Severe Glabellar Rhytides: Results from a
Prospective Open-Label Study.
Mitchell A. Stotland, M.D.; Jonathan W. Kowalski, Pharm.D., M.S.; Belinda B. Ray, M.A.

COSMETIC
ORIGINAL ARTICLES: Discussion

Discussion.
Jean Carruthers, M.D.
1394

COSMETIC
ORIGINAL ARTICLES

A Primary Protocol for the Management of Ear Keloids: Results of

1395 Excision Combined with Intraoperative and Postoperative Steroid
Injections.
Daniel J. Rosen, M.D.; Mitesh K. Patel, M.D.; Katherine Freeman, Dr.P.H.; Paul R. Weiss,
M.D.
Magnetic Resonance Imaging and Explantation Investigation of Long-
1401 Term Silicone Gel Implant Integrity.
Nick Collis, M.Phil., B.Sc., F.R.C.S.Plast.(Ed.); Janet Litherland, M.R.C.P., F.R.C.R.; David
Enion, F.R.C.S.(G.), F.R.C.R.; David T. Sharpe, M.A., F.R.C.S.
Interest in Cosmetic Surgery and Body Image: Views of Men and
1407 Women across the Lifespan.
David A. Frederick, M.A.; Janet Lever, Ph.D.; Letitia Anne Peplau, Ph.D.

CME

CME Management of Wrist Injuries.

73e Kenji Kawamura, M.D., Ph.D.; Kevin C. Chung, M.D., M.S.

SPECIAL TOPIC
Objective Interpretation of Surgical Outcomes: Is There a Need for
1419 Standardizing Digital Images in the Plastic Surgery Literature?
Wendy L. Parker, M.D., Ph.D.; Marcin Czerwinski, M.D.; Hani Sinno, B.Sc.; Photis Loizides,
M.D.; Chen Lee, M.D.

EDITORIAL
It's Okay to Say "I'm Sorry".
Rod J. Rohrich, M.D.
1425

Our Complication, Your Problem.

Steven P. Davison, D.D.S., M.D.; Wajhma Massoumi, M.D.
1428

REVIEWS
Local Flap Reconstruction: A Practical Approach.
James Thornton, M.D.
1430
Surgical Management of Vitiligo.
Gervaise L. Gerstner, M.D.; Alan Matarasso, M.D.
1430

LETTERS
The Zygomatic-Orbital Artery.
Egidio Riggio, M.D.
1432
 The Zygomatic-Orbital Artery: Reply.
Eman Elazab Beheiry, M.B.Ch.B., M.Sc., Ph.D.
1432
Surgical Treatment of Ear Defects.
Isaac J. Peled, M.D.
1433
Surgical Treatment of Ear Defects: Reply.
Fabio M. Abenavoli, M.D.
1433

An Alternative Approach to Brow Lift Fixation: Temporoparietal

1433 Fascia, Galeal, and Periosteal Imbrication.
Colin Morrison, M.Sc., F.R.C.S.(Plast.); James Zins, M.D.
An Alternative Approach to Brow Lift Fixation: Temporoparietal
1434 Fascia, Galeal, and Periosteal Imbrication: Reply.
Fernando O. Tuccillo, M.D.; Oscar Zimman, M.D., Ph.D.; Patricio Jacovella, M.D., Ph.D.;
Gabriel Repetti, M.D.
Did Hitler Have a Rhinoplasty?
Anne G. Warren, B.A.; Robert M. Goldwyn, M.D.
1435
Breast Cancer in the Previously Augmented Breast and Sentinel
1435 Lymph Node Mapping: Theoretical and Clinical Considerations.
Alexandre Mendonça Munhoz, M.D.; Cláudia Maria Aldrighi, M.D.
Epinephrine Use in the Fingers.
Apostolos D. Mandrekas, M.D.; George J. Zambacos, M.D.
1436

Epinephrine Use in the Fingers: Reply.

Donald H. Lalonde, M.D., M.Sc.; Christopher James Thomson, M.D.; Keith Denkler, M.D.;
1437
Anton Feicht, Ph.D.
The Evidence for and against the Effectiveness of Pressure Garment
1437 Therapy for Scar Management.
Alexander Anzarut, M.D., M.Sc.

The Evidence for and against the Effectiveness of Pressure Garment

1438 Therapy for Scar Management: Reply.
Gregory R. D. Evans, M.D.
 BREAST

Breast Reduction: Modified “Lejour Technique”

in 500 Large Breasts
Albert K. Hofmann, M.D.
Margot C. Wuestner-
Hofmann, M.D.
Franco Bassetto, M.D.
Carlotta Scarpa, M.D.
Francesco Mazzoleni, M.D.
Ulm, Germany; and Padova, Italy
Background: The “minimal scar technique” for breast reduction, developed by
Marchac, Lassus, and Lejour, has become an increasingly practiced alternative
to standard operative procedures.
Methods: The authors introduced the modified “Lejour technique” in nearly
500 breast reductions in 250 overweight patients (adipose breasts) with a re-
section weight of more than 700 g. Their technique is a step-wise modification
of the following procedures, resulting from their experience with complications
and outcomes. Planning of the nipple-areola complex is carried out for each
patient, and the glandular body is undermined only centrally and atraumatically,
without liposuction. The superior mastopexy suture is waived in favor of the
submammary fold being fixed using three H points. The three H points serve
as a pivot by which later sagging is avoided. The skin closure does not have a
shaping function without tension. The vertical pleated suture is not forced but
adjusted to the retraction ability of the patient’s skin. Use of the vertical pleated
suture is limited; in cases of longer incisions, it is combined with a horizontal
submammary transverse pleated suture.
Results: In 250 patients with an average follow-up of 4.2 years, the average
resection weight was 985 g for the right breast and 923 g for the left. The
operation lasted from 120 to 180 minutes. The results were evaluated as very
good in 75 percent, good in 19 percent, satisfactory in 5 percent, and unsatis-
factory in 1 percent. The complication rate was 14 percent.
Conclusions: The authors’ experience has shown that this technique can be ap-
plied as a standard technique. It is particularly suitable for larger breasts, because
it reduces aesthetic deficiencies and simplifies the reduction technique. (Plast.
Reconstr. Surg. 120: 1095, 2007.)

I
n the early 1990s, Marchac and de Olarte,1
Lassus,2 and Lejour3 introduced the “mini-
mal scar technique” for breast reduction.
This approach has become an increasingly prac-
ticed alternative to standard operative proce-
dures.4 –7 In the last few years, there has been a
trend in plastic surgery toward reducing overall
scar length by confining the scar to one vertical
incision.8 –11 Results from patients with younger or
more retractable skin, minimal breast hypertro-
phy, and a resection weight of less than 500 g have
confirmed that a long transverse scar in the sub-
mammary fold can be avoided with no adverse
effect on the aesthetic shape of the breast.12,13
This is not the case for patients with voluminous
breasts, older patients with less elastic skin, or pa-
From Ulm Klinik Rosengasse and the Plastic Surgery Insti-
tute, University of Padova.
Received for publication January 29, 2005; accepted July 8,
2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279150.85155.1e
tients with multiple striae. The scar minimalization
technique frequently leads to problems with scar
healing, due to excessive pleating and consequent
compromised blood supply to the wound edges or
to overlong vertical scars that protrude caudally
below the submammary fold and are aesthetically
unsatisfactory, as they cannot be hidden by a bra.
Residual folds or ugly puckering at the caudal scar
pole require secondary surgical correction.14 Many
patients are unconvinced by the benefits of shorter
scars when the advantages are in conflict with a
better aesthetic appearance. In our experience,
tension-free scars in the submammary fold, when
they do not visibly extend beyond the breast base
medially or laterally, nearly always produce un-
obtrusive, dash-like scarring and are preferable
to an unattractive, forced, vertical scar.
One of the main benefits of the modified Lejour
technique is that all phases of the operative plan-
ning (detailed down to the skin suture) can be
adapted to the individual patient. As a standard
procedure, therefore, it can be used on all breast
types.15–18

www.PRSJournal.com 1095
 Plastic and Reconstructive Surgery • October 2007

PATIENTS AND METHODS Lejour technique” in approximately 25 percent of

Between 1996 and 2003, we performed 1968
mammary reductions in approximately 1000 pa-
tients in two centers, the Ulm Clinic Rosengasse and
the Padova Plastic Surgery Institute. In small reduc-
tions (⬍500 g), we preferred the pure vertical tech-
nique. From our early experience with the vertical
technique, we knew about the problems with the
persistent vertical dog-ear deformity at the nadir of
the incision and about the lateral axillary fullness in
larger breasts. Therefore, we used our “modified
the patients; these patients were overweight and had
a breast resection weight of more than 700 g.
By using this technique in these 250 patients
with 500 breast reductions, we avoided the aes-
thetic deficiencies and simplified the reduction
technique for large breasts. We found no contra-
indications, even in cases of large resection
weights of 1000 g or more.
All 250 patients with large breast reductions of
more than 700 g who were operated on with the

Fig. 1. (Above) Individual planning of the displacement axis and the height of the new nipple. (Center) Planning of the
lateral and medial resection margins. (Below) Marking of the caudal incision line and superior nipple definition.

1096
Volume 120, Number 5 • Breast Reduction
modified technique were examined postopera-
tively, and their progress during this time was doc-
umented. The data gathered were used to deter-
mine whether this procedure is suitable for high
resection weights in adiposity. Nearly all patients
had a history of either futile attempts at dieting or
weight loss of a maximum 20 kg.
Technique
The operative treatment begins with preoper-
ative planning and site marking. The axis on which
the nipple is going to be superiorly relocated is
then chosen. This is ascertained by laying a mea-
suring tape around the patient’s neck and moving
it from nipple to nipple. In contrast to using a
fixed template, this method allows the optimum
nipple relocation to be planned for the individual
patient. The exact positioning of the nipple on the
marked axis is felt by palpation of the tissue start-
ing from the middle of the submammary fold. The
bilateral vertical margins for the skin resection are
Fig. 2. (Above) The nipple-supporting flap is planned distally
up to 2 fingerwidths from the nipple. (Below) The mamilla is cut
around in the size planned, cutting through the epidermis
only.
marked by laying the breast first laterally and then
medially, drawing two connecting lines to the pre-
viously marked middle breast axis (Fig. 1, above
and center).
The breast must be pushed up into a conical
shape during marking. The two vertical lines are
then joined together by an arched line running
about two fingerwidths above the submammary
fold. Another curved line is then drawn around
the future position of the nipple, which vary in
accordance with the plastic surgeon’s preferred
method (Fig. 1, below).
First, infiltrate up to tumescence subglandu-
larly and epifascially with 250 ml of solution (500
ml of sodium chloride plus 1.5 mg of epineph-
rine). In this way, the prepared tissue is loosened
and bleeding is simultaneously arrested. After a
tourniquet is applied, the diameter of the nipple
is determined using a template; it may vary be-
tween 4 and 5 cm, depending on the size of the
breast.19 The de-epithelialization area is then
marked, with a gap of at least two fingerwidths left
Fig. 3. (Above) Subcutaneous skin mobilization with scissors.
(Below) Blunt undermining of the breast gland on the pectoralis
fascia.
1097
 Plastic and Reconstructive Surgery • October 2007

below the nipple so that blood flow is not com-
promised after flap preparation.
Next is the excision of the nipple and the
marked flap, whereby the cutis is only superficially
transected (Fig. 2).20 The entire excised flap is
de-epithelialized. The skin is completely cut through
in the area of the preoperative markings using an
electric cauterizer. The skin is laterally and medially
undermined atraumatically (i.e., mobilized) using
scissors. It is very important to find the correct tissue
layer, which is recognizable by its minimal resistance.
Thinning of the skin is required for optimal retrac-
tion (Fig. 3), but there must be no risk to the blood
supply from overskeletization of the skin. Next, the
breast glandular tissue is mobilized; this has to be
carried out strictly epifascially. Mobilization is begun
sharply and caudally using scissors, but superior mo-
bilization can be continued bluntly. In this way, dam-
age to the pectoralis fascia can be largely excluded.
Mobilization continues to the upper margin of the
gland at the height of about the third intercostal
space, to create a vertical tunnel about 8 to 10 cm
wide (Fig. 4, above, left and center).
The outcome of bilateral division of the breast
gland is a medial and lateral mammary gland pil-
lar. The surgeon then cuts around the de-epithe-
lialized skin flap, and the actual resection of the
tissue that is going to be reduced takes place. The
tissue can be resected with scissors or a scalpel
(Fig. 4, above, right and center). It is important that
a nipple-supporting flap with a thickness of at least
one to two fingerwidths remains.21 This is obliga-
tory in the central or nipple-supporting area; the
layer may taper at the edges. The flap is then tested
for deformability.
The nipple is superiorly positioned and se-
cured with sutures. Both side pillars of the mam-
mary gland, which are connected to the pectoral

Fig. 4. (Above, left and center) Bilateral division of the mammary gland and cutting around the gland flap. (Above, right, and center,
left and center) Gland resection creating a nipple-supporting superior pedicle flap. (Center, right) The resected tissue. (Below) The
nipple-supporting superior pedicle flap and connection of the lateral and medial gland pillar by suture to form the new breast.

1098
Volume 120, Number 5 • Breast Reduction

muscle, are joined caudally with three or four
sutures beginning underneath the areola (Fig. 4,
below). The sutures shape the breast and produce
a conical appearance. The sutures also progres-
sively decrease the breast base from top to bottom.
The sutures must not catch the pectoralis fascia;
otherwise, natural ptosis will not take place. The
remaining caudal gland pillar is medially and lat-
erally resected at the height of the planned sub-
mammary fold.
The three H points (i.e., the radical key su-
tures) are of vital importance because they form a
permanent anchor for the submammary fold (Fig.
5, above, left and center). They stabilize the form and
height of the fold and stop subsequent caudal
sagging of the breast; that is, natural ptosis is guar-
anteed with a stable submammary fold. A superior
mastopexy suture can be waived. If insufficient
postoperative retraction for a large skin surplus is
expected, direct skin resection can be beneficial in
avoiding wound-healing problems and their po-
tential correction. A completely tension-free skin
closure is crucial (Fig. 5, above, right and center).
The vertical and transverse pleating of the skin
suture is conducive to final shaping and scar short-
ening. If the skin has good retraction ability, skin
resection and the consequent additional submam-
mary suture are waived. It is vital that the pleated
suture does not compromise the blood supply to
the wound margins, with the associated impair-
ment to wound healing. The vertical suture should
not be compulsory (Fig. 5, below).
RESULTS
All 250 patients were controlled during the
investigation period (8 years), with an average fol-
low-up of 4.2 years. Patient ages ranged from 19 to
72 years (average age, 39.2 years). Their average
body mass index was 31 ⫾ 4; their average weight
and height were 83.6 ⫾ 12.6 kg and 163.6 ⫾ 6.6

Fig. 5. (Above, left and center) Caudal glandular resection, with H point anchorage of the submammary fold with three radical sutures.
(Above, right and center, left) Caudal skin resection for excessive surplus skin and double-layer wound closure. (Center, center and right)
Pleating of the transverse and vertical skin sutures for scar shortening and ultimate breast shaping. (Below) Singular vertical scar with
shortening from pleating with good tissue retraction.

1099
 Plastic and Reconstructive Surgery • October 2007
cm, respectively. The resection weight ranged
from 741 to 3249 g (average, 985 g) for the right
breast and 719 to 3370 g (average, 923 g) for the
left breast.
In one case, a free graft of the nipple was
necessary. Decisions about the incision/scar line
always depended on the skin and soft-tissue situ-
ation. The operative time ranged from 120 to 180
minutes, with a well-trained fellow performing si-
multaneous sutures.
Follow-up care included single drains for each
breast until postoperative day 2, inpatient treat-
ment for 3 to 5 days, and a special bra that patients
wore for 12 weeks. We generally recommend to
our patients the “triple rule”: 3 days in hospital, 3
weeks of no strenuous activity, and 3 months with
a special bra and no sports.
The results of follow-up examinations of the
250 patients were as follows: very good, 75 percent;
good, 19 percent; satisfactory, 5 percent; unsatis-
factory, 1 percent (Figs. 6 through 8). The eval-
uation was performed using a special internal hos-
pital score with criteria such as volume, shape,
Fig. 6. Preoperative and 3-month postoperative views of mammary reduction of 800 g on both sides. Note the auspicious
development of a vertical scar.
1100
scars, sensibility, and patient satisfaction. The fol-
low-up was conducted by an independent person
in training for plastic surgery.22
Our complications rates are listed in Table
1.23 Figure 9 shows necrosis complications in two
patients.
In our experience, adiposity and gigantomasty
are not in themselves contraindications to the
modified Lejour mammary reduction technique.
Despite large volume reductions, a very good
breast shape can be achieved in most cases. The
complication rate for overweight patients was signif-
icantly higher than that for our other clinical pa-
tients. It is striking that the majority of complications
and, indeed, all serious complications occurred dur-
ing the initial phases of the technique, which argues
for a typical learning curve. After a lengthy treatment
course, the patients who had complications also
showed satisfactory aesthetic results.24 As for nipple
sensitivity, 220 patients achieved normal nipple sen-
sitivity following a period of deteriorated sensation.
Twenty-eight patients reported reduced sensitivity,
and two patients reported loss of sensitivity.25,26
Volume 120, Number 5 • Breast Reduction

Fig. 7. (Above) Preoperative and 6-month postoperative views of mammary reduction of 870 g on both sides.
(Second row) Preoperative and 6-month postoperative views of mammary reduction of 1250 g for the right breast
and 1070 g for the left breast. (Third row) Preoperative and 3-month postoperative views of mammary reduction
of 950 g on both sides. (Below) Preoperative and 6-month postoperative views of mammary reduction of 1530 g
on both sides.

1101
 Plastic and Reconstructive Surgery • October 2007

Fig. 8. (Above and second row) Preoperative and 2-year postoperative views of mammary reduction of 1250 g on
both sides. (Third row and below) Preoperative and 4-year postoperative views of mammary reduction of 1650 g
on both sides.

1102
Volume 120, Number 5 • Breast Reduction
Table 1. Complications after 500 Mammaplasties in
250 Adipose Patients (resection weight >700 g)
Complications
Nonserious
Seroma
Hematoma
Soft-tissue infection
Delayed healing of skin23
Surface skin necrosis (max 2 ⫻ 3 cm)
Serious
Fatty tissue necrosis and wound dehiscence
With regard to breastfeeding, three patients
became pregnant after the operation and breast-
fed their babies with no problems.
DISCUSSION
Our 500 breast reductions in 250 overweight
patients with voluminous breasts exhibited the fol-
lowing benefits and characteristics compared with
more established procedures:
1. The position of the nipple-areola complex
was located individually for each patient on
the breast-neck axis using the finger pres-
sure resistance test.
2. Shaping of the breast gland was achieved
in skin closure without a mastopexy suture
by anchoring the breast fold using H
points.
3. Entirely tension-free wound closure was
achieved by shortening the scar with pleat-
Fig. 9. (Left) Fat and tissue necrosis. (Right) The left breast shows delayed wound healing due to a small
amount of skin necrosis; this was considered a minor complication. The right breast represents a serious
complication, with wound dehiscence and “fatty tissue necrosis.”
ing, although this was controlled by the in-
dividual retraction ability of the skin and the
No. % blood flow to the wound margins.
When in doubt, primary resection of the cau-
15 3 dal skin surplus was performed and the caudally
10 2
12 2.4 transverse suture was made tension-free by short-
8 1.6 ening (i.e., pleating).27 We have not experienced
16 3.2 a single case of hypertrophy or aesthetically ob-
9 1.8 jectionable scarring after this alternative proce-
dure, whereas forced vertical scars have often re-
quired secondary correction. Liposuction is not
used because the breast gland can be better
shaped when there is no denaturing of the orig-
inal anatomy. If it is necessary, liposuction can
be used in isolated cases to contour the lateral
fat ridges along the sides of the thorax. Shaping
the breast and positioning it using glandular
and mastopexy sutures are an integral part of
most established reduction techniques.28 Earlier
techniques attached great importance to exact
preoperative planning using fixed templates
and the specification of a skin incision pattern
to achieve the desired shape.29 Our experience
has shown that only the reduction technique has
a bearing on the subsequent breast shape. Shape
is not significantly influenced by suture tech-
nique, gland tissue, or skin tension (or lack
thereof) or by external fixation techniques, such
as tape dressings or special bras. In fact, the
reduction technique has to embrace the indi-
vidual dynamics of the body tissues with regard
1103
 Plastic and Reconstructive Surgery • October 2007
to proportion, structure, volume, elasticity, and
blood flow. Gland and skin sutures serve merely
to loosely adapt the breast shape, which has
been created by the reduction technique. Only
the breast fold is of importance, and only the
breast fold can be influenced. Anchoring over
several points can avoid the familiar, undesir-
able sagging of the short-scar techniques and act
as a fixed pivot point to induce a natural ptosis.
From the beginning to the end of the operation,
the modified reduction technique following
Lejour’s method gives the operating surgeon
the freedom to vary the technique by adapt-
ing it to each patient following the axiom of
minimum tissue trauma and maximum aesthetic
benefit.
Having applied the described technique for
more than 6 years, whereby all modifications have
been based on long-term experience, we consider
our procedure to be an excellent treatment option
for breast reductions of all sizes, shapes, and tissue
situations. It is especially suited to the reduction of
very large breasts in overweight patients. The com-
plication rate for our patients was comparable to
that of other authors24 and has become signifi-
cantly lower with long-term experience.
Franco Bassetto, M.D.
Plastic Surgery Institute
Via Giustiniani, 2
35128-Padova, Italy
carlotsc@tin.it
DISCLOSURE
None of the authors has a financial interest in any
of the products, devices, or drugs mentioned in this
article.
REFERENCES
1. Marchac, D., and de Olarte, G. Reduction mammaplasty and
correction of ptosis with a short inframammary scar. Plast.
Reconstr. Surg. 69: 45, 1982.
2. Lassus, C. A new technique for breast reduction. Int. Surg. 53:
69, 1970.
3. Lejour, M. Vertical mammaplasty and liposuction of the
breast. Plast. Reconstr. Surg. 94: 100, 1994.
4. Hidalgo, D. A., Elliot, L. F., Palumbo, S., Casas, L., and
Hammond, D. Current trends in breast reduction. Plast.
Reconstr. Surg. 104: 806, 1999.
5. Chen, C. M., White, C., Warren, S. M., Cole, J., and Isik, F.
Simplifying the vertical reduction mammaplasty. Plast. Re-
constr. Surg. 113: 162, 2004.
6. Riascos, A. Vertical mammaplasty for breast reduction. Aes-
thetic Plast. Surg. 23: 213, 1999.
7. Spear, S. L., and Howard, M. A. Evolution of the vertical
reduction mammaplasty. Plast. Reconstr. Surg. 112: 855, 2003.
1104
8. Erdogan, B., Ayhan, M., Deren, O., and Tuncel, A. Impor-
tance of pedicle length in inferior pedicle technique and
long-term outcome of areola-to-fold distance. Aesthetic Plast.
Surg. 26: 436, 2002.
9. Lejour, M. Reduction of mammaplasty scars: From a short
inframammary scar to a vertical scar. Ann. Chir. Plast. Esthet.
35: 369, 1990.
10. Lassus, C. Breast reduction: Evolution of a technique–-A
single vertical scar. Aesthetic Plast. Surg. 11: 107, 1987.
11. Chen, T. H., and Wei, F. C. Evolution of the vertical reduc-
tion mammaplasty: The S approach. Aesthetic Plast. Surg. 21:
97, 1997.
12. Lassus, C. A 30-year experience with vertical mammaplasty.
Plast. Reconstr. Surg. 97: 373, 1996.
13. Hall-Findlay, E. J. Pedicles in vertical breast reduction and
mastopexy. Clin. Plast. Surg. 29: 379, 2002.
14. Lassus, C. An “all season” mammaplasty. Aesthetic Plast. Surg.
10: 9, 1986.
15. Lejour, M. Vertical Mammaplasty and Liposuction of the Breast.
St. Louis, Mo.: Quality Medical Publishing, 1994.
16. Lejour, M. Evaluation of fat in breast tissue removed by
vertical mammaplasty. Plast. Reconstr. Surg. 99: 386, 1997.
17. Menke, H., Restel, B., and Olbrisch, R. R. Vertical scar re-
duction mammaplasty as a standard procedure: Experiences
in the introduction and validation of a modified reduction
technique. Eur. J. Plast. Surg. 22: 74, 1999.
18. Malata, C. M., Hodgson, E. L., Chikwe, J., Canal, A. C., and
Purushotham, A. D. An application of the Lejour vertical
mammaplasty pattern for skin-sparing mastectomy: A pre-
liminary report. Ann. Plast. Surg. 51: 345, 2003.
19. van Thienen, C. E. Areolar vertical approach (AVA) mam-
maplasty: Lejour’s technique evolution. Clin. Plast. Surg. 29:
365, 2002.
20. Hammond, D. C. Short scar periareolar inferior pedicle re-
duction (SPAIR) mammaplasty/mastopexy: How to do it
step by step. Perspect. Plast. Surg. 15: 61, 2001.
21. Exner, K. Scheufler, O. Dermal suspension flap in vertical-
scar reduction mammaplasty. Plast. Reconstr. Surg. 109: 2289,
2002.
22. Chung, J. S., Murphy, R. X., Jr., Reed, J. F., and Kleinman,
L. C. Quality analysis of bilateral reduction mammaplasty
using a state-legislated comparative database and an internal
hospital-based system. Ann. Plast. Surg. 51: 446, 2003.
23. Mottura, A. A. Circumvertical reduction mastoplasty: New
considerations. Aesthetic Plast. Surg. 27: 85, 2003.
24. Lejour, M. Vertical mammaplasty: Early complications after
250 personal consecutive cases. Plast. Reconstr. Surg. 104: 764,
1999.
25. Dellon, A. L. Sensibility of the breast following reduction
mammaplasty (Discussion). Ann. Plast. Surg. 51: 6, 2003.
26. Ferreira, M. C., Costa, M. P., Cunha, M. S., Sakae, E., and Fels,
K. W. Sensibility of the breast after reduction mammaplasty.
Ann. Plast. Surg. 51: 1, 2003.
27. Meyer, R. “L” technique compared with others in mamma-
plasty reduction. Aesthetic Plast. Surg. 19: 541, 1995.
28. Graf, R., Reis de Araujo, L. R., Rippel, R., Neto, L. G., Pace,
D. T., and Biggs, T . Reduction mammaplasty and mastopexy
using the vertical scar and thoracic wall flap technique. Aes-
thetic Plast. Surg. 27: 6, 2003.
29. Orak, F., Yücel, A., and Senyuva, C. Wineglass pattern for
vertical mammaplasty. Aesthetic Plast. Surg. 21: 180, 1997.

Breast Reduction: Modified “Lejour Technique” in 500
Large Breasts
Elizabeth J. Hall-Findlay,
M.D.
Banff, Alberta, Canada
T his is a good review of 250 patients who un-
derwent large breast reductions using the
authors’ modification of Lejour’s vertical tech-
nique. Their results are excellent.
When the resection amounts were greater than
700 g, the authors would add a horizontal scar if
there was excess skin of poor quality. They used a
superior pedicle, minimal liposuction, and no pec-
toralis fascia sutures. To control the inframammary
fold, they used three H point sutures to prevent
the fold from descending. They emphasize a ten-
sion-free skin closure and rely on the nature of the
parenchymal resection and on closure of the pil-
lars to shape the breast.
I agree with much of what they say, but I would
prefer to have seen where and how the H point
sutures are actually placed. A drawing would have
helped. I cannot accept without proof that they
can prevent the fold from descending by using
these sutures. I believe them, because I have mea-
sured the postoperative rise in the inframammary
fold that occurs even without sutures. We all
should avoid making statements such as this with-
out documentation. These sutures might, however,
also help prevent seroma formation. This would
make an interesting study.
The authors rely on the level of the inframam-
mary fold to determine their new nipple posi-
tion. This is an important point, because some
patients have very low folds and others have very
high folds. There is significant variation from
one person to another, and the new nipple po-
sition cannot be determined by an arbitrary dis-
tance from the suprasternal notch. The authors
use the palpation method, whereby they put one
finger in the fold and transfer it to another
finger placed on the external skin surface. This
is shown in their Figure 1, above, right, but it is
clear from this image that the outside finger is
actually placed much higher than the true infra-
mammary fold.
Surgeons need to lower the position of the new
nipple in vertical reductions from what they are
Received for publication March 27, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279140.58432.27
www.PRSJournal.com
DISCUSSION
used to using when designing an inverted-T reduc-
tion. There is no one correct measurement, be-
cause some surgeons use the finger method and
some surgeons sit while others stand when they
make this determination. Figure 1 shows how
much difference it can make if the surgeon is
sitting or standing when making the new nipple
determination. The inframammary fold was
marked between the breasts using a measuring
tape held underneath the breasts. The new nipple
position lines up with the level of the inframam-
mary fold and measures 25 cm from the supraster-
nal notch. This image was taken from the sitting
position, but when the surgeon stands, the infra-
mammary fold will seem to match up with a point
that measures 22 cm. All that can be said is to use
the inframammary fold as the guide and lower the
position when switching to the vertical technique.
This lowering is necessary to accommodate the
increased projection that results from the increase
in breast coning. The best nipple position is at the
point of maximum projection of the breast. Be-
cause there is more flexibility in determining the
new nipple position when the patient has lots of
upper pole fullness, the design was raised in this
patient to the level that has the star beside it on the
right breast (Fig. 1).
The authors emphasize that the resection
should avoid the pectoralis fascia. Being too close
to the pectoralis fascia results in more bleeding
(and is theoretically likely to damage innervation).
They do not believe that the pectoralis fascia su-
tures described by Lejour are necessary. Both of
these modifications make the procedure easier to
perform.
Smaller breast reductions will require only a ver-
tical skin excision. Larger breast reductions, as
shown in this article, may be better served with a
horizontal skin excision when necessary. I have
removed more than 1200 g per side without add-
ing a horizontal excision, but I have occasionally
added a T incision in a patient with an 800-g re-
moval. The skin excision is needed far less often
than one would expect. I am “tempted” when the
vertical length exceeds 12 to 14 cm.
The authors make it clear that they believe a
tension-free skin closure is important in both the
1105
 Plastic and Reconstructive Surgery • October 2007
Fig. 1. This image of preoperative patient marking shows the
difficulty in determining the new nipple position when trying to
line it up with the level of the inframammary fold (the mark be-
tween the breasts). In this image, with the surgeon sitting in front
of the patient, the new nipple position would be 25 cm from the
suprasternal notch. If the surgeon stands, however, the new nip-
ple position would appear to match up at a distance of 22 cm
from the suprasternal notch. The same problem occurs when one
uses the finger palpation method. For this reason, it is difficult to
suggest a definite marking position to other surgeons. The best
advice is to have the surgeon place the new nipple position 2 cm
below what they are used to using for the inverted-T inferior pedicle
technique. This recommendation will allow for the higher nipple
position that results postoperatively with the vertical reduction
techniques. The nipple will appear to be higher because of the
increased projection that results from the coning of the im-
proved breast.
short and long term. They will not over “pleat”
or gather the excess skin because it interferes
with wound healing. When the skin quality is
poor and when there is a great deal of excess
skin, they do not hesitate to remove the extra
skin in a T along the inframammary fold. To
take it to extremes, no one should seriously con-
sider a vertical skin resection pattern in a patient
with massive weight loss. There is just too much
extra skin. Even a shorter vertical length will
require a horizontal excision when the skin is
loose and has poor elasticity. Leaving the re-
maining skin attached to the upper skin flaps,
however, is one way (though not the only way) to
help prevent gravity from destroying initial good
results in the obese patient who has lost weight.
I have stopped doing much pleating at all in
my vertical incisions. I measured the vertical
length in my patients before surgery with the
1106
patient standing, before closure, after closure,
and at each postoperative visit. All that hap-
pened was that the vertical incision lengthened
as time passed. In those patients in whom it did
not lengthen, the scar remained puckered and
required revision. Gathering the vertical incision
makes the breast look more acceptable at the
end of the procedure, and it is not easy to leave
the excess skin without being tempted to excise
it as a T. It takes time for a surgeon to be able to
recognize how much skin is too much. When
skin needs to be removed, a T, a J, or an L can be
used to excise the excess.
Long vertical lengths are hard to accept for sur-
geons who are used to using the inverted-T inferior
pedicle. A short vertical incision is necessary to
counteract the skin stretching that occurs with the
inverted-T, because the skin is under tension.
When the vertical approach is used, the skin is not
being used as a “handle.” A distance of 7 to 12 cm
from the areola to the inframammary fold is per-
fectly acceptable in a normal breast. A B cup will
often be 7 cm or less. A C cup may be closer to 9
cm, and a D cup may look quite good at 12 cm. In
the authors’ Figure 8, below, right, it is clear that the
vertical distance is not 5 cm, and the resulting
shape is excellent. We need to change our think-
ing about the 5-cm “rule” when we are not leaving
skin under tension.
Figure 2 shows a 1-month follow-up view of
the patient in Figure 1. She had 675 g removed
from her right breast and 660 g taken from her
left breast. A total of 200 cc of fat was removed
from the preaxillary and lateral chest wall ar-
eas. Liposuction was also used to shape the
inframammary fold. The intraoperative view
(Fig. 2, above, left) shows puckering that would
tempt most surgeons to perform a horizontal
excision, but this was unnecessary, as can be
seen in the 1-month postoperative views.
(There is obviously still some swelling and
more resolution will occur; these images are
only meant to reassure surgeons that resolu-
tion can occur fairly quickly.) The vertical scar
was shortened (pleated, gathered) by 1 cm on
the right and not at all on the left. The lateral
view (Fig. 2, below, right) shows a good shape
even at 1 month, where 9 to 10 cm of vertical
length is more than acceptable.
On a final note, a complication rate of 14
percent will generate some criticism, but it needs
to be properly analyzed. Some surgeons (as have
these authors) include minor complications at
the risk of being criticized. It is analogous to
revision rates. The results may not differ, but the
Volume 120, Number 5 • Discussion

Fig. 2. One-month follow-up view of the patient shown in Figure 1. She had 675 g removed from her right breast and 660 g
from her left breast. A total of 200 cc of fat was removed from the preaxillary and lateral chest wall areas. Liposuction was also
used to shape the inframammary fold. The intraoperative view (above, left) shows puckering that would tempt most surgeons
to perform a horizontal excision, but this was unnecessary, as can be seen in the other views. There is obviously still some
swelling and more resolution will occur. These images are only meant to reassure surgeons that resolution can occur fairly
quickly.

percentages may be different depending on
each surgeon’s threshold for revision. The com-
plication rate for vertical breast reductions is
certainly no more frequent than that for inverted-T
techniques. The authors have documented that
the complication rate was higher in the more
obese patients. This confirms what other surgeons
have noted in their practices.
The authors have developed a common-sense
approach to breast reductions. They use a purely
vertical reduction if the resection is less than 500 g.
If the volume to be removed is more than 700 g,
they use a vertical approach to the parenchymal
resection and will consider adding a horizontal
skin excision when there is too much skin of poor
quality. The actual approach may differ from sur-
geon to surgeon, but the principles remain: leave
behind coned breast parenchyma attached to the
superior skin flaps and close the skin without ten-
sion. The breast is being used to shape the skin,
not vice versa. The decision to excise excess skin is
a separate decision and will depend on the quality
and amount of skin that remain.
The authors are to be complimented on a
straightforward approach to vertical breast re-
ductions with excellent results.
Elizabeth J. Hall-Findlay, M.D.
340-317 Banff Avenue, Box 2009
Banff, Alberta, Canada T1L 1B7
ehallfindlay@banffplasticsurgery.ca
DISCLOSURE
The author of this discussion has no financial in-
terest in any of the products, devices, or drugs mentioned
in this article.

1107
BREAST

Validation of a Questionnaire for Measuring

Morbidity in Breast Hypertrophy
Leif Sigurdson, M.D., M.Sc.,
M.B.A.
Susan A. Kirkland, Ph.D.
Eric Mykhalovskiy, Ph.D.
Halifax, Nova Scotia, Canada
Background: There is a growing body of evidence suggesting that body mass
index and predicted breast resection weight may not be appropriate criteria for
determining insurance eligibility for breast reduction surgery. Eligibility should
ideally be based on need. However, no method for determining need in patients
seeking reduction surgery currently exists. The purpose of this investigation was
to develop a validated questionnaire for measuring the burden of breast
hypertrophy.
Methods: Forty-five symptoms specific to breast hypertrophy were incorporated
into a questionnaire that was subsequently administered to a sample of 101
women. Reliability and validity testing was performed according to established
psychometric criteria.
Results: Three items were omitted based on low item remainder coefficients
(Cronbach’s ␣) and three were eliminated because of excessive skew. Intraclass
correlation coefficients of 0.85 indicated favorable test-retest reliability. Content
validity was achieved through the study design and then confirmed by a group
of 11 plastic surgeons. The questionnaire showed reasonable criterion validity
when compared with corresponding domains in the Short Form-36. Construct
validity was excellent. Exploratory factor analysis revealed five questionnaire
subdomains: (1) physical implications, (2) poor self-concept, (3) body pain, (4)
negative social interactions, and (5) physical appearance.
Conclusions: The authors have developed an evaluative tool termed the Breast
Reduction Assessed Severity Scale Questionnaire for measuring the burden of
breast hypertrophy. The questionnaire produces subdomain scores and an
overall measurement of the burden of breast hypertrophy that may be useful in
the assessment of patients. (Plast. Reconstr. Surg. 120: 1108, 2007.)

T
he majority of the Canadian population is
covered by provincially administered pub-
lic health insurance. In the United States,
over 99 million people were enrolled in health
maintenance organizations or preferred pro-
vider organizations in 2002.1 Most of these insur-
ers provide financial coverage for breast reduc-
tion surgery, provided that certain criteria are
met. Common criteria involve height, weight,
and breast size measurements and an evaluation
of breast hypertrophy symptoms. However,
mounting evidence and expert opinion have
thrown into question the appropriateness of
these criteria.2
From the Division of Plastic Surgery and Department of Com-
munity Health and Epidemiology, Dalhousie University.
Received for publication July 13, 2006; accepted August
16, 2006.
Copyright ©2007 by the American Society of Plastic Sur-
geons
DOI: 10.1097/01.prs.0000279141.00955.e8
The use of symptom-based criteria seems empir-
ically sensible, as it targets women who experience
morbidity related to breast hypertrophy and are
thus in a better position to benefit from surgical
intervention. The use of subjective patient data in
the approach to deciding who receives an interven-
tion is not a new concept; virtually all medical
disciplines consider symptomatology when estab-
lishing indications for treatment. Such an ap-
proach minimizes dependency on more arbitrary
parameters, such as body mass index and breast
size thresholds, which may not reflect patient need.
Supplemental digital content is available for
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printed text; simply type the URL address into
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HTML text and PDF of this article on the
Journal’s Web site (www.PRSJournal.com).

1108 www.PRSJournal.com
Volume 120, Number 5 • Morbidity in Breast Hypertrophy
The problem with symptomatic criteria is that
unlike anthropomorphic parameters, which are
inherently quantifiable, information relating to
subjective patient experience is generally de-
scriptive in nature and thus difficult to objectify
in a standardized manner. Several general qual-
ity-of-life instruments have been used as a means
to evaluate the burden of breast hypertrophy,
though none are currently in regular clinical use
in this context. Examples include questionnaires
such as the Short Form-36, the European Quality
of Life Scale, the McGill Pain Questionnaire, the
Rosenberg Self-Esteem Scale, and the Multidi-
mensional Body-Self Relations Questionnaire.3–9
Although all of these questionnaires produce
quantitative scores and have been validated,
none was developed with breast hypertrophy pa-
tients in mind. The rather broad scope of such
instruments challenges their ability to gather
comprehensive information specific to breast hy-
pertrophy patients.
The Breast-Related Symptoms Questionnaire
developed by Kerrigan et al.9 is the most prom-
ising instrument to date. Their questionnaire
was developed specifically for breast hypertrophy
patients and has gained partial validation
through test-retest reliability. In addition, the
instrument shows initial construct validity in that
it appears to be responsive to changes between
the preoperative and postoperative states.6 They
have also established face validity through the
use of focus groups consisting of women with
breast hypertrophy. Although the questionnaire
is concise and simple to use, it focuses mainly on
pain-related symptoms and may not fully reflect
the spectrum of burden, which is known to in-
clude a significant psychological component.10
Their work nonetheless provides a solid founda-
tion for further research aimed at improving the
evaluation of breast hypertrophy.
Developing a practical and scientifically sound
instrument for evaluating symptom burden re-
quires certain conditions: (1) the instrument must
comprehensively measure the full spectrum of
symptoms experienced by women with breast hy-
pertrophy; (2) it must be amenable to the produc-
tion of a quantitative score; and (3) it must be
created using accepted psychometric standards for
scale development (i.e., proper validation).11
The purpose of this study was to expand on
previous work aimed at measuring morbidity
associated with breast hypertrophy. In a pre-
ceding article, we produced a list of 45 symp-
toms specific to breast hypertrophy that were
ranked according to severity through the use
of focus groups.12 The current study incorpo-
rates these symptoms into a questionnaire de-
signed to objectively measure the burden of
breast hypertrophy.
PATIENTS AND METHODS
One hundred six patients were randomly se-
lected to participate from 168 patients on the prin-
cipal investigator’s (L.S.) waiting list for breast
reduction consultation. Sample sizes in excess of
100 are felt to be reliable for factor analysis.13
Inclusion criteria were as follows: 18 years of age
or older; able to read, speak, and write English;
and able to complete self-administered question-
naires. Subjects were screened for substance abuse
and severe psychopathology.
The study protocol, including the question-
naires administered, was approved by the Capital
District Health Authority Institutional Review
Board. Patients were contacted by telephone and
invited to participate on a voluntary basis. Poten-
tial subjects were informed that their involvement
in this research would in no way influence their
eligibility for insurance coverage or their future
care at the Queen Elizabeth II Health Sciences
Centre. All participants provided written, in-
formed consent on entry into the study.
Administration of Questionnaires
At the time of their initial surgical consulta-
tion, each subject received a set of four question-
naires to be completed before their clinical en-
counter with the plastic surgeon. Three of these
questionnaires (the Short Form-36,14 the Rosen-
berg Self-Esteem Scale,15 and the Breast-Related
Symptoms9) are existing assessment tools that
have been applied to breast hypertrophy patients
in the past. The fourth questionnaire is the as-
sessment device being developed in this study and
is referred to as the Breast Reduction Assessed
Severity Scale Questionnaire. Questionnaires were
completed in the waiting room and subjects were
given as much time as needed to perform this task.
It should be noted that subjects had not yet been
assessed for provincial insurance coverage at the
time of this initial questionnaire administration.
Breast Reduction Assessed Severity Scale
Questionnaire Item Generation
Breast Reduction Assessed Severity Scale items
were derived from previous data generated by fo-
cus groups consisting of women with breast hy-
pertrophy. This process, described in a previous
article, yielded 45 symptoms ranked according to
1109
 Plastic and Reconstructive Surgery • October 2007
severity.12 In the current study, a series of ques-
tionnaire items was produced such that each item
would address a particular symptom from this list.
Items were framed as questions worded in clear
language aimed at the target population; ambig-
uous terms and double negatives were avoided.
Participants were asked to answer each question
using a five-point Likert scale. Four questions were
worded in reverse direction and added to the ini-
tial list to identify acquiescence bias (“yea saying,”
whereby the respondent consistently marks the
same response for all items, reflecting lack of at-
tention to questionnaire content). These reverse-
worded items were intended as flags whereby two
or more contradictory responses would result in
exclusion of that particular questionnaire from
the data set.
After questionnaire administration, data were
entered into an Excel spreadsheet (Microsoft,
Corp., Redmond, Wash.) and analyzed using a
statistical software package (SPSS Version 7.5;
SPSS, Inc., Chicago, Ill.). Responses to each ques-
tionnaire item were analyzed using descriptive sta-
tistics and histograms. Response distributions of
each item were plotted and skew statistics were
calculated (Kolmogorov-Smirnov test). Items with
significant skew or endorsement frequencies of
greater than 90 percent or less than 5 percent were
discarded, as they would be unlikely to be of use
in discriminating differences. Spearman coeffi-
cient matrices were calculated to analyze the de-
gree of individual item correlation with the other
questionnaire items. The matrix was scanned for
insignificant correlations necessitating removal of
that particular item.
Exploratory factor analysis was performed on
the remaining items according to established psy-
chometric inquiry13 to determine whether the
questionnaire could be resolved into conceptually
distinct subdomains. Items loading on any factor
at a level of less than 0.30 were removed from that
factor.
Reliability Testing
Internal consistency represents the extent to
which each item correlates with other items in
its corresponding scale and was calculated using
item remainder coefficients (Cronbach’s ␣).16
Items yielding coefficients of less than 0.70 were
excluded.
Test-retest reliability, a measure of test stability
over time, was determined by readministering the
Breast Reduction Assessed Severity Scale Ques-
tionnaire to the same group of subjects approxi-
1110
mately 4 weeks after its initial completion (but still
before reduction surgery). Test-retest Pearson cor-
relations and the more conservative intraclass cor-
relation coefficients were calculated for the entire
questionnaire and for the subdomains.17 Intraclass
correlations were calculated using two-way mixed
models with absolute agreement.18 Any discrep-
ancies ensuing over the test-retest period were
analyzed using the Wilcoxon signed ranks test.
Validity Testing
In the context of this study, validity testing
refers to the appropriateness, meaningfulness,
and usefulness of the questionnaire under inves-
tigation. Validity assessment involves a number of
components, with particular emphasis placed on
content, construct, and criterion validity.
Content validity reflects the degree to which a
questionnaire addresses a representative range of
data pertinent to the concept under study (i.e., are
all the bases covered?). Content validity is usually
determined through expert judgment. Ideally,
these experts should be individuals with the con-
dition in question.19 As a secondary check on con-
tent validity, the questionnaire items were for-
mally reviewed by a group of 11 plastic surgeons
(breast reduction experts). Using a five-point Lik-
ert scale, each surgeon was asked to rate the rel-
evance of individual items based on their under-
standing of breast hypertrophy morbidity. Items
with an average relevance rating of less than 2 of
5 were considered problematic.
Construct validity is a stringent test in which
the questionnaire is evaluated as to how well it
performs according to a stated hypothesis. For
example, scores on a breast hypertrophy morbid-
ity questionnaire would be expected to improve
following surgical correction of this condition.
Construct validity was assessed by comparing pre-
operative and 6-month postoperative Breast Re-
duction Assessed Severity Scale scores for 23 par-
ticipants who ultimately underwent breast
reduction surgery. Paired two-tailed t tests were
used for the analysis. An ␣ level of less than 0.05
was considered statistically significant.
Criterion validity concerns the extent to
which the results of a questionnaire correlate
with previously validated questionnaires ad-
dressing the same concept. The Short Form-3614
and the Rosenberg Self-Esteem Scale15 have
both undergone extensive validation and use in
the clinical setting. Although the Breast-Related
Symptoms questionnaire has not been com-
pletely validated, it was included in our assess-
Volume 120, Number 5 • Morbidity in Breast Hypertrophy
ment of criterion validity because of its wide-
spread use, breast hypertrophy specificity, and
established construct validity.6 Pearson correla-
tion coefficients were measured between sub-
scales identified in the factor analysis and cor-
responding subscales in the Short Form-36.
Questions loading on the corresponding factors
were used in the analysis.
The demographic data were analyzed using
descriptive statistics. Ninety-five percent confi-
dence intervals were calculated when appropriate.
RESULTS
Five women from a group of 106 potential
subjects declined to participate, yielding a sample
of 101 female subjects. Average participant age was
37.7 years (range, 16 to 60 years). Fifty-seven per-
cent were married, with the remainder being sin-
gle (20 percent), divorced/separated (13 per-
cent), or living common-law (10 percent). The
majority (58 percent) was in the middle income
bracket, with 16 percent in the high-income
bracket (annual family income ⬎$75,000) and 13
percent in the lower income bracket (annual fam-
ily income ⬍$30,000); the remaining participants
declined to provide this particular information.
The most common education level obtained in-
cluded some form of university or technical school
training (45 percent), with 26 percent having com-
pleted at least a bachelor degree. The rest were
divided approximately equally among high school
graduates and nongraduates. The study sample
was predominantly Caucasian (93 percent), with
the remainder being African Canadian (4 per-
cent) or of other ethnic origin.
All participants satisfactorily completed the
Breast Reduction Assessed Severity Scale Ques-
tionnaire. None required elimination for acqui-
escence bias. All Breast Reduction Assessed Sever-
ity Scale items showed some degree of positive
skew, with none conforming to a normal distribu-
tion. One item covered a very limited range of the
Likert scale across subjects and was therefore ex-
cluded. Two items were discarded on the basis of
excessive skew. The Spearman correlation matri-
ces revealed significant relationships between
each individual item with other items in the ques-
tionnaire and none required elimination at this
step.
Factor Analysis
Analysis of the correlation matrix generated
by the factor analysis did not demonstrate any
singularity (multicollinearity). The Kaiser-Meyer-
Olkin measure of sampling accuracy was 0.791,
indicating an acceptable sample size.20 Bartlett’s
test of sphericity was highly significant, indicating
that the R matrix was not an identity matrix, thus
permitting the use of factor analysis. Kaiser-Meyer-
Olkin values in the anti-image correlation matrix
were all found to be well above 0.5. Only 24 per-
cent of the values in the residual matrix were
greater than 0.05, suggesting that the factor model
was reasonable.
Orthogonal and oblique rotations were per-
formed. The oblique oblimin rotation with Kaiser
normalization showed a component correlation
matrix, suggesting dependence between factors
(the maximum correlation was 0.339 between fac-
tors, with an average of 0.21). The oblique oblimin
rotation was therefore preferred.
The Scree plot generated by the oblique ob-
limin rotation suggested that five factors were ap-
propriate for rotation. All eigenvalues were greater
than 1. Each item loaded on at least one factor at
a level exceeding 0.32 and therefore none required
removal. The five-factor solution (Table 1) ac-
counted for 50.7 percent of the variability. The num-
ber of items loading on each factor was relatively
even, with 78 percent of items loading on factors
other than body pain.
The factor analysis enabled division of the
Breast Reduction Assessed Severity Scale Ques-
tionnaire into five conceptual subdomains: (1)
physical implications, (2) poor self-concept, (3)
body pain, (4) negative social interactions, and (5)
physical appearance. Mean subdomain scores in-
dicate that the physical implications, poor self-
concept, body pain, and physical appearance sub-
scales affected women more or less equally,
whereas negative social interactions was consid-
ered less problematic (Table 2).
Reliability Analysis
Internal Consistency
Means, standard deviations, and ceiling and
floor effects were calculated for each category de-
termined through the factor analysis (Table 2).
Table 1. Factor Table
Factor No. of Questions
No. Factor Loading*
1 Physical implications 13
2 Poor self-concept 10
3 Body pain 12
4 Negative social interactions 10
5 Physical appearance 10
*Loading at the ⬎0.35 level, all factors had eigenvalues greater than
1. Some questions loaded on more than one factor.
1111
 Plastic and Reconstructive Surgery • October 2007

Table 2. Descriptive Statistics and Reliability Estimates for the BRASS Questionnaire
No. of Internal Test-Retest
Items in Consistency Intraclass
Scale Subscale Mean SD Floor (%)* Ceiling (%)† Reliability Correlation‡
Physical implications 13 3.83 1.31 21.5 26.2 0.86 0.78
Poor self-concept 5 3.81 1.23 7.5 36.8 0.90 0.69
Body pain 8 3.83 1.31 10.1 40.6 0.72 0.79
Negative social interactions 6 2.96 1.53 25.6 23.6 0.85 0.76
Physical appearance 7 4.06 1.24 7.4 52.1 0.73 0.74
BRASS, Breast Reduction Assessed Severity Scale.
*Floor effect: the percentage of respondents who receive the lowest possible score such that repeated application of the test would not show
any change even if the patient clinically deteriorated.
†Ceiling effect: the percentage of respondents who receive the highest possible score such that repeated application of the test would not show
any change even if the patient clinically improved.
‡Mean test-retest interval, 29 days.

Ceiling and floor effects represent the percentage 1.0. Only the questions exploring alterations in
of respondents who receive the lowest and highest dietary habits and difficulties finding appropriate
scores, respectively (Table 2). Three additional footwear had ratings of less than 2 of 5, indicating
questionnaire items were eliminated based on low discordance with the focus group results.
item-total ␣ coefficients. The ␣ coefficient for the Criterion Validity
remaining 39 items was 0.93 (␣ coefficients ⬎0.90 With the exception of the negative social in-
indicate excellent internal reliability, whereas co- teractions subscale, each Breast Reduction As-
efficients in the range 0.70 to 0.90 indicate ac- sessed Severity Scale subscale showed moderate
ceptable reliability for most research purposes).21 though significant correlations with conceptually
Stability (Test-Retest) similar subscales from the Short Form-36 (Table
Seventy-five percent of participants submitted 3). Similarly, the poor self-concept subscale of the
the repeat Breast Reduction Assessed Severity Breast Reduction Assessed Severity Scale Ques-
Scale Questionnaire administered to determine tionnaire showed moderate correlation with the
test-retest reliability. Three of these question- Rosenberg Self-Esteem Scale (which is not com-
naires were incomplete, yielding an effective re- posed of separate subscales). The Breast Reduc-
sponse rate of 72 percent. The average time be- tion Assessed Severity Scale summary score corre-
tween the initial and repeat testing was 29.2 ⫾ 9.9 lated strongly with the total Breast-Related
days. The Pearson correlation was 0.865 (p ⬍ Symptoms score (0.834, p ⬍ 0.0001).
0.001) and the more conservative intraclass cor- Construct Validity
relation coefficient was 0.853 (95 percent confi- The questionnaire showed very strong con-
dence interval, 0.776 to 0.905; p ⬍ 0.0001) for the struct validity. Postoperative scores were signifi-
entire questionnaire. Intraclass correlations for cantly and markedly improved across all of the
each subdomain are listed in Table 2; correlation
coefficients of greater than 0.70 are generally ac-
ceptable for group comparisons in clinical trials Table 3. Factor Correlations with the Short Form-36
and other clinical studies.22 Interestingly, there and Rosenberg Self-Esteem Scales*
were significant improvements in the physical im- Pearson
plications, poor self-concept, and body pain sub- Comparison Correlation p
domains (Wilcoxon signed ranks test, p ⬍ 0.004) Physical functioning (SF-36) and
over the test-retest period. physical implications 0.518 ⬍0.001
Physical health summary score
(SF-36) and physical
Validity Testing implications 0.446 ⬍0.001
Content Validity Bodily pain (SF-36) and body
pain 0.517 ⬍0.001
Content validity is secured primarily by the fact Social functioning (SF-36) and
that the Breast Reduction Assessed Severity Scale negative social interactions 0.273 ⬍0.006
Questionnaire was derived from focus groups con- Mental health (SF-36) and poor
sisting of women with breast hypertrophy. Content self-concept 0.432 ⬍0.001
Rosenberg Self-Esteem Scale and
validity was strengthened by having the question- poor self-concept 0.454 ⬍0.001
naire items reviewed by 11 plastic surgeons. The SF-36, Short Form-36.
average relevance rating of all 45 items was 3.5 ⫾ *n ⫽ 101 for all comparisons.

1112
Volume 120, Number 5 • Morbidity in Breast Hypertrophy
70
60
50
40
Score
30
20
10
0 subdomains, internal consistency and stability
PI NSI PSC PA BP BRASS
Pre-op Post-op
Fig. 1. Construct validity: preoperative and postoperative
Breast Reduction Assessed Severity Scale (BRASS) scores. Error
bars represent SEM. PI, physical implications; NSI, negative social
interactions; PSC, poor self-concept; PA, physical appearance; BP,
body pain.
subdomains measured (Fig. 1). Almost complete
resolution of breast-related symptoms was realized
following reduction surgery in the 23 patients who
had the procedure.
The final Breast Reduction Assessed Severity
Scale Questionnaire was composed of 39 items
of an initial catalogue of 45 items. The ques-
tionnaire includes these items plus three re-
verse-worded items to allow detection of acqui-
escence bias (see Appendix, Supplemental
Digital Content 1, the Breast Reduction Assessed
Severity Scale Questionnaire, http://links.lww.
com/A54). The questionnaire’s scoring algo-
rithms and weightings can be found in Appen-
dices, Supplemental Digital Content 2 and 3
(http://links.lww.com/A55 and http://links.lww.
com/A56), respectively. A downloadable copy of
the questionnaire (Microsoft Word) and scoring al-
gorithms (Microsoft Excel) are also available at
http://web.mac.com/lsigurdson.
DISCUSSION
The findings of this investigation provide sup-
port for the reliability and validity of a new method
(Breast Reduction Assessed Severity Scale Ques-
tionnaire) for measuring the burden of breast hy-
pertrophy. Our results indicate that the experi-
ence of having breast hypertrophy is multifaceted
and can be categorized into separate but interre-
lated conceptual subdomains: (1) physical impli-
cations, (2) poor self-concept, (3) body pain, (4)
negative social interactions, and (5) physical ap-
pearance. The fact that each subdomain was rep-
resented more or less equally, as reflected by the
questionnaire scores, broadens the scope of this
assessment device and represents an improvement
over existing measures that focus almost exclu-
sively on pain.9
The internal consistency (a measure of reli-
ability) of the Breast Reduction Assessed Severity
Scale Questionnaire was excellent such that each
item consistently drew from the overall experi-
ence of breast hypertrophy. With respect to indi-
vidual Breast Reduction Assessed Severity Scale
over time were less favorable, suggesting that the
questionnaire should be used in its entirety rather
than administered by subdomain.
The establishment of validity was of para-
mount importance in this study. The Breast Re-
duction Assessed Severity Scale Questionnaire
demonstrates content validity because the items
were created by women who suffer from the con-
dition in question, with subsequent confirmation
by expert surgeons. The fact that criterion validity
was only moderate in strength was not unexpected
because neither the Short Form-36 nor the Rosen-
berg Self-Esteem Scale was designed with breast
hypertrophy patients in mind. In fact, the lack of
a target population is one of the main features that
differentiate these instruments from the Breast
Reduction Assessed Severity Scale Questionnaire.
Inherent differences in conceptual categories
across the different questionnaires may thus rep-
resent an unavoidable obstacle to the establish-
ment of true criterion validity. The importance of
the Breast Reduction Assessed Severity Scale Ques-
tionnaire’s strong construct validity cannot be
overemphasized. The marked effect sizes detected
in all of the subdomains bode well for its use in the
perioperative setting.
Several limitations should be noted. Our sam-
ple size was on the lower side of what is considered
acceptable for assessing scale reliability; replica-
tions with larger samples would strengthen our
findings.17 Furthermore, the relative homogeneity
of subjects used in this study should be kept in
mind when administering the Breast Reduction
Assessed Severity Scale Questionnaire to patients
outside of the Caucasian, educated, and middle
class socioeconomic demographic. Given the ab-
sence of a measure of social desirability bias, the
degree to which responses were influenced by the
desire to score highly on the scale is unknown.
Improvements observed over the test-retest period
may have occurred on the basis of exaggerated
1113
 Plastic and Reconstructive Surgery • October 2007
subject responses before being seen in consulta-
tion. However, in a prospective attempt to mitigate
this effect, subjects were clearly informed that the
questionnaire would not be used to determine
eligibility for surgery. The 30-day test-retest inter-
val was longer than the generally recommended
14-day period.17 Ideally, the second administration
should have been performed before the subject
was first seen in consultation, as knowledge of
their eligibility status (which is acquired during
this visit) may have introduced bias. Rectification
of these limitations would likely have improved
the already acceptable intraclass correlation co-
efficients. In contrast, significant improvements
observed in the physical implications, poor self-
concept, and body pain subdomains over the
4-week test-retest period may represent addi-
tional evidence of construct validity (clinical
responsiveness).
At this point, the Breast Reduction Assessed
Severity Scale Questionnaire is recommended for
assessing changes in a given individual’s breast-
related health. Further study should enable its use
as a discriminative index in evaluating the need for
breast reduction surgery.
CONCLUSIONS
We have developed a questionnaire for eval-
uating symptom burden in women with breast hy-
pertrophy. Compared with existing measures of
morbidity, the Breast Reduction Assessed Severity
Scale Questionnaire is specific to breast hypertro-
phy and has more to offer in terms of scope and
psychometric rigor. The questionnaire may pro-
vide objectivity and consistency in the compre-
hensive assessment of breast reduction patients,
thereby serving as a useful adjunct to the surgeon’s
clinical judgment.
Leif J. Sigurdson, M.D., M.Sc., M.B.A.
4437-1796 Summer Street
New Halifax Infirmary
Queen Elizabeth II Health Sciences Centre
Halifax, Nova Scotia B3H 3A7, Canada
leif.sigurdson@dal.ca
ACKNOWLEDGMENT
This work was funded by a Canadian Society of
Plastic Surgery outcomes grant and by the Nova Scotia
Health Research Foundation.
DISCLOSURE
None of the authors has any financial or commercial
interest in anything arising from this study.
1114
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 BREAST

Immediate Nipple Reconstruction on a Free

TRAM Flap Breast Reconstruction
Eric H. Williams, M.D.
Lawrence Z. Rosenberg,
M.D.
Paul Kolm, Ph.D.
Jorge I. de la Torre, M.D.
R. Jobe Fix, M.D.
Birmingham, Ala.; and Newark, Del.
Background: Reconstruction of the nipple-areola complex is usually deferred
until breast mound reconstruction is complete. The authors review their ex-
perience with a technique that allows for shaping of a free transverse rectus
abdominis myocutaneous (TRAM) flap and immediate nipple reconstruction
and compare this technique with delayed nipple reconstruction.
Methods: A retrospective chart review demonstrated 21 patients who under-
went immediate nipple reconstruction, 10 of whom had complete photographs
and records for review. Ninety patients underwent delayed nipple reconstruc-
tion. Twenty of these patients were chosen for comparison, 15 of whom had
complete photographs and records. Age, body mass index, comorbidities, pro-
cedures required, complications, and time to completion were reviewed. A
multiobserver, multicharacteristic, standardized photographic review of cos-
metic outcomes was conducted.
Results: Time from mastectomy to completion of reconstruction, not including
areolar tattooing, was 1 day (median) versus 125 days (median) in the immediate
and delayed groups, respectively (p ⫽ 0.003). The number of procedures re-
quired to complete reconstruction before areolar tattooing was one (median)
in the immediate group and two (median) in the delayed group (p ⬍ 0.001).
Complication rates were similar in both groups. Subjective review demonstrated
no difference in the aesthetic outcome of the breast mound or nipple-areola
complex reconstruction.
Conclusions: Patients having immediate nipple reconstruction in the setting of
a free TRAM breast reconstruction completed their reconstruction earlier,
required fewer procedures, and had aesthetic results comparable to patients
having traditional delayed nipple reconstruction. Complications and revision
rates were comparable. (Plast. Reconstr. Surg. 120: 1115, 2007.)

R
econstruction of an aesthetic breast after
mastectomy requires creation of both the
breast mound and the nipple-areola com-
plex. The transverse rectus abdominis myocu-
taneous (TRAM) flap has been a cornerstone
of breast reconstruction since its description
by Hartrampf et al.1,2 The free TRAM flap and
its various modifications give additional recon-
structive options with autologous tissue.3–7
From the Department of Surgery, Division of Plastic Surgery,
University of Alabama at Birmingham, and the Christiana
Center for Outcomes Research.
Received for publication May 17, 2006; accepted August 15,
2006.
Presented in part in abstract form at the American Society of
Reconstructive Microsurgery Annual Scientific Meeting, in
Tucson, Arizona, January 14 through 17, 2006, and at the
American Society of Plastic Surgeons Senior Resident Con-
ference, in Arlington, Virginia, March 23 through 25, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279142.46729.94
Many techniques have been used to recon-
struct the nipple-areola complex. The nipple can
be preserved,8,9 shared,10,11 or reconstructed with
local12–29 or distant tissues.30 –32 Areola restoration
has been accomplished by preservation, 8,9
sharing, 33 full-thickness skin grafts, 33–36 or
tattooing.37– 43
With few exceptions, reconstruction of the
nipple-areola complex has been reported as a
separate procedure subsequent to primary re-
construction of the breast mound.9,44 – 46 Colen46
introduced the concept of immediate nipple re-
construction with a bilobed flap created from a
dog-ear of redundant tissue on a folded free
TRAM flap. His work forms the foundation of
our study.
Our report compares the preliminary results
of patients who have undergone immediate or
delayed nipple reconstruction in the setting of a
free TRAM flap. All patients underwent delayed
areolar tattooing.

www.PRSJournal.com 1115
 Plastic and Reconstructive Surgery • October 2007
PATIENTS AND METHODS
Institutional review board approval was obtained
for a medical record review of breast reconstruction
patients operated on at the University of Alabama at
Birmingham. Chart review demonstrated 129 pa-
tients who had undergone breast reconstruction
with a free TRAM flap by the senior author (R.J.F.)
between November 1, 2000, and April 5, 2005. Twenty-
one of these patients underwent immediate nip-
ple reconstruction; 10 of these patients had com-
plete records, including adequate postoperative
photographs. Of the remaining 108 patients, 90
underwent delayed nipple reconstruction. Twenty
patients were blindly selected to provide a repre-
sentative comparison. Fifteen of these 20 patients
had complete records, including adequate post-
operative photographs.
Covariates including age, body mass index,
medical comorbidities, type of nipple-areola com-
plex reconstruction, postoperative complications,
the number of operations required for complete
breast reconstruction, length of time until tattoo-
ing of areola, and length of follow-up were com-
piled in a Microsoft Office Access 2003 database
(Microsoft Corp., Redmond, Wash.). The number
of days required to complete reconstruction and
number of procedures were analyzed by means of
the nonparametric Mann-Whitney test.
Subjective Review
Evaluations of preoperative and postoperative
photographs were performed by nine health care
professionals (three medical students, two plastic
surgical residents, two plastic surgical allied health
professionals, and two board-certified plastic sur-
geons) not directly involved in care of the patients.
All evaluators were given the same standardized
photographs (frontal, lateral, and oblique) in the
same randomized order and were asked to com-
plete a multicomponent evaluation on each recon-
structed breast and nipple-areola complex. Judges
were asked to evaluate nipple-areola placement, nip-
ple projection, nipple size, breast mound projection,
breast mound symmetry, and overall breast recon-
struction on a scale of 1 (poor result) to 4 (excellent
result).
Data derived from judgments of the photo-
graphs were captured in Microsoft Office Excel
2003 and analyzed by linear mixed (random and
fixed) effects models for clustered data. Random
effects in the models were patients and judges; the
fixed effects were group and question (character-
istic). A group-by-question interaction effect was
also included. All available data were used in the
1116
analyses. Statistical analyses were performed using
Microsoft Office Excel 2003 with Anaylse-it, and
S-Plus, Version 7 (Insightful, Inc., Seattle, Wash.).
Surgical Technique
Free TRAM Flap with Delayed Nipple
Reconstruction
A contralateral free TRAM flap is harvested;
anastomosis of the inferior epigastric vessels is per-
formed to the internal mammary vessels. The rec-
tus muscle is secured to the chest wall with ab-
sorbable suture and then the whole flap is inset
into the breast defect with the tail of the flap (zone
3) in the axilla or vertically oriented. The dermis
of the TRAM is sutured to the chest wall. The
mastectomy skin flap is redraped and the buried
portion of the TRAM is deepithelialized. Con-
tralateral procedures are often performed con-
comitantly to improve breast symmetry.
Six to 8 weeks after the completion of breast
mound reconstruction or after completion of any
additional chemotherapy and radiation therapy,
nipple reconstruction is performed. Other revi-
sions to the abdomen or breast mound are per-
formed as indicated. The areola is created by in-
tradermal tattooing 6 to 8 weeks after nipple
reconstruction.
Free TRAM Flap with Immediate Nipple
Reconstruction
A contralateral free TRAM flap is harvested
and anastomosis is performed in the same way as
described above. The flap is positioned such that
the rectus abdominis muscle lies transversely
across the chest wall with the tail of the flap (zone
3) in the axilla, the periumbilical border oriented
laterally, and the trimmed edge of the flap (zone
2) oriented inferiorly (Fig. 1).
Enhanced flap projection is created by wrap-
ping the flap into a conical shape. In unilateral
procedures, thin flaps usually wrap well when the
apex of the fold is placed in the umbilical margin.
This will place the fold in the 6-o’clock to 9-o’clock
position for right breast reconstruction and in the
3-o’clock to 6-o’clock range for left breast recon-
struction (Fig. 1). Once the flap is wrapped and
folded, the apex of the cone will become the apex
of the breast and subsequently the location of the
nipple-areola complex. Symmetry is optimized by
comparing the two different sides. The redundant
skin adjacent to the folded crease (periumbilical
skin) is temporarily imbricated with staples to pro-
vide a smooth breast contour and to adjust the
point of maximum projection to the desired po-
sition (Fig. 2). The edges of the imbricated tissue
Volume 120, Number 5 • Immediate Nipple Reconstruction
Fig. 1. (Above) Positioning of a unilateral free TRAM flap. Roman
numerals mark the flap zones. A contralateral free TRAM flap is
anastomosed to the internal mammary vessels. The flap is placed
on the chest wall so that the tail of the flap (zone 3) lies in the axilla.
This places the rectus muscle transversely across the chest wall,
where it is sutured carefully in place. The periumbilical border is
oriented laterally. The trimmed edge of the flap (zone 2) will lie
along the inferior mammary fold. (Below) The breast shape and
excess tissue for nipple reconstruction are created by wrapping
the flap into a cone. The flap is wrapped along the umbilical mar-
gin. This places the crease in the 6-o’clock to 9-o’clock position for
right breast reconstruction and in the 3-o’clock to 6-o’clock range
for left breast reconstruction. *Umbilical margin.
are marked with methylene blue. When the staples
are released, a wedge of redundant tissue is re-
vealed that can be fashioned into a bilobed fishtail
flap for nipple reconstruction (Fig. 2).
To fashion the nipple, the common base of the
bilobed fishtail flap is designed to measure 150
percent of the base width of the normal nipple to
allow for atrophy of the reconstruction. The bi-
lobed fishtail flap is elevated with a thin layer of fat
that deepens at the common base of the two limbs.
The skin edges from the flap harvest site are ap-
proximated to provide a solid platform for the
reconstructed nipple, and the circular base on
which the nipple will rest is deepithelialized. One
limb wraps circumferentially to form the cylindri-
cal post of the nipple and the other limb folds over
the top to form the lid. The flaps are secured with
absorbable suture (Fig. 2).
Finally, the buried portion of the TRAM flap
is deepithelialized, and the TRAM is inset into the
mastectomy skin defect. Simultaneous contralat-
eral procedures including breast augmentation,
reduction mammaplasty, or mastopexy are per-
formed during the initial operation to facilitate
immediate symmetry.
In bilateral cases, the flaps are smaller and
zone 2 is not available. Therefore, to cone the
TRAM flap for bilateral cases, the folded edge is
placed in the middle of the cut edge of zone 1.
When the TRAM is inset, the fold will be oriented
more vertically in the 5- to 7-o’clock range to en-
sure adequate positioning of the breast mound on
the chest wall (Fig. 3).
The goal is to complete the entire surgical
reconstruction and contralateral symmetry proce-
dures during the first operation. Subsequent in-
tradermal tattooing of the areola in the office 6 to
8 weeks later completes the reconstructed breast.
RESULTS
Ten patients underwent immediate nipple re-
construction on 12 free TRAM flaps (eight uni-
lateral; two bilateral). Ten flaps were immediate
free TRAM flaps (10 of 12), and two flaps were
delayed free TRAM flaps (two of 12). Eleven of the
immediate nipple reconstructions were per-
formed using a fishtail flap and one using a tri-
lobed star flap. Eleven areolae were tattooed; one
patient did not have areola reconstruction. The
mean patient age was 53.7 years (range, 44.1 to
61.4 years). The mean body mass index was 23.8
kg/m2 (range, 19.3 to 28.5 kg/m2). Comorbidities
included hypertension [n ⫽ 2 (20 percent)].
Fifteen patients underwent traditional delayed
nipple reconstruction on 17 breast reconstruc-
tions (13 unilateral and two bilateral). Thirteen
were immediate free TRAM flaps (13 of 17) and
four were delayed free TRAM flaps (four of 17).
Sixteen reconstructions were performed using a
trilobed star flap; one was performed with a fishtail
flap. Sixteen areolae were tattooed; one patient
did not pursue areola reconstruction. The mean
patient age was 52.9 years (range, 39.5 to 67.1
years). The mean body mass index was 28.0 kg/m2
(range, 21.3 to 37.1 kg/m2) (unpaired t test, p ⫽
0.02) Comorbidities in seven of the 15 patients (47
1117
 Plastic and Reconstructive Surgery • October 2007

Fig. 2. Nipple reconstruction technique. (Above, left) Once the flap is wrapped and folded, the apex of the cone will
become the apex of the breast and subsequently the location of the nipple-areola complex. The skin adjacent to the
folded crease (periumbilical skin) is temporarily imbricated with staples to provide a smooth breast contour and to
adjust the point of maximum projection. The edges of the imbricated tissue are marked with methylene blue. (Above,
right) The staples are released to reveal a wedge of redundant tissue. (Center, left) A bilobed fishtail flap is elevated
with a thin layer of fat that deepens at the base. (Center, right) The skin edges from bilobed flap harvest site are
approximated to provide a solid platform for the reconstructed nipple. The true base on which the nipple will rest
is deepithelialized. One limb wraps circumferentially to form the cylindrical post of the nipple and the other limb
folds over the top to form the lid. The flaps are secured with absorbable suture. (Below) Final intraoperative nipple
size and projection are demonstrated.

1118
Volume 120, Number 5 • Immediate Nipple Reconstruction

Table 1. Patient Characteristics

Nipple Reconstruction

Immediate Delayed
No. of patients 10 15
Breasts reconstructed 12 17
Immediate TRAM flap 10 13
Delayed TRAM flap 2 4
Age, years
Mean 53.7 52.9
Range 44.1–61.4 39.5–67.1
Race
White 9 13
Black 1 1
Hispanic 0 1
Body mass index, kg/m2
Mean 23.8 28.0
Range 19.3–28.5 21.3–37.1
Type of nipple reconstruction
Fishtail flap 11 1
Trilobed flap 1 16
Areola eventually tattooed (%) 11 (91.6) 16 (94.1)
Comorbidities (%) 2 (20) 9 (47)
Hypertension 2 5
Morbid obesity 0 4
Diabetes mellitus 0 1
Coronary arterial disease 0 1
Chronic obstructive
pulmonary disease 0 1
Current smoker 0 2
Contralateral procedures for
symmetry (%) 3 (38) 9 (69)
Augmentation 2 1
Mastopexy 1 4
Fig. 3. Shaping the breast mound for bilateral cases. (Above) To Reduction 0 4
cone the TRAM flap for bilateral cases, the fold is placed in the
middle of the cut edge of zone 1. The crease will be oriented more
vertically in the 5- to 7-o’clock range to ensure adequate posi-
tioning on the chest wall. The nipple is then created the same way riod of time. The median number of days required
as demonstrated in Figure 2. (Below) Markings for TRAM flap har- to complete the reconstruction, not including tat-
vest. The flaps are smaller and zone 2 is not available. tooing, was 1 day in the immediate group and 125
days in the delayed group (p ⫽ 0.003, Mann-Whit-
ney test). Immediate nipple reconstruction also
percent) included morbid obesity [body mass shortened the overall reconstructive process with
index ⬎30 kg/m2) (n ⫽ 4 (27 percent)], diabetes a median of 104 days when compared with 193
[n ⫽ 1 (6.7 percent)], hypertension [n ⫽ 5 (33.3 days in the delayed group (p ⫽ 0.03, Mann-Whit-
percent)], coronary artery disease [n ⫽ 1 (6.7 ney test) (Table 2).
percent)], chronic obstructive pulmonary disease Patients with immediate nipple reconstruction
[n ⫽ 1 (6.7 percent)], and concurrent tobacco use required fewer procedures to complete their recon-
[n ⫽ 2 (13.3 percent)] (Table 1). struction. Six patients undergoing immediate nipple
Three of eight (37.5 percent) of the immedi- reconstruction required only one operative proce-
ate nipple reconstruction group required a con- dure before tattooing; four patients required two
tralateral procedure to enhance symmetry, includ- procedures. The calculated median was one proce-
ing augmentation mammaplasty (n ⫽ 2) and dure. Thirteen patients with delayed nipple recon-
mastopexy (n ⫽ 1). Nine of 13 patients (69 per- struction required two procedures, one required
cent) of the delayed nipple reconstruction group three procedures, and one required four proce-
required contralateral procedures for symmetry, dures before tattooing. The calculated median was
including augmentation mammaplasty (n ⫽ 1), two procedures. These were significantly different
mastopexy (n ⫽ 4), and reduction mammaplasty (p ⬍ 0.001, Kruskal-Wallis test) (Table 2).
(n ⫽ 4) (Table 1). Complication rates concerning the nipple-are-
Patients with immediate nipple reconstruc- ola reconstruction were similar between the two
tion finished their reconstruction in a shorter pe- groups. Three of the 12 (25 percent) immediate

1119
 Plastic and Reconstructive Surgery • October 2007

Table 2. Days and Procedures Required for only one nipple-areola complex out of 13 under-
Reconstruction went revision because of flattening of the nipple
Nipple post. If we combine these data, then we get a total
Reconstruction of four of 25 (16 percent) that required revision.
after TRAM Flap No patient who underwent immediate nipple re-
construction required revision of the nipple-are-
Immediate Delayed p
ola complex due to malpositioning. In the delayed
Days required for nipple reconstruction group, two of 17 nipples
reconstruction
Without tattooing, had to be repeated due to flattening, and one was
no. of days 0.003* repositioned; this gave a revision rate of three of
Median 1 125 17 (17.6 percent). There were no TRAM flap
Range 1–403 77–410
Including tattooing losses in either group.
and subsequent
procedures 0.03* Subjective
Median 104 193
Range 60–442 122–742 Analysis of the subjective photographic review
Procedures comparing outcomes of immediate and delayed
required for nipple reconstructions demonstrated no statistical
reconstruction
Before tattooing ⬍0.001† difference in any characteristic. There was, how-
Median 1.0 2.0 ever, a significant difference in ratings among cer-
Range 1–2 1–3 tain groupings of questions (p ⫽ 0.021) (Table 3).
Including tattooing
and subsequent A range of postoperative outcomes for patients
procedures 0.008† who had immediate nipple reconstruction are
Median 2.5 3.0 demonstrated in Figures 4 through 6.
Range 1–4 2–6
*Mann-Whitney nonparametric.
†Kruskal-Wallis nonparametric analysis of variance.
DISCUSSION
The goals of breast reconstruction include
the recreation of the breast mound and the
nipple reconstructions were repeated because of nipple-areola complex using reliable, reproduc-
loss of projection. Retrospective review does not ible, and predictable methods while minimiz-
provide enough information to determine the ing the number of procedures, inconvenience,
cause of the loss of projection (immediate necro- costs, and morbidity. The TRAM flap and its
sis, slow atrophy, or a combination). When we modifications are a cornerstone of breast
examined the 11 other patients who had imme- reconstruction.1,3,4,47–52 Breast mound and nip-
diate nipple reconstruction, but could not be eval- ple-areola complex reconstruction with autolo-
uated for symmetry because of the lack of ade- gous tissue is most often performed in multiple
quate standardized photographs, we found that operations.53,54 Several authors have described

Table 3. Photograph-Based Subjective Assessment

Nipple Reconstruction after TRAM Flap Surgery
Characteristic
Combined Delayed
Grouping Individual Delayed Immediate p* and Immediate p†
1 Areola color 2.50 ⫾ 1.03 2.29 ⫾ 1.40 NS 2.41 0.021†
2 Projection 2.84 ⫾ 1.03 2.68 ⫾ 0.95 NS 2.77
3 Nipple shape 2.96 ⫾ 0.93 2.97 ⫾ 0.84 NS 2.97
Nipple size 3.00 ⫾ 0.90 3.12 ⫾ 0.81 NS 3.05
Scarring 3.08 ⫾ 0.92 3.06 ⫾ 0.77 NS 3.07
Overall reconstruction 3.11 ⫾ 0.73 3.18 ⫾ 0.74 NS 3.14
Breast mound symmetry 3.12 ⫾ 0.75 3.20 ⫾ 0.72 NS 3.15
4 NAC placement 3.25 ⫾ 0.70 3.24 ⫾ 0.69 NS 3.25
Breast mound projection 3.29 ⫾ 0.67 3.42 ⫾ 0.63 NS 3.34
Combined 3.04 ⫾ 0.87 3.05 ⫾ 0.89 0.994‡
NAC, nipple-areola complex; NS, not significant.
All analyses used nonparametric methods.
*Wilcoxon rank-sum test for differences between groups (delayed vs. immediate) for each individual characteristic.
†For differences in ratings among questions.
‡For combined differences between groups (delayed vs. immediate).

1120
Volume 120, Number 5 • Immediate Nipple Reconstruction
Fig. 4. The patient in case 1 had undergone delayed right free
TRAM flap surgery with immediate nipple reconstruction after
failed implant reconstruction in the setting of irradiation. No pro-
cedures were performed on the contralateral side. She scored an
average rating of 3.0 for overall breast and nipple reconstruction.
Her score was near the bottom of the scores.
their experience with single-step breast and nip-
ple-areola complex reconstruction.9,21,44 – 46,55
Colen46 described the immediate reconstruc-
tion of the nipple with a bilobed fishtail flap on a
free TRAM flap. His technique uses a contralateral
free TRAM flap with anastomosis to the thora-
codorsal vessels rather than the internal mammary
artery. We feel that anastomosis to the internal
mammary artery is technically easier, and the risk
of damage to the pedicle in the event of an un-
planned axillary dissection is virtually nonexistent.
When anastomosis is performed to the thora-
codorsal vessels rather than the internal mammary
artery, the umbilical margin of the TRAM is sub-
sequently placed in the inferior medial position, as
opposed to the inferior lateral position. Subse-
quently, the surgeon may have to wrap the TRAM
flap along a different axis to make a cone.
Fig. 5. The patient in case 2 had undergone bilateral immediate
free TRAM flap surgery with bilateral immediate nipple recon-
struction. She scored an average rating of 3.1 for overall breast
and nipple reconstruction. Her score was just below the average
score.
Projection of the breast mound is related to
the thickness of the TRAM flap in its most central
portion. Projection can be increased by wrapping
the flap and constricting the conical base “similar
to the making of a dunce cap.”46 It is to be stressed
that it may be impossible to “cone” the TRAM of
an obese patient because the flap may be too thick,
and folding it may compromise the blood flow.
This correlates with the fact that the delayed nip-
ple reconstruction group in our patient cohort
had a higher body mass index.
Colen46 stresses the importance of securing
the TRAM flap to the chest wall before redraping
the mastectomy skin over the reconstruction. We
agree with this principle, as this step is crucial in
stabilizing the shape and position of the breast
mound reconstruction and creates a stable base
on which to position the nipple-areola complex.
1121
 Plastic and Reconstructive Surgery • October 2007
Fig. 6. The patient in case 3 had undergone immediate left uni-
lateral free TRAM flap surgery with immediate nipple reconstruc-
tion. She also underwent a delayed right breast implant for sym-
metry. She scored an average rating of 3.4 for overall breast and
nipple reconstruction. Her score was above the average score.
Charanek and colleagues55 describe their tech-
nique of breast reconstruction using a bipedicled
TRAM flap and inclusion of the umbilical scar as
an immediate nipple reconstruction. Projection of
the breast mound is achieved by coning the bi-
pedicled TRAM flap and by folding the deepithe-
lialized lateral corner of the TRAM flap and a
separate pair of supraumbilical fat flaps under-
neath the TRAM to support the breast cone and
prevent its collapse. Their breast mound does ap-
pear to have good projection using this method;
however, the intentional sacrifice of the umbilicus
for nipple reconstruction is not ideal.
Hudson et al.9,45 performed a mound recon-
struction with a pedicled TRAM flap.45 Immediate
nipple reconstruction was performed with a local
C-V flap in zone 2 of the TRAM; it was then deepi-
thelialized and covered with a full-thickness skin
1122
graft from the contralateral areola, ipsilateral are-
ola, or the discarded TRAM flap skin.45 Seven of 17
patients had complications involving the nipple-
areola complex. Two suffered complete loss of
nipple and graft because of superficial infection,
four others had partial loss of the skin grafts, and
one had severe depigmentation.45 Furthermore,
the oncologic safety of ipsilateral areolar grafts is
still not proven in this small short-term study.45
Beegle44 described immediate TRAM flap
and nipple-areola reconstruction on free TRAM
flaps, though he gives little mention as to his
preferred technique of nipple reconstruction.
He does stress that there is a learning curve.44
We agree with his statement that “A wonderful
breast mound can be spoiled by a mediocre
nipple-areola reconstruction.”44 Close attention
to detail and intraoperative planning are essen-
tial to a good cosmetic outcome. We also feel
that if the shape and position of the breast
mound reconstruction is not ideal during the
initial operation, nipple reconstruction should
be delayed.
Although we demonstrate nipple reconstruc-
tion with bilobed flap fashioned from redundant
tissue, one could very likely safely perform recon-
struction of the nipple with a variety of other well-
known local flap choices. If visible dermal bleed-
ing is not seen when one lifts the flaps, one should
abandon the nipple reconstruction and evaluate
the vascular anastomosis. If immediate nipple re-
construction fails, one can return to the tradi-
tional reconstructive paradigm— delayed nipple-
areola complex reconstruction. The subjective
review demonstrated that nipple projection and
size received the two lowest scores of the charac-
teristics evaluated. This emphasizes the need to
make the initial reconstruction larger than the
contralateral side to make up for the expected
atrophy of 40 to 60 percent.
We prefer to reconstruct the areola with a
tattoo. It is safe, fast, and can easily be repeated.
Furthermore, there is no donor site, and it is painless
on the reconstructed mound.10 It should be noted
that “nipple color match” was ranked lowest of all the
characteristics in our study. This may point out the
general tendency for tattoo fading and irregular up-
take of pigments, difficulty with matching the color
pigment to native nipple color, suboptimal tattooing
technique, or nonstandard photographic tech-
niques. Some have suggested tattooing the normal
areola to obtain a better color match.10 Our standard
practice has been to wait 6 to 8 weeks after the initial
operation to perform tattooing; however, others
have advocated immediate tattooing of the nipple
Volume 120, Number 5 • Immediate Nipple Reconstruction
reconstruction.21,41 It is possible that delaying the
areolar tattooing may reduce the potential psycho-
social benefits afforded by a complete single-stage
reconstruction.
Arguments for delaying nipple-areola com-
plex reconstruction focus on the difficulty of de-
termining the appropriate position of the nipple-
areola complex because of postoperative settling
and early postoperative breast mound asymme-
tries. However, in experienced hands, positioning
the neo–nipple-areola complex is straightforward
when a traditional skin-sparing mastectomy is per-
formed through a periareolar incision. The ideal
patient is one with bilateral skin-sparing mastec-
tomies. Furthermore, with the technique de-
scribed above, we feel that settling of the breast
mound is not a serious issue. We are encouraged
that positioning of the nipple-areola complex was
actually one of the highest ranked characteristics
in both the immediate and delayed nipple recon-
struction groups seen in Table 3. Longer follow-
up would be optimal to study the stability of our
results.
A well-performed single-stage breast and
nipple-areola complex reconstruction has sev-
eral advantages. The psychosocial issues sur-
rounding the patient with breast cancer requir-
ing mastectomy may be expected to improve if
an aesthetic breast reconstruction can be per-
formed more quickly and with fewer proce-
dures. Furthermore, efforts to complete breast
reconstruction safely and more efficiently may
decrease the financial burden on the health care
system and the individual patient.9,44 – 46,55
CONCLUSIONS
We believe that, in experienced hands, imme-
diate nipple reconstruction on a coned free
TRAM flap with a bilobed fishtail flap is possible.
As one gains experience, it can be reproducible,
aesthetically adequate, and safe. Reconstruction
may be completed sooner and with fewer proce-
dures. We also believe that the single-stage ap-
proach may be psychologically beneficial and cost
effective. Although our study cohort is small and
there are clear limitations to this retrospective
study, our preliminary results are encouraging.
Eric Howard Williams, M.D.
3333 North Calvert Street, Suite 370
Baltimore, Md. 21208
williamseb@gmail.com
ACKNOWLEDGMENT
The authors thank Willis H. Williams, M.D., for
assistance in preparation of this article.
DISCLOSURES
None of the authors has any conflict of interests to
declare, financial or otherwise. No source of commercial
funding or grant support has been received to support this
research or the preparation and submission of this article.
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nipple reconstruction. Plast. Reconstr. Surg. 68: 245, 1981.
33. Asplund, O. Nipple and areola reconstruction: A study in 79
mastectomized women. Scand. J. Plast. Reconstr. Surg. 17: 233,
1983.
34. Bogue, D. P., Mungara, A. K., Thompson, M., et al. Modified
technique for nipple-areolar reconstruction: A case series.
Plast. Reconstr. Surg. 112: 1274, 2003.
35. Tanabe, H. Y., Tai, Y., Kiyokawa, K., et al. Nipple-areola
reconstruction with a dermal-fat flap and rolled auricular
cartilage. Plast. Reconstr. Surg. 100: 431, 1997.
36. Brent, B. Nipple-areola reconstruction following mastecto-
my: An alternative to the use of labial and contralateral
nipple-areolar tissues. Clin. Plast. Surg. 6: 85, 1979.
37. Becker, H. The use of intradermal tattoo to enhance the final
result of nipple-areola reconstruction. Plast. Reconstr. Surg.
77: 673, 1986.
38. Becker, H. Nipple-areola reconstruction using intradermal
tattoo. Plast. Reconstr. Surg. 81: 450, 1988.
39. Bernard, R. W. Prereconstruction tattooing eliminates the
need for skin grafting in nipple-areola reconstruction. Plast.
Reconstr. Surg. 93: 1531, 1994.
1124
40. Fourie le, R., and Bruce-Chwatt, A. Professional tattooing;
alternative method to nipple reconstruction. Br. J. Plast. Surg.
57: 693, 2004.
41. Hugo, N. E., Sultan, M. R., and Hardy, S. P. Nipple-areola
reconstruction with intradermal tattoo and double-opposing
pennant flaps. Ann. Plast. Surg. 30: 510, 1993.
42. Kesselring, U. K. The use of intradermal tattoo to enhance
the final result of nipple-areola reconstruction. Plast. Recon-
str. Surg. 79: 303, 1987.
43. O’Donoghue, J. M., Clough, K. B., and Sarfati, I. Solving the
problem of color mismatch in nipple-areola reconstruction.
Plast. Reconstr. Surg. 104: 1936, 1999.
44. Beegle, P. H., Jr. Immediate single-stage TRAM and nipple-
areola reconstruction. Clin. Plast. Surg. 21: 321, 1994.
45. Hudson, D. A., and Skoll, P. J. Single-stage, autologous breast
restoration. Plast. Reconstr. Surg. 108: 1163, 2001.
46. Colen, L. B. One-stage reconstruction of the breast using
autologous tissue with immediate nipple reconstruction. In
S. Spear, J. W. Little, M. E. Lippman, and W. C. Wood (Eds.),
Surgery of the Breast: Principles and Art. Philadelphia: Lippin-
cott-Raven, 1998. Pp. 491–509.
47. Arnez, Z. M., Bajec, J., Bardsley, A. F., et al. Experience with
50 free TRAM flap breast reconstructions. Plast. Reconstr.
Surg. 87: 470, 1991.
48. DeBono, R., Thompson, A., and Stevenson, J. H. Immediate
versus delayed free TRAM breast reconstruction: An analysis
of perioperative factors and complications. Br. J. Plast. Surg.
55: 111, 2002.
49. Elliott, L. F., Eskenazi, L., Beegle, P. H., Jr., et al. Immediate
TRAM flap breast reconstruction: 128 consecutive cases.
Plast. Reconstr. Surg. 92: 217, 1993.
50. Feller, A. M., Horl, H. W., and Biemer, E. The transverse
rectus abdominis musculocutaneous free flap: A reliable al-
ternative for delayed autologous tissue breast reconstruction.
Ann. Plast. Surg. 25: 425, 1990.
51. Grotting, J. C., Urist, M. M., Maddox, W. A., et al. Conven-
tional TRAM flap versus free microsurgical TRAM flap for
immediate breast reconstruction. Plast. Reconstr. Surg. 83:
828, 1989.
52. Grotting, J. C. Immediate breast reconstruction using the
free TRAM flap. Clin. Plast. Surg. 21: 207, 1994.
53. Maxwell, G. P., and Andochick, S. E. Secondary shaping of
the TRAM flap. Clin. Plast. Surg. 21: 247, 1994.
54. Chang, B. W. Shaping the autologous breast. Clin. Plast. Surg.
25: 223, 1998.
55. Charanek, A. M., Carramaschi, F. R., and Curado, J. H. Re-
finements in transverse rectus abdominis myocutaneous flap
breast reconstruction: Projection and contour improve-
ments. Plast. Reconstr. Surg. 106: 1262, 2000.
 BREAST

Surveillance Mammography following the

Treatment of Primary Breast Cancer with Breast
Reconstruction: A Systematic Review
G. Philip Barnsley, M.D.
Eva Grunfeld, M.D., D.Phil.
Douglas Coyle, Ph.D.
Lawrence Paszat, M.D., M.Sc.
Halifax, Nova Scotia, and Ottawa
and Toronto, Ontario, Canada
Background: Both the prevalence of breast cancer and the number of breast
cancer patients seeking breast reconstruction are increasing, highlighting the
importance for evidence to direct the clinician in the follow-up of these patients.
Current practice guidelines recommend surveillance mammography of the
contralateral breast in all breast cancer patients, and of the ipsilateral breast in
women treated with breast-conserving surgery. However, there are no guidelines
specifically addressing the role of surveillance mammography for women who
have undergone mastectomy and breast reconstruction.
Methods: A systematic review was conducted to identify studies specifically
addressing the issue of surveillance mammography among women with breast
reconstruction following treatment for primary breast cancer.
Results: This systematic review identified eight articles, consisting of case re-
ports and case series, that address the issue of surveillance mammography of the
ipsilateral breast in women with breast reconstruction. The articles demon-
strated that certain local recurrences are able to be detected by surveillance
mammography.
Conclusion: This study has demonstrated the paucity of evidence and high-
lighted the need for further research to evaluate this issue. (Plast. Reconstr.
Surg. 120: 1125, 2007.)

B
reast cancer remains the most frequently
diagnosed cancer and the second leading
cause of cancer-related death among
women in Canada.1 As most breast cancers are
now diagnosed at an early stage, over 80 percent
of women with breast cancer will be long-term
survivors.2,3 The combination of breast cancer
being the most frequently diagnosed cancer
among Canadian women and the high propor-
tion of long-term survivors makes breast cancer
the most prevalent cancer in women.4,5 Reports
have stated that in Canada there are 151,000
breast cancer survivors,6 more than 2 million in
From the Department of Surgery, Division of Plastic Sur-
gery, the Department of Medicine, Division of Medical
Oncology, and the Department of Community Health and
Epidemiology, Dalhousie University; Department of Epi-
demiology and Community Medicine, University of Ot-
tawa; Ottawa Health Research Institute; Institute for
Clinical Evaluative Sciences; and Sunnybrook and Women’s
College Health Sciences Center.
Received for publication April 20, 2006; accepted August
25, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279143.66781.9a
the United States,7 and that this population con-
tinues to increase in number.5
Since Fisher et al. published the results of a
randomized clinical trial comparing mastectomy
and breast-conserving surgery in 1985,8 the num-
ber of women undergoing breast-conserving sur-
gery has increased.9 In Ontario, the number of
mastectomies decreased from 58.3 per 100,000
women in 1984 and 1985 to 42.9 per 100,000
women 10 years later. This demonstrates that,
despite the appropriateness of breast-conserving
surgery in the treatment of women with early
breast cancer, mastectomy remains common.10
Locoregional recurrence following mastectomy
without reconstruction has been reported to
range from 4.5 percent to greater than 30
percent,11–13 whereas the risk of local recurrence
in remaining breast tissue following breast-
conserving surgery has been reported to be 5 to
15 percent.14 –16
Mammography without any symptomatic or
diagnostic indications following initial treatment
of a primary breast cancer is known as surveil-
lance mammography. Diagnostic mammogra-
phy is performed on suspicion of local recur-

www.PRSJournal.com 1125
 Plastic and Reconstructive Surgery • October 2007
rence or new primary breast cancer. The use of
routine surveillance mammography is recom-
mended with an aim to detect ipsilateral recur-
rence after breast-conserving surgery and to detect
metachronous contralateral breast cancers.17,18 It
has been shown that local recurrences of breast
cancer detected by surveillance mammograms
are a lower stage than those detected clinically,19
and the American Society of Clinical Oncology
recommends regular surveillance mammograms
for all women with a prior diagnosis of breast
cancer.20 In these recommendations, however,
there is no mention of women who have under-
gone reconstructive breast surgery following mas-
tectomy. Women who have undergone mastec-
tomy and breast reconstruction differ from those
who have been treated with mastectomy alone or
with breast-conserving surgery. Women who un-
dergo breast-conserving surgery continue to have
breast tissue that can be imaged mammographi-
cally. Those who have undergone mastectomy
have no breast mound, and mammography of
the mastectomy site is not recommended.12 How-
ever, patients who have undergone breast recon-
struction belong to a unique group where there
has been a mastectomy but a breast mound has
been created that can be imaged mammographi-
cally. This review focuses on this group of
women. It should be emphasized that the con-
tralateral breasts in all of these patients are com-
parable and subject to the same clinical and
mammographic follow-up.
The rate of postmastectomy breast reconstruc-
tion in the United States is 8.3 to 16 percent in
population-based studies, and this rate is increas-
ing over time.21–24 Patients treated at a National
Cancer Institute–recognized cancer treatment
center were 40 percent more likely to undergo
reconstruction following mastectomy, 23 and
these centers have been found to have postmas-
tectomy breast reconstruction rates of up to 45
percent.25 In Ontario, Canada, from 1984 to
1995, the rate of postmastectomy breast recon-
struction was 7.9 percent.10 It has been shown
that residual breast tissue exists in 46 percent of
mastectomized breasts with skin flaps less than
or equal to 5 mm thick and 81 percent of those
with skin flaps greater than 5 mm thick.26 The
recurrence rates of women treated with either
skin-sparing mastectomy or conventional non–
skin-sparing mastectomy has been studied with 6
years of follow-up and found not to be signifi-
cantly different: local recurrence in the conven-
tional group was 7.5 percent and local recur-
rence in the skin-sparing group was 7.0
1126
percent.27 This and other studies show the rate
of local recurrence to range from 2.3 to 7 per-
cent in women with early breast cancer who have
undergone mastectomy and reconstruction,28,29
which is comparable to rates reported following
breast-conserving surgery or mastectomy without
reconstruction. Despite this relatively common
adverse event, there is little agreement on the
appropriateness of routine mammographic sur-
veillance of these patients for early detection of
local recurrence.
SURVEILLANCE MAMMOGRAPHY IN
WOMEN WITH BREAST
RECONSTRUCTION
The role of mammography in the follow-up of
women with breast reconstruction remains con-
troversial. The normal mammographic findings of
autologous breast reconstruction have been de-
scribed and include surgical clips and scars, and
the vascular pedicle supplying the flap.30 Abnor-
mal findings include fat necrosis, lipid cysts, cal-
cifications, lymph nodes, epidermal inclusion
cysts, and recurrence of breast cancer.30 Despite
the fact that breast implants are radiopaque, some
believe that, because of the placement of the im-
plant in the subpectoral plane, the mastectomy
plane is elevated off of the chest wall, allowing it
to be imaged by mammography.31 Although not
advocating surveillance mammography, other au-
thors believe that mammography is useful in eval-
uating women who have undergone autologous
tissue reconstruction and present with physical
findings suspicious for local recurrence.32,33
Guidelines for the follow-up of breast cancer
patients recommend annual mammograms but do
not explicitly give recommendations for women who
have undergone breast reconstruction.12,17,20,34 –39
With the proportion of women undergoing recon-
struction following mastectomy increasing,21–24 this
needs to be addressed. The objective of this sys-
tematic review is to review all of the published
literature addressing the topic of surveillance
mammography of breasts reconstructed following
mastectomy for breast cancer.
PATIENTS AND METHODS
A systematic literature search was conducted us-
ing the same search strategy used in a previous sys-
tematic review addressing the role of surveillance
mammography among women without breast
reconstruction,17 with the additional subject head-
ings “reconstruction” and “mammaplasty” being
added. This search involved all published literature
from January of 1980 to August of 2004 surrounding
Volume 120, Number 5 • Surveillance Mammography
the use of surveillance mammography of the ipsi-
lateral breast in women with breast reconstruction.
As the volume of literature addressing the role of
surveillance mammography in women with breast
reconstruction was expected to be small, case reports
and small case series were included. There were no
restrictions placed regarding the age of the women
in the study. The databases searched included MED-
LINE, EMBASE, Cochrane Library, and the U.S.
National Cancer Institute’s clinical trials database.
References of all retrieved articles were also hand
searched.
Using this strategy, 21 references were identi-
fied for retrieval of title and abstract. These cita-
tions were then reviewed by two independent re-
viewers to identify articles that addressed the
practice of routine surveillance mammography
and its impact on disease outcomes or detection of
recurrences. Any disagreements between the re-
viewers were resolved by discussion. Articles that
appeared to meet this criterion from their titles
and abstracts were retrieved for further review.
Foreign language articles were not translated, and
relevant data were extracted from their English
abstracts.
Using this strategy, 10 articles were retrieved,
of which six were selected for inclusion. Another
two studies were found by hand searching refer-
ences of the six identified articles, bringing the
total to eight. The Canadian Task Force on Pre-
ventive Health Care system for describing levels of
evidence was used to evaluate the strength of each
study.40
RESULTS
Table 1 lists the primary data abstracted from
each study. All articles, including case reports,
were considered because of the paucity of litera-
ture addressing the role of surveillance mammog-
raphy in women who have undergone breast re-
construction. In total, eight articles addressed this
issue,12,31,41– 46 including two case reports, five case
series, and a retrospective case series with impre-
cise numbers and follow-up.31 One series was a
German language article where data were ab-
stracted from the English abstract.41 Four of the
articles included patients with implant-based recon-
struction and five included patients with autologous
reconstructions. Only one article described the
mammography regimen, which consisted of semi-
annual mammograms.42 Only two studies reported
local recurrences detected by surveillance mammog-
raphy or by other means.43,46 Helvie et al. found that
two of the three cases of local recurrence in their
series of women with transverse rectus abdomi-
nis myocutaneous (TRAM) flap breast recon-
struction were detected by surveillance mam-
mography, whereas the third was a palpable
breast nodule.46 In their descriptive study of
women with local recurrence in TRAM flap
breast reconstruction, Salas et al. report that
three cases of local recurrence were detected by
diagnostic mammograms, whereas one case was
detected by a surveillance mammogram.43 Heinig et
al.41 report that eight of 13 local recurrences in
women with silicone implant– based breast recon-
struction were detected by clinical examination
and mammography, but it was not reported how
many were detected by mammography alone. Fa-
jardo et al. reported on the follow-up of 80 patients
with breast reconstruction, only one of which de-
veloped a local recurrence, and it was not detected
by surveillance mammography.12 The remaining
studies present individual cases of local recur-
rence that were detected by surveillance mam-
mography, without providing follow-up informa-
tion regarding local recurrences detected by other
means.
DISCUSSION
A systematic review was conducted of all rel-
evant literature regarding the use of surveillance
mammography among women who had under-
gone breast reconstruction following their treat-
ment for primary breast cancer. The literature was
searched using a modification of a previously used
search strategy addressing the role of surveillance
mammography among women treated for breast
cancer excluding those with breast reconstruction. It
was decided that because of the extensive heteroge-
neity between the studies in terms of design, follow-
up, and mammography regimen, the data would not
be synthesized in a meta-analysis. Because of this, a
narrative discussion ensues.
The first report in the literature of local breast
cancer recurrence detected by surveillance mam-
mography in a reconstructed breast was in 1992 in
an article by Dowden.31 This report was an infor-
mal report stating the observations of one plastic
surgeon who advised his patients who under-
went an implant-based breast reconstruction to
have mammography of their reconstructed
breast. In the 3 years after this change in his
practice, he observed three cases of local recur-
rence in the reconstructed breasts that were di-
agnosed by surveillance mammography. Dow-
den estimated that 180 of his patients had
mammography during this time, but the fre-
quency of mammography was not described.
1127
1128
Table 1. Studies on Mammography following Breast Reconstruction
No. of Cases in Years to Detection Rate by
Level of Series (no. with Stage at Initial Recurrence Mammography Mammography
Source Evidence* CBC or IR) Diagnosis Initial Treatment Type of Reconstruction (median) Regimen Alone
Dowden, Case series (III) Approximately Not reported Modified radical Immediate submuscular 1 yr, 3 yr, 2 yr Not described 3
199231 180 (IR, n ⫽ 3) mastectomy implant
Fajardo Case series (III) 80 (IR, n ⫽ 1; Not reported Mastectomy Implants (65), Not reported Frequency not 0
et al., silicone for autologous (19), for described
199312 implant) reconstruction bilateral reconstruction
cases reconstructions (4) cases
Mund Case report 1 Stage II Modified radical Delayed TRAM flap 7 yr 3 mammograms 1
et al., mastectomy in 7 yr
199444
Salas Case series (III) 4 DCIS Modified radical Immediate TRAM flap 10 mo, 3 yr, Not described, 1
et al., mastectomy 2 yr, 4 yr surveillance
199843 (1), total mammography
mastectomy (3), (1), diagnostic
contralateral mammography
prophylactic (3)
mastectomy (4)
Helvie Case series (III) 6 DCIS Mastectomy TRAM flap 42 mo Only 1 patient 1
et al., underwent
199845 mammographic
surveillance
Clark Case report 1 DCIS Total mastectomy Delayed submuscular 3.5 yr Semiannually 1
et al., and implant
199942 prophylactic
contralateral
mastectomy
Helvie Case series (III) 113 (IR, n ⫽ 3) Not reported, Mastectomy Immediate or delayed All ⬎5 yr None 2 of 3
et al., included TRAM flap
200246 prophylactic
mastectomies
Heinig Inadequate 169 (IR, n ⫽ 13) Not reported Mastectomy Silicone implant Not reported Not reported Clinical examination
et al., description and mammography
41
1997† of methods detected 8 of 13
in abstract (not reported
which were
detected by
mammography
alone)
IR, ipsilateral recurrence; DCIS, ductal carcinoma in situ; TRAM, transverse rectus abdominis myocutaneous.
*Level III evidence refers to evidence from opinions of respected authorities on the basis of clinical experience, descriptive studies, or reports of expert committees (from Canadian Task
Force on Preventive Health Care (1997). CTFPHC history/methodology. Available at http://www.ctfphc.org/. Accessed July 15, 2005).
†German language and data were abstracted from the translated abstract.
Plastic and Reconstructive Surgery • October 2007
Volume 120, Number 5 • Surveillance Mammography
In 1993, Fajardo et al. published a retrospec-
tive case series evaluating the role of surveillance
mammography of the mastectomy site.12 Only one
of 80 women with reconstruction developed a lo-
cal recurrence, and this was not detected by sur-
veillance mammography. The frequency of sur-
veillance mammography was not reported, nor
was it clear that these patients had undergone
surveillance mammography or diagnostic mam-
mography. It is also important to note that this
study included only women who underwent mas-
tectomy and also had surveillance mammography
at the same institution. These inclusion criteria
represent a significant potential bias, as women
treated elsewhere would not be included in this
study.
The first report in the literature describing the
detection of a local recurrence in an autologous
breast reconstruction appeared in 1994.44 The pa-
tient described in this report underwent modified
radical mastectomy for ductal carcinoma with lym-
phatic involvement. One year after her mastec-
tomy she underwent a TRAM flap breast recon-
struction. Over the next 7 years, she had three
bilateral mammographic evaluations for surveil-
lance. The third of these evaluations revealed a
nonpalpable mass that was diagnosed as a local
recurrence of her breast cancer. This case report
showed the possibility of detecting a local breast
cancer recurrence in an autologous reconstruc-
tion with surveillance mammography. There was
no discussion in this report about the number of
patients treated by the author or their institution,
leaving one to question how common such an
event could be in practice.
Another case series appeared in the literature
in 1998 reporting local breast cancer recurrences
detected by mammography.43 In this report, four
patients initially treated for ductal carcinoma in
situ are described following local recurrence of
their breast cancers within TRAM flap breast re-
constructions. Of these four cases, three under-
went mammography following clinical suspicion
of recurrence following clinical examination and
one had a local recurrence detected by surveil-
lance mammography. The three patients who
were diagnosed with local recurrence following
suspicious clinical examination did not participate
in a follow-up program that included surveillance
mammography of the reconstructed breast. The
identification of another patient with an autolo-
gous breast reconstruction who had a subclinical
local recurrence detected by surveillance mam-
mography further contributes to the knowledge
that these recurrences can indeed be identified by
surveillance mammography. This leads one to
wonder whether the other three patients in this
case series might have been identified earlier as
having a local recurrence if they had participated
in regular surveillance mammography.
In 1998, a case series of women with TRAM
flap reconstructions following mastectomy for
breast cancer appeared in the literature.45 This
series consisted of seven women treated for local
recurrence in a TRAM flap–reconstructed breast
at a single institution. Routine surveillance mam-
mography of TRAM flap–reconstructed breasts is
not performed at this institution, only diagnostic
mammography following suspicious clinical exam-
ination. Only one of these patients had their local
recurrence diagnosed by surveillance mammog-
raphy; the remaining patients had a palpable
lump in their reconstructed breast. The lone pa-
tient whose local recurrence was detected by sur-
veillance mammography was followed at another
institution, where surveillance mammography was
available. Two of the patients diagnosed with local
recurrence by diagnostic mammography were
found to have lymph node involvement, whereas
the patient who was diagnosed with local recur-
rence by surveillance mammography was found
to be free of lymphatic spread. As routine mam-
mographic surveillance is not offered at this
institution, it is questioned whether a surveil-
lance program including surveillance mammog-
raphy would have resulted in earlier detection of
the locally recurrent disease of the patients who
presented with a palpable lump on physical ex-
amination. As a result of this series of patients,
the institution involved has established surveil-
lance mammography as part of its routine fol-
low-up for all patients with TRAM flap breast
reconstruction.
A case report involving a woman with ductal
carcinoma in situ treated by mastectomy and recon-
struction with a saline implant has been published
reporting a local recurrence in a reconstructed
breast detected by surveillance mammography.42
The patient in this report underwent semiannual
physical examination and surveillance mammog-
raphy following her breast reconstruction. It was
on surveillance mammography almost 3 years af-
ter her reconstruction that a recurrence was de-
tected by surveillance mammography, not by phys-
ical examination. One year after the excision of
the recurrence, there was no evidence of spread of
this breast cancer. This was the first reported case
of a local recurrence detected by surveillance
mammography in an implant-based reconstruc-
tion since Dowden published the original obser-
1129
 Plastic and Reconstructive Surgery • October 2007
vation that mammography could detect local re-
currences in these women.
The most recent study in the literature ad-
dressing the role of surveillance mammography in
women with breast reconstruction was published
in 2002.46 In this study, 214 consecutive surveil-
lance mammograms were evaluated in 113 women
at a single center. Seven of these 113 patients
underwent prophylactic mastectomy followed by
reconstruction. The decision to undergo surveil-
lance mammography was made clinically by the
patient’s treating physician. Of the six patients
who had suspicious mammograms and went on to
have a biopsy, two were found to have a local
recurrence. One patient with a suspicious mam-
mogram did not have a biopsy, as she was diag-
nosed with metastatic disease. Follow-up beyond
the study period identified two other patients for
whom local recurrence was detected by mammog-
raphy alone. Two patients in the study group went
on to develop recurrences that were detected by
physical examination. There was one false-nega-
tive mammogram. The positive predictive value,
sensitivity, and specificity were calculated to be 33
percent, 67 percent, and 98 percent, respectively.
The major shortcomings of this study were that
they did not include women who underwent an
implant-based reconstruction and that they only
included women who pursued their follow-up and
mammographic surveillance at their institution.
The mammographic appearance of recurrent
carcinoma in autologous tissue reconstructions is
similar to that of primary breast cancer,45 and pro-
ponents of surveillance mammography feel that
screening breast cancer patients with autologous
tissue reconstruction can detect nonpalpable can-
cer before clinical examination.43,46 Others feel
that mammography is indicated only in patients
who present postoperatively with suspicious phys-
ical findings.32 This systematic review found only
case reports and level III evidence in terms of
guiding the clinician in the management of these
patients. There is no well-designed cohort study or
randomized controlled trial addressing this issue,
and only one of the articles identified described
the mammography regimen.42 The articles iden-
tified in this review do, however, demonstrate the
reality that cases of local recurrence can be de-
tected by surveillance mammography in women
with breast reconstruction following mastectomy,
and that more research is needed in this area to
guide the clinician in the management of these
patients. A randomized, controlled, clinical trial
would be the ideal design with which to evaluate
the role of surveillance mammography among this
1130
group of women; however, the cost and length of
follow-up required to show a survival benefit
would not be practical. The Surveillance, Epide-
miology and End Results database is a national
program which amalgamates data from various
cancer registries in the United States. This data-
base collects data on patient demographics, pri-
mary tumor site, tumor morphology and stage at
diagnosis, first course of treatment, and follow-up
for vital status,47 and thus would likely not capture
breast reconstruction or surveillance mammogra-
phy. Perhaps the best way to evaluate this issue
would be through a decision aid technique that
incorporates modeling, such as an economic anal-
ysis. Clearly, further information is required to
guide the clinician in the surveillance of this group
of women.
CONCLUSIONS
With the prevalence of breast cancer survivors
increasing, clear guidelines are required for their
follow-up, including the use of appropriate sur-
veillance mammography. Not only is the preva-
lence of breast cancer survivors increasing, but the
number of women pursuing breast reconstruction
is increasing as well. With this increase clearly
documented,21–24 evidence guiding the follow-up
of these patients is required. This systematic re-
view has demonstrated a lack of evidence and
highlighted the need for further research to eval-
uate this issue.
G. Philip Barnsley, M.D.
Halifax Infirmary, Room 4437
1796 Summer Street
Halifax, Nova Scotia B3H 3A7, Canada
barnsley@dal.ca
ACKNOWLEDGMENT
This research is supported by the Canadian Cancer
Society.
DISCLOSURE
None of the authors has any financial interest in any
product evaluated in this study.
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8. Fisher, B., Redmond, C., Fisher, E. R., et al. Ten-year results
of a randomized clinical trial comparing radical mastectomy
and total mastectomy with or without radiation. N. Engl.
J. Med. 312: 674, 1985.
9. Lazovich, D., Solomon, C. C., Thomas, D. B., et al. Breast
conservation therapy in the United States following the 1990
National Institutes of Health Consensus Development Con-
ference on the treatment of patients with early stage invasive
breast carcinoma. Cancer 86: 628, 1999.
10. Baxter, N., Goel, V., and Semple, J. L. Utilization and re-
gional variation of breast reconstruction in Canada. Plast.
Reconstr. Surg. 115: 338, 2005.
11. Lythgoe, J. P., and Palmer, M. K. Manchester regional breast
study: 5 and 10 year results. Br. J. Surg. 69: 693, 1982.
12. Fajardo, L. L., Roberts, C. C., and Hunt, K. R. Mammo-
graphic surveillance of breast cancer patients: Should the
mastectomy site be imaged? A.J.R. Am. J. Roentgenol. 161: 953,
1993.
13. Fisher, B., Slack, N. H., Cavanagh, P. J., et al. Postoperative
radiotherapy in the treatment of breast cancer: Results of the
NSABP clinical trial. Ann. Surg. 172: 711, 1970.
14. Recht, A., Schnitt, S. J., Connolly, J. L., et al. Prognosis
following local or regional recurrence after conservative sur-
gery and radiotherapy for early stage breast carcinoma. Int.
J. Radiat. Oncol. Biol. Phys. 16: 3, 1989.
15. Fowble, B., Solin, L. J., Schultz, D. J., et al. Breast recurrence
following conservative surgery and radiation: Patterns of fail-
ure, prognosis, and pathologic findings from mastectomy
specimens with implications for treatment. Int. J. Radiat.
Oncol. Biol. Phys. 19: 833, 1990.
16. Pass, H., Vicini, F. A., Kestin, L. L., et al. Changes in man-
agement techniques and patterns of disease recurrence over
time in patients with breast carcinoma treated with breast-
conserving therapy at a single institution. Cancer 101: 713,
2004.
17. Grunfeld, E., Noorani, H., McGahan, L., et al. Surveillance
mammography after treatment of primary breast cancer: A
systematic review. Breast 11: 228, 2002.
18. Grunfeld, E., Dhesy-Thind, S., and Levine, M. Clinical prac-
tice guidelines for the care and treatment of breast cancer:
Follow-up after treatment for breast cancer (summary of the
2005 update). C.M.A.J. 172: 1319, 2005.
19. Weight, S. C., Windle, R., and Stotter, A. T. Optimizing
surveillance mammography following breast conservation
surgery. Eur. J. Surg. Oncol. 28: 11, 2002.
20. Smith, T. J., Davidson, N. E., Schapira, D. V., et al. American
Society of Clinical Oncology 1998 update of recommended
breast cancer surveillance guidelines. J. Clin. Oncol. 17: 1080,
1999.
21. Polednak, A. P. How frequent is postmastectomy breast re-
constructive surgery? A study linking two statewide databases.
Plast. Reconstr. Surg. 108: 73, 2001.
22. Polednak, A. P. Postmastectomy breast reconstruction in
Connecticut: Trends and predictors. Plast. Reconstr. Surg. 104:
669, 1999.
23. Morrow, M., Scott, S. K., Menck, H. R., et al. Factors influ-
encing the use of breast reconstruction postmastectomy:
A National Cancer Database study. J. Am. Coll. Surg. 192:
1, 2001.
24. Desch, C. E., Penberthy, L. T., Hillner, B. E., et al. A socio-
demographic and economic comparison of breast recon-
struction, mastectomy, and conservative surgery. Surgery 125:
441, 1999.
25. Christian, C. K., Edge, S., Niland, J., et al. A multi-institu-
tional analysis of the socioeconomic determinants of breast
reconstruction. Ann. Surg. 243: 241, 2006.
26. Torresan, R. Z., dos Santos, C. C., Okamura, H., and Al-
varenga, M. Evaluation of residual glandular tissue after skin-
sparing mastectomies. Ann. Surg. Oncol. 12: 1037, 2005.
27. Kroll, S. S., Khoo, A., Singletary, S. E., et al. Local recurrence
risk after skin-sparing and conventional mastectomy: A 6-year
follow-up. Plast. Reconstr. Surg. 104: 421, 1999.
28. Langstein, H. N., Cheng, M. H., Singletary, S. E., et al. Breast
cancer recurrence after immediate reconstruction: Patterns
and significance. Plast. Reconstr. Surg. 111: 712, 2003.
29. Spiegel, A. J., and Butler, C. E. Recurrence following treat-
ment of ductal carcinoma in situ with skin-sparing mastec-
tomy and immediate breast reconstruction. Plast. Reconstr.
Surg. 111: 706, 2003.
30. Hogge, J. P., Zuurbier, R. A., and de Paredes, E. S. Mam-
mography of autologous myocutaneous flaps. Radiographics
19: S63, 1999.
31. Dowden, R. V. Mammography after implant breast recon-
struction. Plast. Reconstr. Surg. 96: 119, 1992.
32. Eidelman, Y., Liebling, R. W., Buchbinder, S., et al. Mam-
mography in the evaluation of masses in breasts recon-
structed with TRAM flaps. Ann. Plast. Surg. 41: 229, 1998.
33. Leibman, A. J., Styblo, T. M., and Bostwick, J., III. Mammog-
raphy of the postreconstruction breast. Plast. Reconstr. Surg.
99: 698, 1997.
34. Kollias, J., Evans, A. J., Wilson, A. R., et al. Value of con-
tralateral surveillance mammography for primary breast can-
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35. Schapira, M. M., McAuliffe, T. L., and Nattinger, A. B. Un-
derutilization of mammography in older breast cancer sur-
vivors. Med. Care 38: 281, 2000.
36. Pandya, K. J., McFadden, E. T., Kalish, L. A., et al. A retro-
spective study of earliest indicators of recurrence in patients
on Eastern Cooperative Oncology Group adjuvant chemo-
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55: 202, 1985.
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monitoring of the contralateral breast improved the prog-
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597, 1986.
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Treat. 81: 107, 2003.
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Committee on Clinical Practice Guidelines for the Care and
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40. Canadian Task Force on Preventive Health Care (1997).
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ctfphc.org/. Accessed July 15, 2005.
41. Heinig, A., Heywang-Kobrunner, S. H., Viehweg, P., et al.
Value of contrast medium magnetic resonance tomography
of the breast in breast reconstruction with implant (in Ger-
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42. Clark, L., Ritter, E., Glazebrook, K., and Tyler, D. Recurrent
ductal carcinoma in situ after total mastectomy. J. Surg. Oncol.
71: 182, 1999.
43. Salas, A. P., Helvie, M. A., Wilkins, E. G., et al. Is mammog-
raphy useful in screening for local recurrences in patients
1131
 Plastic and Reconstructive Surgery • October 2007

with TRAM flap breast reconstruction after mastectomy for
multifocal DCIS? Ann. Surg. Oncol. 5: 456, 1998.
44. Mund, D. F., Wolfson, P., Gorczyca, D. P., et al. Mammo-
graphically detected recurrent nonpalpable carcinoma de-
veloping in a transverse rectus abdominis myocutaneous
flap: A case report. Cancer 74: 2804, 1994.
45. Helvie, M. A., Wilson, T. E., Roubidoux, M. A., et al. Mam-
mographic appearance of recurrent breast carcinoma in six
patients with TRAM flap breast reconstructions. Radiology
209: 711, 1998.
46. Helvie, M. A., Bailey, J. E., Roubidoux, M. A., et al. Mammographic
screening of TRAM flap breast reconstructions for detection of
nonpalpable recurrent cancer. Radiology 224: 211, 2002.
47. National Cancer Institute. Overview of the SEER program.
Available at: http://seer.cancer.gov/about/. Accessed Au-
gust 10, 2006.

Online CME Collections

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1132
 IDEAS AND INNOVATIONS
Skin Banking Closure Technique in Immediate
Autologous Breast Reconstruction
Eric C. Liao, M.D., Ph.D.
Brian I. Labow, M.D.
James W. May, Jr., M.D.
Boston, Mass.
I
mmediate breast reconstruction has been facil-
itated by the use of skin-sparing mastectomy.1,2
With preservation of the native breast skin en-
velope, various methods of autologous or pros-
thetic reconstruction can be performed. Numer-
ous techniques have been described to evaluate
skin flap viability, with clinical observation or fluo-
rescein testing being the most commonly practiced
methods.3–7
Outcome studies of immediate breast recon-
struction following skin-sparing mastectomy re-
port mastectomy skin flap necrosis rates in the
10 to 16 percent range.8 –14 Tobacco smoke, body
mass index greater than 30, and prior breast
irradiation were identified to be risk factors for
mastectomy skin flap necrosis. In the series re-
ported by Carlson et al., 97 percent of skin ne-
crosis healed by secondary intention.8 If skin flap
necrosis results in significant full-thickness es-
char, debridement and revision of the recon-
struction may be required. These wound issues
are especially problematic if postoperative irra-
diation is planned but must be delayed to allow
healing of the reconstructed breast mound.
We present a strategy to manage mastectomy
skin flaps when the viability is unclear in imme-
diate autologous breast reconstruction. This ap-
proach is based on the basic principle of delayed
wound closure, with a planned second-look pro-
cedure, where the interval of time permits de-
marcation of nonviable tissue.
TECHNIQUE
Once the skin-sparing mastectomy has been
performed and the transverse rectus abdominis
myocutaneous (TRAM) flap elevated, the mastec-
tomy skin flaps are carefully inspected. If there is
From Massachusetts General Hospital, Harvard Medical
School.
Received for publication October 12, 2006; accepted Decem-
ber 21, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279144.50653.5a
www.PRSJournal.com
any doubt as to the viability of the mastectomy
skin, a fluorescein dye test is performed as previ-
ously described.5 Viability of the mastectomy skin
flap is demonstrated by fluorescein with Wood’s
lamp examination of the fluorescein-perfused
skin. Our clinical experience agrees with reports
that the fluorescein test overestimates the ultimate
area of tissue necrosis.4,15,16 Areas determined to
be nonviable, either by lack of capillary refill or by
complete nonfluorescence, are aggressively de-
brided at the initial operation. With aggressive
initial debridement of the mastectomy skin flap,
only three of the 34 patients who underwent au-
tologous breast reconstruction by a single surgeon
(J.W.M.) in the years 2001 to 2005 required the
skin banking technique to balance preservation of
mastectomy skin with excision of ischemic skin
(Table 1).
In situations where the viability of significant
areas of the mastectomy skin is in question, we
propose the skin banking closure strategy. Here,
the TRAM flap skin paddle is not fully deepithe-
lialized. Instead, excess skin is “banked” on the
TRAM flap skin paddle, which is buried under the
vulnerable mastectomy skin flap and loosely
closed to give the semblance of a breast mound
(Fig. 1). Areas of the TRAM flap skin banked in
this manner can vary. One can preserve the entire
TRAM skin paddle, or only save the TRAM flap
skin where the overlying mastectomy skin flap is
suspected to be ischemic. The patient is then al-
lowed to recover from anesthesia and observed,
with a second-stage procedure planned. Because
the wound is closed preliminarily, the patient can
begin rehabilitation and has a breast mound as
expected from immediate breast reconstruction.
Over the next 3 postoperative days, the mas-
tectomy skin flap is observed closely for signs of
ischemia, such as blistering or eschar formation.
The patient is scheduled to return to the operat-
ing room on postoperative day 4 or 5, for a
planned second-look procedure that is performed
with sedation alone; no general anesthetic is nec-
essary. If at that time there is no additional mas-
1133
 Plastic and Reconstructive Surgery • October 2007

Table 1. Delayed Mastectomy Skin Flap Closure in flap necrosis, wound dehiscence or infection,
Autologous (TRAM Flap) Breast Reconstruction longstanding dressing changes, and secondary
Age BMI healing, which may otherwise complicate autolo-
(years) (kg/m2) Smoking Radiation Disease gous breast reconstruction.
48 31.3 No None IDC The three patients presented in this series all
42 22.7 No Postoperative IDC healed after the revised mastectomy skin flap clo-
55 22.4 Past* None DCIS sure procedures without complication. With over
BMI, body mass index; IDC, invasive ductal carcinoma; DCIS, ductal 12 months’ follow-up, none of the patients re-
carcinoma in situ.
*A 20-pack-year smoking history; the patient quit 15 years previously. quired additional revision surgery. Two of the
three patients underwent nipple-areola recon-
struction and all three patients were pleased with
the reconstructive outcome.
tectomy skin necrosis, the TRAM flap can then be
further deepithelialized and the final TRAM inset
may be performed. Alternatively, if additional DISCUSSION
mastectomy skin flap necrosis does develop, this Native skin flap necrosis after skin-sparing
second-look procedure affords an opportunity to mastectomy in not uncommon, affecting 10 to 16
debride the skin flap to clearly viable margins. In percent of women that undergo immediate breast
this way, we avoid the situation of mastectomy skin reconstruction.8 –14 The skin banking closure strat-

Fig. 1. Skin banking closure strategy. (Above, left) Preoperative marking of a Wise pattern incision for the skin-sparing mas-
tectomy. (Above, right) After the breast specimen is removed with mastectomy skin flap in a Wise pattern. (Below, left) Appear-
ance of the breast on postoperative day 4, at the time of second-stage wound closure. (Below, right) The mastectomy flaps are
opened to reveal a TRAM paddle with skin preserved in the inferior portion, in the event that mastectomy flap necrosis develops
at the triple point of the Wise pattern closure.

1134
Volume 120, Number 5 • Skin Banking Closure Technique
egy described above uses a planned second-look
procedure, where the mastectomy skin flap is al-
lowed to demarcate, allowing a more precise de-
termination of the nonviable skin flap margin.
This technique is rarely needed and is only used
if intraoperative circumstances suggest a vulnera-
ble nature of the mastectomy skin flap. This strat-
egy has the advantages of enabling one to com-
pletely excise nonviable skin and avoid wound
complications while avoiding overresection, allow-
ing better preservation of native breast skin.
The ability to more precisely define the margin
of ischemic skin has been the focus of numerous
investigations. Thermography, photoplethysmogra-
phy, laser Doppler flowmetry, laser scanning imag-
ing, orthogonal polarization spectral imaging, and
near-infrared spectroscopy are among the methods
described.6,7,15,17–20 These methods have remained
largely experimental because of the lack of reliabil-
ity, cost of equipment, or difficulty in implementa-
tion for most clinical settings. Fluorescein dye testing
remains the most easily applicable examination with
which to complement observational assessment but
is limited by overestimation of ischemic tissue, lead-
ing to overresection.4,15,16
In contrast, a skin banking closure technique
requires no specialized equipment and is easily
achievable in any clinical setting. The costs of the
delayed closure approach are an additional trip to
the operating room and potentially a longer hos-
pital stay. However, because the second TRAM
inset procedure involves debridement of a dener-
vated mastectomy skin flap and TRAM skin paddle
deepithelialization, local anesthesia with light se-
dation is all that is required.
An alternative to the skin banking closure
strategy that we outlined is to deepithelialize the
TRAM skin paddle and bank the skin at 4°C for use
in the event that mastectomy skin necrosis devel-
ops. However, skin grafting in a delayed fashion
still requires a graft bolster and additional time for
graft survival and would produce an inferior aes-
thetic result.
It is important to point out that the native
breast skin envelope preserved from the skin-
sparing mastectomy behaves as a random flap,
not as a skin graft. Viability of the mastectomy
skin flap is dependent on perfusion within the
subdermal plexus. The mastectomy skin flap,
even when thinned, is not a skin graft. Mecha-
nisms such as inosculation and vascular in-
growth that sustain a skin graft do not partici-
pate in perfusion of the mastectomy skin flap. It
has not been shown that the TRAM flap con-
tributes to the viability of the overlying mastec-
tomy skin flap. Conversely, we believe the buried
TRAM flap with an intact banked skin paddle as
described in this technique does not compro-
mise the viability of the mastectomy skin flap.
Although we describe the skin banking strat-
egy in the context of a TRAM flap in immediate
autologous breast reconstruction, this concept of
preserving the skin component of any tissue trans-
fer for final inset at a later time can be generalized
to other clinical situations. Whenever the recipi-
ent site contains skin of equivocal viability, a sec-
ond-stage procedure can be planned with the skin
of the transferred tissue left intact for inset at the
later stage, with the wound preliminarily closed.
One may be well served to use this approach when
managing patients at risk for mastectomy skin flap
necrosis. The skin banking closure strategy can be
a valuable lifeboat, for both the patient and the
surgeon.
SUMMARY
Wound complications following skin-sparing
mastectomy and immediate breast reconstruction
are common. Most reports cite wound complica-
tion rates in the 10 to 16 percent range, with active
smoking and high body mass index the main risk
factors. Although many wound complications are
minor and can be allowed to heal by secondary
intention, in some instances secondary wound
healing after breast reconstruction causes signifi-
cant morbidity, may delay planned postoperative
radiation treatment, or may lead to inferior aes-
thetic results that require additional operative
procedures. We present a skin banking closure
technique to manage mastectomy skin flaps when
the viability is unclear in immediate autologous
breast reconstruction. This approach is based on
the basic principle of delayed wound closure, with
a planned second-look procedure, where the time
interval permits demarcation of nonviable tissue.
These concepts can be generalized to other clin-
ical scenarios where tissue transfer with a cutane-
ous component is used to reconstruct a site where
the recipient site skin viability is in question.
James W. May, Jr., M.D.
Division of Plastic Surgery
Massachusetts General Hospital
55 Fruit Street
Boston, Mass. 02114
jwmay@partners.org
DISCLOSURE
None of the authors has any disclosures of commer-
cial associations or financial relationships.
1135
 Plastic and Reconstructive Surgery • October 2007

REFERENCES
1. Toth, B. A., and Lappert, P. Modified skin incisions for
mastectomy: The need for plastic surgical input in preoper-
ative planning. Plast. Reconstr. Surg. 87: 1048, 1991.
2. Kroll, S. S., Ames, F., Singletary, S. E., and Schusterman, M.
A. The oncologic risks of skin preservation at mastectomy
when combined with immediate reconstruction of the breast.
Surg. Gynecol. Obstet. 172: 17, 1991.
3. Myers, M. B., Brock, D., and Cohn, I., Jr. Prevention of skin
slough after radical mastectomy by the use of a vital dye to
delineate devascularized skin. Ann. Surg. 173: 920, 1971.
4. Thorvaldsson, S. E., and Grabb, W. C. The intravenous flu-
orescein test as a measure of skin flap viability. Plast. Reconstr.
Surg. 53: 576, 1974.
5. Singer, R., Lewis, C. M., Franklin, J. D., and Lynch, J. B.
Fluorescein test for prediction of flap viability during breast
reconstructions. Plast. Reconstr. Surg. 61: 371, 1978.
6. Olivier, W. A., Hazen, A., Levine, J. P., et al. Reliable assess-
ment of skin flap viability using orthogonal polarization im-
aging. Plast. Reconstr. Surg. 112: 547, 2003.
7. Scheufler, O., Exner, K., and Andresen, R. Investigation of
TRAM flap oxygenation and perfusion by near-infrared re-
flection spectroscopy and color-coded duplex sonography.
Plast. Reconstr. Surg. 113: 141, 2004.
8. Carlson, G. W., Bostwick, J., III, Styblo, T. M., et al. Skin-
sparing mastectomy: Oncologic and reconstructive consid-
erations. Ann. Surg. 225: 570, 1997.
9. Chang, D. W., Reece, G. P., Wang, B., et al. Effect of smoking
on complications in patients undergoing free TRAM flap
breast reconstruction. Plast. Reconstr. Surg. 105: 2374, 2000.
10. Chang, D. W., Wang, B., Robb, G. L., et al. Effect of obesity
on flap and donor-site complications in free transverse rectus
abdominis myocutaneous flap breast reconstruction. Plast.
Reconstr. Surg. 105: 1640, 2000.
11. Peyser, P. M., Abel, J. A., Straker, V. F., et al. Ultra-conser-
vative skin-sparing ‘keyhole’ mastectomy and immediate
breast and areola reconstruction. Ann. R. Coll. Surg. Engl. 82:
227, 2000.
12. DeBono, R., Thompson, A., and Stevenson, J. H. Immediate
versus delayed free TRAM breast reconstruction: An analysis
of perioperative factors and complications. Br. J. Plast. Surg.
55: 111, 2002.
13. Sorensen, L. T., Horby, J., Friis, E., et al. Smoking as a risk
factor for wound healing and infection in breast cancer
surgery. Eur. J. Surg. Oncol. 28: 815, 2002.
14. Rashid, M., Ilahi, I., ur Rehman Sarwar, S., et al. Skin sparing
mastectomy and immediate breast reconstruction. J. Coll.
Physicians Surg. Pak. 15: 467, 2005.
15. Graham, B. H., Walton, R. L., Elings, V. B., and Lewis, F. R.
Surface quantification of injected fluorescein as a predictor
of flap viability. Plast. Reconstr. Surg. 71: 826, 1983.
16. Myers, B., and Donovan, W. An evaluation of eight methods
of using fluorescein to predict the viability of skin flaps in the
pig. Plast. Reconstr. Surg. 75: 245, 1985.
17. Eichhorn, W., Auer, T., Voy, E. D., and Hoffmann, K. Laser
Doppler imaging of axial and random pattern flaps in the
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Tolentino, G. Laser Doppler velocimetry and fluorescein dye
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19. McCraw, J. B., Myers, B., and Shanklin, K. D. The value of
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20. Thorne, F. L., Georgiade, N. G., and Mladick, R. The use of
thermography in determining viability of pedicle flaps. Arch.
Surg. 99: 97, 1969.

Online CME Collections

This partial list of titles in the developing archive of CME article collections is available online at www.
PRSJournal.com. These articles are suitable to use as study guides for board certification and/or recertification, to help
readers refamiliarize themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old
can be taken for CME credit.
Breast
Current Trends in Breast Reduction—David A. Hidalgo et al.
Benign Tumors of the Teenage Breast—Mary H. McGrath
Breast Reconstruction with Implants and Expanders—Scott L. Spear and Christopher J. Spittler
Breast Cancer: Advances in Surgical Management —Alan R. Shons and Charles E. Cox
Breast Reconstruction with Free Tissue Transfer—Michael S. Beckenstein and James C. Grotting
Recurrent Mammary Hyperplasia: Current Concepts—Rod J. Rohrich et al.
Evolution of the Vertical Reduction Mammaplasty—Scott L. Spear and Michael A. Howard
Breast Augmentation—Cancer Concerns and Mammography: A Literature Review—Michael G. Jakubietz et al.
Breast Augmentation—Scott L. Spear et al.

1136
 EXPERIMENTAL

Dihydrotestosterone Stimulates Proliferation

and Differentiation of Fetal Calvarial
Osteoblasts and Dural Cells and Induces
Cranial Suture Fusion
Ines C. Lin, M.D.
Alison E. Slemp, M.D.
Catherine Hwang, B.S.
Miguel Sena-Esteves, Ph.D.
Hyun-Duck Nah, D.D.S.,
Ph.D.
Richard E. Kirschner, M.D.
Philadelphia, Pa.
Background: The higher prevalence of metopic and sagittal suture synostosis in
male infants suggests a role for androgens in early craniofacial development. These
experiments characterize the influence of androgen stimulation on growth and
differentiation of fetal dural and calvarial bone cells and on cranial suture fusion.
Methods: Primary murine fetal (E18) dural cells and calvarial osteoblasts were
isolated and cultured. Cells were treated for 48 hours with 5␣-dihydrotestosterone
(0 to 1000 nM). Cell proliferation was examined by nonradioactive proliferation
assay; mRNA expression of alkaline phosphatase, transforming growth factor
(TGF)-␤1, and the bone matrix proteins osteopontin, osteocalcin, and type 1
collagen was determined by reverse-transcriptase polymerase chain reaction. In
separate experiments, intact fetal calvariae were grown in tissue culture with 10 nM
5␣-dihydrotestosterone for 7 and 14 days and then examined histologically.
Results: Androgen stimulation at 5 nM increased proliferation of fetal dural cells
by 46.0 percent and of fetal calvarial osteoblasts by 20.5 percent. Dural expression
of osteopontin, osteocalcin, and type 1 collagen was enhanced by 5␣-dihydrotest-
osterone, as was that of TGF-␤1 and alkaline phosphatase. Androgen stimulation
increased calvarial osteoblast expression of alkaline phosphatase and TGF-␤1 but
induced little change in expression of osteocalcin, osteopontin, and type 1 collagen.
In tissue culture, 5␣-dihydrotestosterone stimulated osteoid formation and fusion
of sagittal sutures.
Conclusions: Androgen stimulation of dural cells and osteoblasts isolated from fetal
calvaria promotes cell proliferation and osteoblastic differentiation and can induce
cranial suture fusion. These results suggest that sex steroid hormone signaling may
stimulate sutural osteogenesis by means of osteodifferentiation of dural cells, thus
explaining the male prevalence of nonsyndromic craniosynostosis. (Plast. Reconstr.
Surg. 120: 1137, 2007.)

N
onsyndromic metopic and sagittal suture
synostosis occur more frequently in male
infants, with male-to-female ratios ranging
from 3:1 to 4:1.1–5 The increased prevalence of
From the Divisions of Plastic Surgery and Pediatric General,
Thoracic, and Fetal Surgery, The Children’s Institute for
Surgical Science, The Children’s Hospital of Philadelphia,
University of Pennsylvania School of Medicine, and the
Department of Biochemistry, University of Pennsylvania
School of Dental Medicine.
Received for publication September 30, 2005; accepted April
20, 2006.
Presented at the 47th Annual Meeting of the Plastic Surgery
Research Council, in Boston, Massachusetts, April 19, 2002.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279527.99734.bf
these disorders in male infants remains unex-
plained but may indicate that circulating andro-
gens can influence early development of the
craniofacial skeleton. With development of the
testes beginning at the sixth week of gestation,
the male fetus is exposed to elevated levels of
circulating androgens,6 and the disparity in lev-
els of serum androgens initiates developmental
differences in male and female fetuses.
It has long been recognized that androgens
play an important role in postnatal skeletal de-
velopment and maintenance of bone mass.7,8
Boys with androgen deficiency have lower bone
mineral density and increased bone resorption
compared with those with normal serum andro-
gen levels.7,9 Subsequent androgen replacement

www.PRSJournal.com 1137
 Plastic and Reconstructive Surgery • October 2007
can increase noggin-overexpressing mice, in-
hibit bone resorption, and stimulate bone
formation.9 Androgen supplementation in the
setting of menopause-related osteoporosis and
ovariectomized animal models also has anabolic
effects on the skeleton.9 In vitro studies of hu-
man and mouse-derived osteoblasts and osteo-
blast-like cell lines have demonstrated that the
addition of testosterone or 5␣-dihydrotestoster-
one to culture medium stimulates the prolifera-
tion and differentiation of bone cells.10,11 Andro-
gen receptors have been identified in human
and rat osteoblastic cells12,13 and localized to os-
teoblasts, osteocytes, and hypertrophic chondro-
cytes in human long bones of both boys and
girls.14 We have recently demonstrated the pres-
ence of androgen receptors in calvarial osteo-
blasts and dura mater of the fetal craniofacial
skeleton in both male and female mice.15
Numerous published studies suggest that the
underlying dura mater guides the development of
the calvaria and cranial sutures through patterned
expression of osteogenic growth factors such as
the transforming growth factor (TGF)-␤s.16 –19
Other studies have also demonstrated that immature
dural cells have the capacity to differentiate into os-
teoblasts, producing bone matrix proteins.20,21 Our
recent finding of androgen receptor expression in
fetal dura mater and calvarial osteoblasts suggests
that androgens may act directly on immature dural
cells and calvarial osteoblasts.15 However, no in
vitro studies investigating the osteogenic effects
of androgens on immature dural cells and other
elements of the fetal craniofacial skeleton have
been performed to date. The purpose of these
studies was to examine the effects of androgen
signaling on the proliferation and differentiation
of fetal dural and calvarial bone cells and on the
development of fetal cranial sutures, thereby iden-
tifying a potential role for male sex steroid hor-
mones in both normal and abnormal craniofacial
development.
MATERIALS AND METHODS
Cells were cultured in Dulbecco’s modified Ea-
gle’s medium (Gibco, Grand Island, N.Y.) with 10%
fetal calf serum (volume/volume) (Hyclone, Logan,
Utah); 2 mM L-glutamine (Gibco); and penicillin,
streptomycin, and amphotericin B (Gibco) in tissue
culture plates (Corning, Inc., Corning, N.Y.). 5␣-
Dihydrotestosterone, collagenase (type II), and L-
ascorbic acid 2-phosphate were obtained from
Sigma-Aldrich Corporation (St. Louis, Mo.).
1138
Cell Cultures
Primary fetal calvarial osteoblast and dural cell
cultures were established from temporal and pa-
rietal bones of fetal (E18) mice and the underlying
dura mater, respectively. Briefly, fetal timed-ges-
tation, pregnant CD-1 female mice were killed by
means of isoflurane inhalation or carbon dioxide
asphyxiation according to The Children’s Hospi-
tal of Philadelphia Institutional Animal Care and
Use Committee protocol. Using sterile technique,
the fetuses were removed through a midline lap-
arotomy incision and cleaned in povidone-iodine
and 70% ethanol, and then washed in phosphate-
buffered saline solution (Gibco) and tissue cul-
ture media composed of Dulbecco’s modified Ea-
gle’s medium supplemented with 10% fetal calf
serum; 2 mM L-glutamine; and penicillin, strep-
tomycin, and amphotericin B. The fetal heads
were isolated and dissected to expose the cranial
vault. The dura mater was stripped from the cal-
varia, and the temporal and parietal bones were
finely minced. Cells were isolated by sequential
20-minute digestions at 37°C in Hanks’ balanced
salt solution (Mediatech, Inc., Herndon, Va.) with
0.025% trypsin-ethylenediaminetetraacetic acid
(Gibco) and collagenase (1 mg/ml), and each
fraction was cultured to confluence in tissue cul-
ture media. Dural cells were collected from all
dural fractions, and calvarial osteoblasts were ob-
tained from the second and third enzymatic di-
gests of bone and from explant cultures of the
remaining bone chips. Bone cells were cultured
with tissue culture media supplemented with 50
␮g/ml of L-ascorbic acid 2-phosphate to support
osteoblast differentiation. Previous experiments
in our laboratory have shown similar expression
patterns of androgen receptor in the fetal dura
mater and the overlying craniofacial skeleton in
male and female subjects.15 Thus, cell cultures
originated from digests of pooled male and female
fetal tissue. Cells were used in all experiments on
the first passage after collagenase digestion.
Cell Proliferation
Dural cells or calvarial osteoblasts (10,000 cells
per well) were plated onto 96-well plates and then
cultured in the presence of 5␣-dihydrotestoster-
one or as untreated controls for 48 hours. Cell
proliferation was measured by colorimetric reduc-
tion of 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxy-
methoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium
(MTS; Promega Corp., Madison, Wis.). Prolifera-
tion assays were performed in triplicate, and mean
spectrophotometric absorbances were compared.
Volume 120, Number 5 • Cranial Suture Fusion
As a control, a range of known numbers of dural
cells and osteoblasts were plated and allowed to
adhere overnight, and the MTS cell proliferation
assay was performed to verify the high correlation
between optical density and cell counts (data not
shown).
RNA Extraction and Reverse-Transcriptase
Polymerase Chain Reaction Analysis
First, 2 ⫻ 105 cells were plated onto each well
of a six-well plate and grown overnight in tissue
culture media. Then, cells were cultured in tissue
culture media with 0, 10, 20, 100, or 1000 nM of
5␣-dihydrotestosterone for 48 hours.
Cell monolayers were washed with cold Hanks’
balanced salt solution twice, and total RNA was
extracted with TRIzol Reagent following the prod-
uct’s protocol for RNA isolation (Gibco). Total
RNA was quantitated by spectrophotometry, and
RNA quality was confirmed by gel electrophoresis.
One microgram of RNA was treated with
DNase I (amplification grade; Gibco) and then
reverse transcribed to cDNA using the SuperScript
II First-Strand Synthesis System for RT-PCR (In-
vitrogen Corp., Carlsbad, Calif.). cDNA was then
amplified by polymerase chain reaction using
primers specific for mRNAs indicative of osteo-
blast differentiation: alkaline phosphatase, col-
lagen type I␣, osteopontin, osteocalcin, and
TGF-␤1. Primer sequences are listed in Table 1.
Annealing temperatures and cycle numbers were
determined for each primer sequence using dural
Table 1. Primer Sequences Used in
Reverse-Transcriptase Polymerase Chain Reaction*
Gene Primer Sequences
Alkaline Sense: GAC TGG TAC TCG GAT AAC
phosphatase GAG ATG C
Antisense: TGC GGT TCC AGA CAT
AGT GG
Collagen type Ia Sense: ACC ATC TGG CAT CTC ATG
GC
Antisense: GCA ACA CAA TTG CAC
CTG AGG
Osteopontin Sense: GCC TGA CCC ATC TCA GAA
GCA GAA T
Antisense: TAA GCC AAG CTA TCA
CCT CGG CCG T
Osteocalcin Sense: CTC TGT CTC TCT GAC CTC
ACA G
Antisense: GGA GCT GCT GTG ACA
TCC ATA C
TGF-␤1 Sense: GGT TCA TGT CAT GGA TGG
TG
Antisense: CTG GTA GAG TTC CAC
ATG TTG C
*All sequences are 5= to 3=.
and calvarial cell-derived cDNA. The amplified
product was separated by electrophoresis in a
1.5% agarose gel. Polymerase chain reaction am-
plification was performed with Amplitaq Gold
DNA polymerase (Applied Biosystems, Foster City,
Calif.) and GeneAmp dNTPs (Applied Biosys-
tems). Relative gene expression was measured by
optical density of bands of amplified products.
Optical densities were normalized against ␤-actin
expression. Experiments were performed in trip-
licate, and mean values between treatment groups
were compared.
Tissue Culture of Murine Fetal Calvariae with
5␣-Dihydrotestosterone
Nine calvariae were isolated with attached
dura mater from fetal mice using aseptic tech-
nique. The calvariae were cultured in tissue cul-
ture media with 10 nM of 5␣-dihydrotestosterone
or culture media alone as controls for 7 and 14
days. The concentration of 10 nM of 5␣-dihy-
drotestosterone was selected from our cell culture
data and previously published data demonstrating
the osteogenic effects of 5␣-dihydrotestosterone
on osteoblasts at physiologic levels compared with
supraphysiologic concentrations.10,11 The 5␣-dihy-
drotestosterone–treated group included two or
three calvariae per time point and the control
group had two calvariae per time point. The cal-
variae were then fixed in formalin, decalcified
with Cal-Ex decalcifier (Fisher Scientific, Pitts-
burgh, Pa.), embedded in paraffin, and sectioned
at 4 to 6 ␮m. Specifically, multiple coronal sections
of the sagittal sutures made at various points span-
ning the sagittal suture were stained with hema-
toxylin and eosin and examined for cell prolifer-
ation and osteoid formation at the osteogenic
fronts and across the suture. Between 12 and 25
sections of each sagittal suture, treated or un-
treated, were studied under light microscopy.
RESULTS
5␣-Dihydrotestosterone Stimulates Mitogenesis
of Fetal Dural Cells and Fetal Calvarial
Osteoblasts
Figure 1 depicts the proliferation of fetal dural
cells and fetal calvarial osteoblasts after 48 hours
of culture with 0, 5, 10, 20, 100, or 1000 nM of
5␣-dihydrotestosterone, as measured by spectro-
photometry. In both cell populations, the most
significant responses to 5␣-dihydrotestosterone
were noted at 5 nM and 10 nM. The proliferative
effects waned at higher concentrations of approx-
imately 20 and 100 nM but were more noticeable
1139
 Plastic and Reconstructive Surgery • October 2007

Fig. 1. Cell proliferation of fetal calvarial osteoblasts (above) and dural

cells (below) after 48 hours of exposure to 5␣-dihydrotestosterone. Primary
fetal calvarial osteoblasts and dural cells were obtained from fetal mice and
pulsed with 5␣-dihydrotestosterone at 0, 5, 10, 20, 100, and 1000 nM for 48
hours. Proliferation was measured by spectrophotometry from nonradio-
active proliferation assay. These results show that maximal proliferation
occurred at 5 nM 5␣-dihydrotestosterone, with an increase of 20.5 percent
over controls in calvarial osteoblasts (above) and 46.0 percent in dural cells
(below).

at the highest dose tested of 1000 nM of 5␣-dihy-
drotestosterone. The calvarial osteoblasts prolif-
erated to almost the same degree as the peak at 5
nM of 5␣-dihydrotestosterone. Exposure to 5 nM
of 5␣-dihydrotestosterone for 48 hours resulted in
a 20.5 percent increase in cell number of the cal-
varial bone cells compared with no 5␣-dihydrotes-
tosterone in cell culture and a 46.0 percent in-
crease in the number of dural cells compared with
controls.
5␣-Dihydrotestosterone Stimulates Osteogenic
Differentiation of Fetal Dural Cells in a
Dose-Dependent Fashion
Fetal dural cells were cultured with 0, 10, 20,
100, or 1000 nM of 5␣-dihydrotestosterone for 48
hours, and the mRNA transcripts were amplified
for markers of osteoblastic differentiation or for
␤-actin as an internal control. Figure 2 shows the
overall dose-dependent increase in the number of
gene transcripts of collagen type 1␣, alkaline phos-
phatase, osteopontin, osteocalcin, and TGF-␤1,
normalized against ␤-actin amplification, seen
with escalating doses of 5␣-dihydrotestosterone.
Effects of 5␣-Dihydrotestosterone on the
Differentiation of Fetal Calvarial Osteoblasts
Figure 3 illustrates the expression of genetic
markers for osteoblast differentiation, normalized
against ␤-actin expression, isolated from fetal cal-
varial osteoblasts cultured with 0, 10, 20, 100, or
1000 nM of 5␣-dihydrotestosterone for 48 hours.
Alkaline phosphatase transcription increased in a
dose-dependent fashion, as in dural cell cultures.

1140
Volume 120, Number 5 • Cranial Suture Fusion

Fig. 2. Gene expression of osteoblast markers in fetal dural cells after 48 hours of culture with 5␣-dihydrotestosterone. After 48 hours
of culture with 0, 10, 20, 100, or 1000 nM 5␣-dihydrotestosterone, total RNA from fetal murine dural cells was isolated, and mRNA
transcripts were reverse-transcribed and amplified using primers for collagen type I␣ (above, left), alkaline phosphatase (above, right),
osteopontin (center, left), TGF-␤1 (center, right), and osteocalcin (below). Relative gene expression was calculated by optical densi-
tometry normalized to ␤-actin expression.

In contrast, there was decreased expression of col-
lagen type 1␣ in osteoblasts at all concentrations
of 5␣-dihydrotestosterone. Osteopontin and os-
teocalcin mRNA levels were also not affected by
5␣-dihydrotestosterone, and the level of osteopon-
tin expression was high in controls as a baseline.
TGF-␤1 gene expression rose in a limited fashion
at physiologic levels of 5␣-dihydrotestosterone but
did not change with higher concentrations of 5␣-
dihydrotestosterone.
5␣-Dihydrotestosterone Induces Fusion of Fetal
Sagittal Sutures In Vitro
After 7 days of 5␣-dihydrotestosterone stimu-
lation, all three sagittal sutures demonstrated cell

1141
 Plastic and Reconstructive Surgery • October 2007

Fig. 3. Gene expression of osteoblast markers in fetal calvarial osteoblasts after 48 hours of culture with 5␣-dihydrotestosterone.
After 48 hours of culture with 0, 10, 20, 100, or 1000 nM 5␣-dihydrotestosterone, total RNA from fetal murine calvarial bone cells was
isolated, and mRNA transcripts were reverse-transcribed and amplified using primers for collagen type I␣ (above, left), alkaline
phosphatase (above, right), osteopontin (center, left), TGF-␤1 (center, right), and osteocalcin (below). Relative gene expression was
calculated by optical densitometry normalized to ␤-actin expression.

proliferation at the osteogenic fronts and new os-
teoid formation bridging the sutures (Fig. 4). All
control sagittal sutures remained acellular and
patent. After 14 days of incubation with 5␣-dihy-
drotestosterone, all treated sagittal sutures dem-
onstrated even greater bone matrix deposition,
with osteoid obliterating the sutures (Fig. 5).
Again, both control sutures at day 14 remained
patent, with no osteoid formation. These findings
were consistent at multiple sections of each suture.
Of note, overlapping of the sagittal sutures in cul-
ture was an artifact of the tissue culture and his-
tologic processing technique.
DISCUSSION
These experiments demonstrate that (1)
physiologic doses of 5␣-dihydrotestosterone
stimulate proliferation of fetal dural cells and
calvarial osteoblasts, (2) 5␣-dihydrotestosterone
has a positive dose-dependent effect on dural cell
expression of osteoblast markers, (3) 5␣-dihy-
drotestosterone has limited effects on expression

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Volume 120, Number 5 • Cranial Suture Fusion

Fig. 4. Coronal sections of sagittal sutures from calvariae grown in organ culture with 10 nM 5␣-dihydrotestosterone for 7 days.
Calvariae with intact dura mater were harvested from fetal mice and grown in organ culture with (above) and without 5␣-dihy-
drotestosterone (below) for 7 days. Sagittal sutures exposed to 5␣-dihydrotestosterone demonstrate bridging by new bone forma-
tion (arrow). The control sutures remain patent [hematoxylin and eosin; original magnification, ⫻20 (left) and ⫻40 (right)].

of osteoblast markers of differentiation in more head circumference in male fetuses, resulting in

mature osteoblasts from fetal calvariae, and (4)
the addition of 5␣-dihydrotestosterone to culture
media can induce fusion of the sagittal suture in
tissue culture.
Epidemiologic studies have consistently doc-
umented a male predominance of certain forms of
craniosynostosis, such as nonsyndromic metopic
and sagittal craniosynostoses. In 1976, Hunter
and Rudd reported that 73 percent of cases of
sagittal synostosis studied involved male children,5
whereas Shillito and Matson’s 1968 review docu-
mented that male infants made up 78 percent of
cases of sagittal synostosis.22 More recent studies
confirm these earlier observations. Lajeunie et al.
analyzed patients with metopic and sagittal synos-
tosis in France and reported male-to-female ratios
of 3.3:1 and 3.5:1, respectively.1,2 In the study by
Sloan et al., 77 percent of patients treated surgi-
cally for sagittal synostosis were male.23 It has been
postulated that the male predominance in certain
forms of craniosynostosis is attributable to a larger
late gestational intrauterine constraint.4,23 We hy-
pothesize that higher levels of circulating serum
androgens in male infants may predispose such
infants to enhanced bone formation, and our re-
sults suggest that this mechanism, on a cellular
level, is possible.
The finding that 5␣-dihydrotestosterone at
physiologic levels stimulates proliferation of fetal
calvarial osteoblasts supports previous research
demonstrating that 5␣-dihydrotestosterone stim-
ulates proliferation of bone cells.10,11 Kasperk et al.
were the first to report that androgens directly
stimulate proliferation of the osteosarcoma cell
line TE89.10 More specifically, cell proliferation
was increased after 5␣-dihydrotestosterone expo-
sure at 1 and 10 nM but not at 5␣-dihydrotestos-
terone concentrations higher than 10 nM.10 Gray
et al. studied the effects of 5␣-dihydrotestosterone
on primary osteoblast cultures from rat calvarial
and long bones and found significant increases in
DNA synthesis at 10 and 100 nM of 5␣-dihydro-

1143
 Plastic and Reconstructive Surgery • October 2007

Fig. 5. Coronal sections of sagittal sutures from calvariae grown in organ culture with 10 nM 5␣-dihydrotestosterone for 14 days.
Calvariae with intact dura mater were harvested from fetal mice and grown in organ culture with (above) and without (below)
5␣-dihydrotestosterone for 14 days. There is extensive new bone formation (arrow) within the sagittal suture after exposure to
5␣-dihydrotestosterone, leading to suture fusion. Control suture remains patent [hematoxylin and eosin; original magnification,
⫻20 (left) and ⫻40 (right)].

testosterone.11 Other researchers have reported
that 5␣-dihydrotestosterone inhibits cell prolifer-
ation in bone cells. Using HOS-TE85 cells, Benz et
al. found that 10 nM of 5␣-dihydrotestosterone in
culture decreased cell counts in 3 days.30 These
conflicting results may be attributable to differ-
ences inherent in the type and origin of cells and
in the time points studied.
The effects of 5␣-dihydrotestosterone on dif-
ferentiation of calvarial bone cells in vitro were
mixed. The presence of 5␣-dihydrotestosterone
stimulated alkaline phosphatase in a dose-depen-
dent manner. Collagen type 1␣ gene expression
decreased in the presence of 5␣-dihydrotestoster-
one, and osteopontin and osteocalcin expression
varied minimally. With high relative osteopontin
expression, it may be that the osteoblasts are near-
ing late stages of maturation. This may explain the
limited effects of 5␣-dihydrotestosterone on ge-
netic markers of osteoblast differentiation. This
rationale may also clarify the decrease in collagen
type 1␣ seen with increasing concentrations of
5␣-dihydrotestosterone. The variation in the ef-
fects of 5␣-dihydrotestosterone mirror those pre-
viously reported in published studies. Takeuchi et
al. found that 5␣-dihydrotestosterone stimulation
of HOS-TE85 cells increased the calcium content
of the extracellular matrix but had no effect on
osteocalcin production or alkaline phosphatase
activity.31 Conversely, Kasperk et al. demonstrated
that 5␣-dihydrotestosterone stimulated alkaline
phosphatase activity, osteocalcin secretion, and
mineral formation.32 Gray et al. found increased
collagen type 1␣ synthesis in neonatal calvarial
explant cell cultures with 5␣-dihydrotestosterone
in culture but minimal change in alkaline phos-
phatase activity in primary long bone cultures with
5␣-dihydrotestosterone.11 Again, the apparently
conflicting results of this study and previous publi-
cations may be attributable to variation in the origin
of cells studied and may reflect the mixed cell pop-
ulation that can be found in primary bone cultures.

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Volume 120, Number 5 • Cranial Suture Fusion
The influence of androgens on dural cell pro-
liferation and differentiation has not been previ-
ously investigated. Dura mater is fibrous tissue
with a rich collagen framework produced by dural
fibroblasts. Immature dura mater from fetal and
neonatal animals appears to also contain subpopu-
lations of osteoprogenitor-like cells that are able to
differentiate into osteoblasts and of cells that are
able to promote calvarial osteoblast differentia-
tion through paracrine signaling.20,21,33 Trans-
planted immature dura mater can induce bony
regeneration of calvarial defects compared with
transplanted adult dura mater.34 Manipulation of
the regional dura mater underlying the sutures
has been shown to induce or prevent cranial su-
ture fusion.16,18 These studies indicate that cells
from different regions of dura mater behave dif-
ferently, such that one area of dura mater may
promote osteogenesis and suture fusion and an-
other area of dura mater maintains suture pa-
tency. Furthermore, the same region of dura ma-
ter may change over time, maintaining suture
patency early in development and permitting su-
ture fusion as the craniofacial skeleton matures.
Thus, dural cells in aggregate may contain cells
with pro-osteogenic capacities and cells pro-
grammed to inhibit osteogenesis and suture fu-
sion. In our experiments with murine fetal dura,
technical limitations restricted analysis to the ef-
fects of androgens on pooled dural cells. Inter-
estingly, 5␣-dihydrotestosterone has a greater pro-
liferative effect on fetal dural cells than on fetal
calvarial osteoblasts. 5␣-Dihydrotestosterone also
promotes the osteoblastic differentiation of fetal
dural cells, as demonstrated by gene expression of
bone matrix proteins and osteogenic growth fac-
tors. In our experiments, 5␣-dihydrotestosterone
had a dose-dependent effect on the expression of
alkaline phosphatase, collagen type 1␣, osteopon-
tin, and osteocalcin by fetal dural cells. These
genes are all expressed by differentiating osteo-
blasts, and osteocalcin is indicative of late-stage
mature osteoblasts in active mineralization. These
results confirm previous research demonstrating
that cell lines derived from immature dura mater
tissue contain a subpopulation of osteoblast-like
cells.21 Our results suggest that androgens may
further stimulate the proliferation and osteogenic
differentiation of immature dural cells.
5␣-Dihydrotestosterone dramatically stimu-
lated TGF-␤1 gene expression in fetal dural cells
and slightly increased TGF-␤1 expression in fetal
bone cells at physiologic levels. TGF-␤ is stored in
large quantities in the bone matrix, and expres-
sion of its isoforms has been characterized in var-
ious stages of suture development. Opperman et
al. found that TGF-␤1 expression increases in fus-
ing murine sutures.17 Furthermore, 5␣-dihydrotes-
tosterone–stimulated alkaline phosphatase pro-
duction in osteoblasts is inhibited by neutralizing
antibodies to TGF-␤.32 Stimulation of TGF-␤1 ex-
pression in dural cells by 5␣-dihydrotestosterone
suggests that androgen-induced bone formation
may be mediated by TGF-␤1 and may play a role
in normal and/or pathologic suture fusion. The
role of TGF-␤ in androgen-induced osteogenesis
in the fetal craniofacial skeleton remains to be
further investigated.
5␣-Dihydrotestosterone induced fusion in mu-
rine sagittal sutures in tissue culture; this suture is
normally patent in vivo and in vitro.35 This is the
first report of the ability of androgens to induce
fusion of normally patent cranial sutures. All sag-
ittal sutures that were exposed to physiologic levels
of androgen in vitro showed signs of new bone
formation when compared with controls. The gen-
der of the fetuses from which the calvariae were
harvested should not have influenced the tissue
cultures, because the calvariae were cultured in
isolation from any endogenous source of testos-
terone. Furthermore, we have recently demon-
strated with immunohistochemical techniques
that the expression of androgen receptor in the
craniofacial skeleton is similar between male and
female fetuses.15 Our finding of 5␣-dihydrotestos-
terone–induced fusion of sagittal sutures in tissue
culture is not to be directly compared with the
clinical presentation of sagittal suture synostosis in
male infants, but this study does demonstrate that
5␣-dihydrotestosterone at physiologic concentra-
tions has the capability of inducing fusion of sag-
ittal sutures in tissue culture.
The results of the present study indicate that
androgens promote proliferation of dural cells
and osteoblasts and osteogenic differentiation of
dural cells in the fetal craniofacial skeleton and
fusion of the sagittal suture in vitro, suggesting a
possible explanation for the epidemiologic obser-
vations of a higher incidence of certain nonsyn-
dromic synostoses in male infants. 5␣-Dihydrotes-
tosterone has a much more dramatic effect on
fetal dural cells, with regard to both proliferation
and differentiation, when compared with calvarial
osteoblasts. When considered with the sagittal su-
ture fusion observed in organ culture, one may
postulate that the sutural effects of 5␣-dihydrotes-
tosterone are a result of differentiating dural cells
being recruited into the suture, thereby promot-
ing bony deposition and ultimately suture fusion.
This hypothesis can thereby account for the sag-
1145
 Plastic and Reconstructive Surgery • October 2007
ittal suture fusion induced by 5␣-dihydrotestoster-
one in vitro and the limited differentiation after
5␣-dihydrotestosterone stimulation that was seen
in the fetal calvarial osteoblasts. Another possible
mechanism of androgen-induced calvarial suturo-
genesis is the increased release of intercellular
mediators, such as growth factors, by fetal dural
cells following androgen stimulation, thereby
resulting in stimulation of osteoblast activity.
Recent co-culture experiments with immature
dural cells and calvarial osteoblasts demonstrate
that immature dural cells, likely through se-
creted mediators, enhance osteoblast prolifera-
tion and differentiation.33
CONCLUSIONS
These experiments demonstrate the mito-
genic and osteogenic effects of 5␣-dihydrotestos-
terone on fetal dural cells and calvarial osteoblasts
and the promotion of sagittal suture fusion by
5␣-dihydrotestosterone exposure in vitro. These
observations lend support to the hypothesis that
androgens may play a role in pathologic suture
fusion.
Richard E. Kirschner, M.D.
Division of Plastic Surgery
The Children’s Hospital of Philadelphia
Wood Ambulatory Care Building, First Floor
34th and Civic Center Boulevard
Philadelphia, Pa. 19104-4399
kirschner@email.chop.edu
ACKNOWLEDGMENT
This work was supported by a Cleft Palate Founda-
tion Research grant.
DISCLOSURE
The authors have no financial conflicts of interest in
the publication of this article.
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and Renier, D. Genetic study of scaphocephaly. Am. J. Med.
Genet. 62: 282, 1996.
2. Lajeunie, E., Le Merrer, M., Marchac, D., and Renier, D.
Syndromal and nonsyndromal primary trigonocephaly: Anal-
ysis of a series of 237 patients. Am. J. Med. Genet. 75: 211, 1998.
3. Mulliken, J. B., Vander Woude, D. L., Hansen, M., LaBrie,
R. A., and Scott, R. M. Analysis of posterior plagiocephaly:
Deformational versus synostotic. Plast. Reconstr. Surg. 103:
371, 1999.
4. Graham, J. M., Jr., deSaxe, M., and Smith, D. W. Sagittal
craniostenosis: Fetal head constraint as one possible cause.
J. Pediatr. 95: 747, 1979.
5. Hunter, A. G., and Rudd, N. L. Craniosynostosis. I. Sagittal
synostosis: Its genetics and associated clinical findings in 214
patients who lacked involvement of the coronal suture(s).
Teratology 14: 185, 1976.
1146
6. Hughes, I. A. Minireview: Sex differentiation. Endocrinology
142: 3281, 2001.
7. Wiren, K. M., and Orwoll, E. S. Androgens: Receptor ex-
pression and steroid action in bone. In J. P. Bilezikian, L. G.
Raisz, and R. A. Rodan (Eds.), Principles of Bone Biology 1. San
Diego: Academic Press, 2002. Pp. 757–772.
8. Vanderschueren, D., and Bouillon, R. Androgens and bone.
Calcif. Tissue Int. 56: 341, 1995.
9. Hofbauer, L. C., and Khosla, S. Androgen effects on bone
metabolism: Recent progress and controversies. Eur. J. En-
docrinol. 140: 271, 1999.
10. Kasperk, C. H., Wergedal, J. E., Farley, J. R., Linkhart, T. A.,
Turner, R. T., and Baylink, D. J. Androgens directly stimulate
proliferation of bone cells in vitro. Endocrinology 124: 1576,
1989.
11. Gray, C., Colston, K. W., Mackay, A. G., Taylor, M. L., and
Arnett, T. R. Interaction of androgen and 1,25-dihydroxyvi-
tamin D3: Effects on normal rat bone cells. J. Bone Miner. Res.
7: 41, 1992.
12. Colvard, D. S., Eriksen, E. F., Keeting, P. E., et al. Identifi-
cation of androgen receptors in normal human osteoblast-
like cells. Proc. Natl. Acad. Sci. U.S.A. 86: 854, 1989.
13. Orwoll, E. S., Stribrska, L., Ramsey, E. E., and Keenan, E. J.
Androgen receptors in osteoblast-like cell lines. Calcif. Tissue
Int. 49: 183, 1991.
14. Abu, E. O., Horner, A., Kusec, V., Triffitt, J. T., and Compston,
J. E. The localization of androgen receptors in human bone.
J. Clin. Endocrinol. Metab. 82: 3493, 1997.
15. Lin, I. C., Slemp, A. E., Hwang, C., Karmacharya, J., Gordon,
A. D., and Kirschner, R. E. Immunolocalization of androgen
receptor in the developing craniofacial skeleton. J. Craniofac.
Surg. 15: 922, 2004.
16. Bradley, J. P., Levine, J. P., McCarthy, J. G., and Longaker, M.
T. Studies in cranial suture biology: Regional dura mater
determines in vitro cranial suture fusion. Plast. Reconstr. Surg.
100: 1091, 1997.
17. Opperman, L. A., Nolen, A. A., and Ogle, R. C. TGF-beta 1,
TGF-beta 2, and TGF-beta 3 exhibit distinct patterns of ex-
pression during cranial suture formation and obliteration in
vivo and in vitro. J. Bone Miner. Res. 12: 301, 1997.
18. Opperman, L. A., Passarelli, R. W., Morgan, E. P., Reintjes,
M., and Ogle, R. C. Cranial sutures require tissue interactions
with dura mater to resist osseous obliteration in vitro. J. Bone
Miner. Res. 10: 1978, 1995.
19. Opperman, L. A., Sweeney, T. M., Redmon, J., Persing, J. A.,
and Ogle, R. C. Tissue interactions with underlying dura
mater inhibit osseous obliteration of developing cranial su-
tures. Dev. Dyn. 198: 312, 1993.
20. Mehrara, B. J., Greenwald, J., Chin, G. S., et al. Regional
differentiation of rat cranial suture-derived dural cells is
dependent on association with fusing and patent cranial
sutures. Plast. Reconstr. Surg. 104: 1003, 1999.
21. Greenwald, J. A., Mehrara, B. J., Spector, J. A., et al. Biomo-
lecular mechanisms of calvarial bone induction: Immature
versus mature dura mater. Plast. Reconstr. Surg. 105: 1382,
2000.
22. Shillito, J., Jr., and Matson, D. D. Craniosynostosis: A review
of 519 surgical patients. Pediatrics 41: 829, 1968.
23. Sloan, G. M., Wells, K. C., Raffel, C., and McComb, J. G.
Surgical treatment of craniosynostosis: Outcome analysis of
250 consecutive patients. Pediatrics 100: E2, 1997.
24. Hughes, I. A., Lim, H. N., Martin, H., et al. Developmental
aspects of androgen action. Mol. Cell. Endocrinol. 185: 33,
2001.
25. Voutilainen, R. Differentiation of the fetal gonad. Horm. Res.
38 (Suppl. 2): 66, 1992.
Volume 120, Number 5 • Cranial Suture Fusion

26. Slob, A. K., Ooms, M. P., and Vreeburg, J. T. Prenatal and
early postnatal sex differences in plasma and gonadal tes-
tosterone and plasma luteinizing hormone in female and
male rats. J. Endocrinol. 87: 81, 1980.
27. Weisz, J., and Ward, I. L. Plasma testosterone and proges-
terone titers of pregnant rats, their male and female fetuses,
and neonatal offspring. Endocrinology 106: 306, 1980.
28. Houtsmuller, E. J., de Jong, F. H., Rowland, D. L., and Slob,
A. K. Plasma testosterone in fetal rats and their mothers on
day 19 of gestation. Physiol. Behav. 57: 495, 1995.
29. Meulenberg, P. M., and Hofman, J. A. Maternal testosterone
and fetal sex. J. Steroid Biochem. Mol. Biol. 39: 51, 1991.
30. Benz, D. J., Haussler, M. R., Thomas, M. A., Speelman, B., and
Komm, B. S. High-affinity androgen binding and androgenic
regulation of alpha 1(I)-procollagen and transforming
growth factor-beta steady state messenger ribonucleic acid
levels in human osteoblast-like osteosarcoma cells. Endocri-
nology 128: 2723, 1991.
31. Takeuchi, M., Kakushi, H., and Tohkin, M. Androgens di-
rectly stimulate mineralization and increase androgen re-
ceptors in human osteoblast-like osteosarcoma cells. Biochem.
Biophys. Res. Commun. 204: 905, 1994.
32. Kasperk, C. H., Wakley, G. K., Hierl, T., and Ziegler, R. Gonadal
and adrenal androgens are potent regulators of human bone
cell metabolism in vitro. J. Bone Miner. Res 12: 464, 1997.
33. Spector, J. A., Greenwald, J. A., Warren, S. M., et al. Co-
culture of osteoblasts with immature dural cells causes an
increased rate and degree of osteoblast differentiation. Plast.
Reconstr. Surg. 109: 631, 2002.
34. Hobar, P. C., Schreiber, J. S., McCarthy, J. G., and Thomas,
P. A. The role of the dura in cranial bone regeneration in the
immature animal. Plast. Reconstr. Surg. 92: 405, 1993.
35. Bradley, J. P., Levine, J. P., Blewett, C., Krummel, T.,
McCarthy, J. G., and Longaker, M. T. Studies in cranial suture
biology: In vitro cranial suture fusion. Cleft Palate Craniofac.
J. 33: 150, 1996.

Instructions for Authors: Update

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Editor a statement that the study was approved by an institutional review committee or ethics committee and
that all human subjects gave informed consent. Such approval should be described in the Methods section
of the manuscript. For studies conducted with human subjects, the method by which informed consent was
obtained from the participants (i.e., verbal or written) also needs to be stated in the Methods section.
In those situations where a formal institutional review board process is not available, the authors must indicate
that the principles outlined in the Declaration of Helsinki have been followed. More information regarding
the Declaration of Helsinki can be found at http://www.wma.net/e/policy/b3.htm.

1147
EXPERIMENTAL

The Effect of Fibrin on the Survival of Ischemic

Skin Flaps in Rats
Zhi Qi, M.D.
Yuanjun Gu, M.D., Ph.D.
Dohoon Kim, Ph.D.
Akihito Hiura, M.D., Ph.D.
Shoichiro Sumi, M.D., Ph.D.
Kazutomo Inoue, M.D.,
Ph.D.
Kyoto, Japan
Background: Skin flap necrosis is one of the hazards encountered in plastic and
reconstructive surgery. Angiogenic agents may be useful for treating it by in-
creasing blood flow. The angiogenic effect of fibrin in vitro has been demon-
strated, but little is known about its in vivo effect. Te authors tested the hy-
pothesis that local application of fibrin can improve the survival of ischemic skin
flaps.
Methods: A cranially based dorsal skin flap (3 ⫻ 7 cm) was made in each rat.
Fibrin (8 mg suspended in 400 ␮l of phosphate-buffered saline) was applied to
the subcutaneous side of elevated skin flaps in the experimental group (n ⫽ 15),
and phosphate-buffered saline alone was delivered in the control group (n ⫽
15). Tissue blood flow of the skin flaps was measured four times (before the
operation and on days 1, 3, and 7) at 1, 3, and 5 cm distal to the baseline of the
skin flap. The survival rate of the skin flaps was measured on day 7 and histologic
assessments were performed.
Results: The blood flow change rate at 5 cm in the experimental group was
significantly higher than that in the control group on day 7 (60.9 ⫾ 5.7 percent
versus 13.7 ⫾ 4.8 percent, p ⬍ 0.001). The survival rate of skin flaps was also
significantly improved in the experimental group (77.0 ⫾ 2.0 percent) in
comparison with the control group (54.7 ⫾ 2.2 percent, p ⬍ 0.01). Histologic
analysis showed many more blood vessels in the experimental group in com-
parison with the control group.
Conclusion: The local application of fibrin could improve the blood flow and
survival of ischemic skin flaps. (Plast. Reconstr. Surg. 120: 1148, 2007.)

S
kin flaps are usually made for the primary
coverage of a large bare area of the body
resulting from skin and tissue defects.1 In
skin flap surgery, distal ischemic necrosis is the
most important complication encountered.2–5 A
number of pharmacologic approaches have
been presented to overcome this problem; how-
ever, their effects have not been as efficacious as
expected.2 One alternative approach, surgical
delay, has been widely used to improve the sur-
vival of ischemic skin flaps. However, this ap-
proach has the disadvantage of being a two-stage
procedure, which causes increased surgical inva-
siveness and complications.2,6 – 8
Recently, angiogenic treatment with growth
factors has been reported to be effective in the
treatment of ischemic diseases.1,2,5,9 –12 The prin-
From the Department of Organ Reconstruction, Institute for
Frontier Medical Sciences, Kyoto University.
Received for publication February 8, 2006; accepted June 14,
2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279524.05541.5b
ciple of therapeutic angiogenesis is to achieve
adequate blood flow by enhancing capillary for-
mation, so that nutrients and oxygen are pro-
vided to ischemic tissues, thus preventing isch-
emic tissue necrosis. From this perspective,
angiogenic treatment can be regarded as a
promising approach for enhancing the survival
of ischemic tissues.2,9
Angiogenesis is a complex process and is reg-
ulated not only by angiogenic growth factors but
also by cellular environmental factors, such as
the extracellular matrix composition.13–16 Fibrin,
one of the important components of the extra-
cellular matrix, is formed after wounding or
when plasma leaks from blood capillaries to
form fibrinous exudates and has been used as a
type of hemostatic agent during surgery.17 Re-
cently, accumulated research evidence has
shown that fibrin promotes the capillary forma-
tion of endothelial cells in vitro.13,17–22 According
to these reports, fibrin acts not only as a sealing
matrix but also as a temporary scaffold that pro-
vides support for endothelial cells to migrate
and further enhances a series of interactions

1148 www.PRSJournal.com
Volume 120, Number 5 • Fibrin and Ischemic Skin Flaps
between endothelial cells and the extracellular
matrix to promote the proliferation of endothe-
lial cells, thus leading to angiogenesis.
Therefore, fibrin seems likely to be used as an
angiogenic agent in the treatment of wound
healing and ischemic tissues. However, its angio-
genic effect in vivo has rarely been reported. In
the present study, we examined the effect of
fibrin on an ischemic skin flap model and found
that a single application of fibrin could improve
the blood flow and survival of ischemic skin
flaps.
MATERIALS AND METHODS
Rat Ischemic Skin Flap Model
A total of 30 adult male Wistar rats (Shimizu
Laboratory Supplies Co., Ltd., Kyoto, Japan)
weighing 280 to 320 g were randomly divided into
a control group and an experimental group of 15
rats per group. Each rat was anesthetized by in-
traperitoneal injection of sodium pentobarbital
(25 mg/kg). After shaving the dorsal hair, the
shape of a cranially based dorsal skin flap (3 ⫻ 7
cm), beginning 1 cm below the inferior edge of
the scapula, was marked with a permanent marker
on the back of each rat. Under sterile conditions,
a full-thickness skin flap including subcutaneous
tissue was undermined and elevated on the base-
line. Eight milligrams of fibrin suspended in 400 ␮l
of phosphate-buffered saline was applied to the
subcutaneous side of the skin flap evenly in the
experimental group, and 400 ␮l of phosphate-
buffered saline alone was similarly applied in the
control group. The skin flap was then returned
immediately to its original place and secured to
the adjacent skin. Approval of this experiment was
obtained from the Animal Care Committee of the
Institute for Frontier Medical Sciences, Kyoto Uni-
versity, and the animals were treated according to
the experimental protocols under its regulations.
Fibrin Preparation
Fibrin was formed by adding 125 units of
thrombin (Sigma Chemical Co., St. Louis, Mo.) to
500 mg of fibrinogen (Sigma) dissolved in 500 ml
of phosphate-buffered saline (pH 7.2), followed
by mixing at room temperature for 1 hour, result-
ing in the formation of a gelatinous mass of dia-
lyzed fibrin. The dialyzed fibrin was washed with
distilled water for 30 minutes, three times. The
fibrin was then obtained on a paper filter (Advan-
tec Co., Ltd., Tokyo, Japan) and frozen at ⫺80°C
overnight in a centrifuge tube, followed by drying
overnight in a drying machine (FDU-830; Tokyo
Science Machine Co., Ltd., Tokyo, Japan). Finally,
fibrin was aliquoted at 8 mg per tube, sterilized in
a gas sterilizer (SA-360; Yoshimoto Sanyo Co., Ltd.,
Tokyo, Japan), and stored at room temperature
until use.
Measurement of Tissue Blood Flow
Tissue blood flow of the skin flaps was mea-
sured with a laser Doppler flow meter (LC-1;
Canon, Tokyo, Japan).23 Measurements were per-
formed four times (before surgery and on days 1,
3, and 7) at 1, 3, and 5 cm distal to the baseline of
the skin flap on the middle line of the skin flaps.
The output of the flow meter was set to take a
measurement every 6 seconds for the duration of
1 minute. The average of these 10 values was used
as the result of blood flow at each point. The blood
flow change rate was expressed as the percentage
of the value before surgery at the same position
(blood flow change rate ⫽ blood flow measured at day
1, 3, or 7/blood flow measured before operation ⫻ 100).
Measurement of Survival Rate of Skin Flaps
The survival rate of the skin flaps was observed
7 days after the operation by a blinded observer.
Rats were killed and photographs were taken with
a digital camera (Powershot A5; Canon, Tokyo,
Japan). After gross observation of the skin flaps,
zones of dark color and those covered with scabs
were defined as the necrotic area, and the other
areas of the skin flaps were defined as the surviving
area. To assess the survival rate, the digital image
was further processed with planimetric evaluation
using image analysis software (Mac Aspect version
3.3). The total area and the surviving area of each
flap were measured. Finally, the survival rate of the
skin flap was expressed as a percentage of the total
skin flap area (survival rate ⫽ surviving area/total
area ⫻ 100).
Histologic Assessment
A strip of the skin flap with subcutaneous tis-
sues was dissected from killed rats at day 7 for
histologic assessment. The samples were fixed in
4% paraformaldehyde in distilled water for 24
hours, followed by immersion into 70% ethanol at
4°C for 24 to 48 hours. Then, the samples were
embedded in paraffin and 5-␮m-thick sequential
sections were made. Two adjacent sections were
stained with either hematoxylin and eosin or im-
munohistochemical staining for ␣-smooth muscle
actin.
The sections for ␣-smooth muscle actin im-
munohistochemistry were pretreated with a mi-
1149
 Plastic and Reconstructive Surgery • October 2007
crowave in 10 mM citrate buffer (pH 6.0) for 10
minutes and then incubated with monoclonal
mouse anti-human ␣-smooth muscle actin anti-
body (Dako Corp., Carpinteria, Calif.) in a 1:50
dilution at room temperature for 30 minutes. The
sensitive staining technique was performed using
the peroxidase-labeled streptavidin biotin method
(LSAB Kit; Dako).
Finally, all specimens were examined under
light microscopy by a blinded observer. To further
study the effect of the single application of fibrin
for angiogenesis, the number of smooth muscle
actin–positive blood vessels was counted in four
random fields (original magnification, ⫻200) in
10 rats (five rats in the control group and five rats
in the experimental group). We further examined
the correlation between the blood flow change
rate and the skin flap survival rate.
Statistical Analysis
All values are expressed as the mean ⫾ SEM.
Statistical analysis was performed with analysis of
variance, and statistical significance was accepted
for values of p ⬍ 0.05.
RESULTS
Gross Observation
We observed the gross appearance in the con-
trol group daily after operation. On day 1, there
were no obvious changes. Various degrees of epi-
dermolysis appeared 2 to 3 days after surery. At day
4, necrosis began to appear clearly in the distal
portion of the skin flap, and 7 days after surgery,
a necrotic area was clearly defined with apparent
demarcation in all skin flaps.
Tissue Blood Flow
The results of the blood flow change rate are
listed in Table 1. There was a clear blood flow
gradient in the skin flap at each time point through-
out the experiment. There was no significant differ-
ence between the control group and the experimen-
tal group at 1 cm at any time point. In contrast, at 3
and 5 cm, the blood flow in the experimental group
Table 1. Comparison of Blood Flow Change Rate at Different Positions
1 cm (%)
Day Control Experimental Control
1 54.3 ⫾ 5.0 65.1 ⫾ 5.1 43.2 ⫾ 4.4
3 63.6 ⫾ 5.7 75.3 ⫾ 9.2 49.1 ⫾ 3.8
7 71.4 ⫾ 8.8 82.8 ⫾ 5.2 49.9 ⫾ 4.3
*p ⬍ 0.05.
†p ⬍ 0.001.
1150
was significantly higher than that in control group
on day 3 and day 7, respectively. Especially at 5 cm,
7 days after surgery, a dramatic difference was ob-
served between the control group (13.7 ⫾ 4.8 per-
cent) and the experimental group (60.9 ⫾ 5.7 per-
cent, p ⬍ 0.001). These results are also shown in
Figure 1. These figures suggest that the blood flow
generally tended to increase in a time-dependent
manner at 1 cm (Fig. 1, above) and 3 cm (Fig. 1,
center) except for that at 5 cm (Fig. 1, below) on day
7 in the control group. At this point, the blood flow
showed an apparent decrease and the values even
dropped to zero in nine cases.
Skin Flap Survival Rate
On day 7, a clear demarcation between the
surviving and necrotic regions was observed in the
skin flaps in both the control and the experimen-
tal groups. The surviving region appeared soft,
with a normal pink color. In contrast, the necrotic
region appeared rigid and had a dark color. It was
easy to distinguish between the surviving and ne-
crotic regions (Fig. 2). There was a significant
difference (p ⬍ 0.01) in the survival rate between
the control group (54.7 ⫾ 2.2 percent) and the
experimental group (77.0 ⫾ 2.0 percent).
Histologic Assessment
On hematoxylin and eosin staining, necrosis was
pathologically confirmed in the control group, and
blood vessels were barely detected, even in the seem-
ingly viable area of this group. In contrast, in the
experimental group, cells maintained their normal
morphologies, with very little evidence of necrosis,
and a greater number of blood vessels were observed
(Fig. 3). Similar findings were further confirmed by
␣-smooth muscle actin staining. A number of
smooth muscle actin–positive blood vessels were ob-
served in the experimental group but were barely
observed in the control group (Fig. 4). The quan-
tification of smooth muscle actin–positive blood ves-
sels showed a significant increase in the experimen-
tal group in comparison with that in the control
group (p ⬍ 0.001).
3 cm (%) 5 cm (%)
Experimental Control Experimental
58.2 ⫾ 4.0 26.0 ⫾ 2.8 35.7 ⫾ 4.0
67.8 ⫾ 4.6* 30.2 ⫾ 3.2 42.9 ⫾ 3.6*
71.7 ⫾ 5.1* 13.7 ⫾ 4.8 60.9 ⫾ 5.7†
Volume 120, Number 5 • Fibrin and Ischemic Skin Flaps
Fig. 1. Blood flow change rate at different positions in the con-
trol and experimental groups. Blood flow change rates at 1 cm
(above), 3 cm (center), and 5 cm (below) were expressed (*p ⬍
0.05; **p ⬍ 0.001).
Correlation between Blood Flow and Skin Flap
Survival Rate
There was a significantly positive correlation
between the survival rate and the blood flow
change rate at 5 cm on day 7. Parts of the data were
omitted because their blood flow values dropped
to zero (Fig. 5).
DISCUSSION
The angiogenic effect of fibrin has been in-
troduced by many researchers, but the studies are
limited to its function in vitro,13,17–22 leaving its
angiogenic effect in vivo still unknown. Regarding
the effect in vivo, beneficial effects of fibrin glue
on flaps have been studied in rat skin flap
models.24,25 However, in these studies, the authors
attributed the improved skin flap survival to the
adhesive effect of fibrin without assessing blood
flow or histology. Moreover, although Currie et
al.26 in their review stated that fibrin improves the
take of skin graft partly by accelerating angiogen-
esis, they drew this conclusion according to some
experimental results in vitro, without citing any in
vivo studies. Therefore, we examined the effect of
a single application of fibrin on an ischemic skin
flap model and evaluated not only the survival of
skin flaps but also the blood flow and histology.
According to some studies in vitro, some inter-
actions between fibrin and endothelial cells seem to
play a key role in the whole angiogenic course. Un-
der appropriate conditions, similar to those in tissue
repair and wound healing, endothelial cells im-
mersed in fibrin undergo a series of morphologic
changes, leading to the formation of a capillary-like
structure.17,18,21,22 Moreover, fibrin prepared by treat-
ing fibrinogen with thrombin is known to have an
angiogenic property, because thrombin mediates
the exposure of biochemical determinants in the
N-terminal region of fibrin that provides biological
signals to endothelial cells to make them differen-
tiate into capillaries. This terminal domain of fibrin,
peptide ␤ 15-42, appears to exert most of these bi-
ological effects in this process.17,18,21
To study distal ischemia, an appropriate isch-
emic skin flap model is necessary. In this study, we
used a skin flap model of acute ischemia, accord-
ing to the study of McFarlane et al.27 and the
previous study of Sumi et al., from our group.28
As for the advantages of this ischemic skin flap
model, they are that it is easy to make, and the
obvious distal necrosis in the control group (ap-
proximately 55 percent) can be easily observed.
In making this model, the most important point
is the size, especially the proportion of the
length to the width, because this influences the
percentage of necrotic area. To determine the
size of a skin flap, a series of preliminary exper-
iments of different flap sizes have been imple-
mented (data not shown). Finally, a size that
measured 3 ⫻ 7 cm (width ⫻ length) was de-
cided on because it showed an obvious distal
necrosis with good reproducibility.
1151
 Plastic and Reconstructive Surgery • October 2007

Fig. 2. The gross observation of the ischemic skin flaps at postoperative day 7. Clear demarcation between
the surviving and necrotic regions and a different survival rate between the control group and the experi-
mental group were observed.

Fig. 3. Hematoxylin and eosin staining of the skin flaps. Widespread necrosis in the control group (left) and a number of blood
vessels in the experimental group were observed (right) (above, original magnification, ⫻40; below, original magnification,
⫻200). Arrowheads, necrosis; arrows, blood vessels.

1152
Volume 120, Number 5 • Fibrin and Ischemic Skin Flaps

Fig. 4. ␣-Smooth muscle actin immunostaining of the skin flaps. A number of smooth muscle actin–positive cells forming blood
vessels were observed in the experimental group (right) but were barely observed in the control group (left) (above, original
magnification, ⫻40; below, original magnification, ⫻200). Arrows, blood vessels.

Fig. 5. A positive correlation between the blood flow change rate at 5 cm

on day 7 and the survival rate of skin flaps was observed.

1153
 Plastic and Reconstructive Surgery • October 2007
Hammond et al. studied the factors that in-
fluence survival of the dorsal skin flap model and
found that isolation of the flap from the under-
lying bed worsened the survival of flap, suggesting
an important role of angiogenesis from the bed.29
However, we did not isolate the flap from the
underlying bed in this model; therefore, we were
not sure whether increased blood flow was attrib-
utable to a direct angiogenic effect on the flap
itself or from the underlying bed. Further inves-
tigations are necessary to answer this important
question.
We knew that the absolute values of blood flow
were extremely important for assessing the extent
of ischemia. The laser Doppler flow meter was
used in the present study, and its output voltage
should be proportional to the absolute blood flow,
at least when the factors other than circulation do
not change. The good accuracy of this instrument
has been reported by Nohira et al.23; however, we
found that the output showed large differences
among the rats, even at the same position before
the operation (e.g., at 1 cm, the output range
differed between 0.8 and 2.4 mV). These differ-
ences were influenced by the individual condi-
tions of the sampling tissue volume. Therefore, we
did not use the absolute value of output voltage
but rather used the blood flow change rate as the
parameter with which to assess the extent of isch-
emia, because it gave more appropriate results
with which to observe the changes. Although the
measurements of blood flow were not performed
in a completely blinded manner, the bias was sub-
stantially controlled by the standardized proce-
dure and the automatic data record.
According to the blood flow change rate
shown in Table 1, we found that there was no
significant difference between the control group
and the experimental group at 1 cm throughout
the experiment, because of the relatively adequate
blood supply at this position. At the same time, on
day 1, no significant differences were found be-
tween the groups at any of the positions, suggest-
ing that fibrin has little effect as a simple vasodi-
lator. At 3 cm, on day 3 and day 7, the blood flow
change rate in the experimental group became
significantly higher than that in the control group
(p ⬍ 0.05). Moreover, at 5 cm, a surprisingly large
difference between groups was found from day 3
to day 7 (i.e., a clear increase in the experimental
group, in contrast to a decrease in the control
group, in which nine cases showed a blood flow of
zero because of distal necrosis appearing during
this period).
1154
In this study, only a single application of fibrin
caused a significant improvement in the survival
rate, with increased blood flow and numbers of
blood vessels in the experimental group. Al-
though the exact mechanism of this effect is not
clear, it is likely that angiogenesis induced by fi-
brin, at least in part, contributed to these benefi-
cial differences.
We showed benefits of fibrin for ischemic
skin flaps in rats, and the similar benefits of
fibrin were also observed in mice and rabbits in
our group (data not shown). Therefore, we be-
lieve that fibrin can be used as a medicine in
pedicle skin flap surgery and skin transplanta-
tion in clinical practice.
CONCLUSIONS
This study showed that a single application of
fibrin could improve the blood flow and survival
of ischemic skin flaps, seemingly because of its
angiogenic effect. Although the exact mechanism
of this effect awaits further investigation, this sim-
ple approach seems to have great clinical potential
in the field of plastic and reconstructive surgery.
Shoichiro Sumi, M.D., Ph.D.
Department of Organ Reconstruction
Institute for Frontier Medical Sciences
Kyoto University
53 Shogoin Kawara-cho
Sakyo-ku, Kyoto 606-8507, Japan
sumi@frontier.kyoto-u.ac.jp
ACKNOWLEDGMENTS
This study was supported in part by a grant from
the Ministry of Education, Culture, Sports, Science,
and Technology, Japan (S-13854020), and a grant
from the Japan Society for the promotion of Science
(B-16390360).
DISCLOSURE
None of the authors has any financial interest to be
disclosed.
REFERENCES
1. Rinsch, C., Quinodoz, P., Pittet, B., et al. Delivery of FGF-2
but not VEGF by encapsulated genetically engineered myo-
blasts improves survival and vascularization in a model of
acute skin flap ischemia. Gene Ther. 8: 523, 2001.
2. Hijjawi, J., Mogford, J. E., Chandler, L. A., et al. Platelet-
derived growth factor B, but not fibroblast growth factor 2,
plasmid DNA improves survival of ischemic myocutaneous
flaps. Arch. Surg. 139: 142, 2004.
3. Alizadeh, N., Pittet, B., Tenorio, X., et al. Active-site inacti-
vated FVIIa decreases thrombosis and necrosis in a random
skin flap model of acute ischemia. J. Surg. Res. 122: 263, 2004.
4. Hsu, O. K., Gabr, E., Steward, E., et al. Pharmacologic en-
hancement of rat skin flap survival with topical oleic acid.
Plast. Reconstr. Surg. 113: 2048, 2004.
Volume 120, Number 5 • Fibrin and Ischemic Skin Flaps
5. Kryger, Z., Zhang, F., Dogan, T., Cheng, C., Lineaweaver, W.
C., and Buncke, H. J. The effects of VEGF on survival of a
random flap in the rat: Examination of various routes of
administration. Br. J. Plast. Surg. 53: 234, 2000.
6. Taran, A., Har-Shai, Y., Lindenbaum, E., et al. Improved
vitality of experimental random dorsal skin flaps in rats
treated with enriched cell culture medium. Plast. Reconstr.
Surg. 104: 148, 1999.
7. Ercocen, A. R., Kono, T., Kikuchi, Y., Kitazawa, Y., and
Nozaki, M. Efficacy of the flashlamp-pumped pulsed-dye la-
ser in nonsurgical delay of skin flaps. Dermatol. Surg. 29: 692,
2003.
8. Karaçal, N., Ambarcioğlu, O., Topal, U., Mamedov, T., and
Kutlu, N. Enhancement of dorsal random-pattern skin flap
survival in rats with topical lidocaine and prilocaine (EMLA):
Enhancement of flap survival by EMLA. J. Surg. Res. 124: 134,
2005.
9. Shimpo, M., Ikeda, U., Maeda, Y., et al. AAV-mediated VEGF
gene transfer into skeletal muscle stimulates angiogenesis
and improves blood flow in a rat hindlimb ischemia model.
Cardiovasc. Res. 53: 993, 2002.
10. Zhang, F., Lei, M. P., Oswald, T. M., et al. The effect of
vascular endothelial growth factor on the healing of isch-
aemic skin wounds. Br. J. Plast. Surg. 56: 334, 2003.
11. Taub, P. J., Marmur, J. D., Zhang, W. X., et al. Locally ad-
ministered vascular endothelial growth factor cDNA in-
creases survival of ischemic experimental skin flaps. Plast.
Reconstr. Surg. 102: 2033, 1998.
12. Bayati, S., Russell, R. C., and Roth, A. C. Stimulation of
angiogenesis to improve the viability of prefabricated flaps.
Plast. Reconstr. Surg. 101: 1290, 1998.
13. Van Hinsbergh, V. W., Collen, A., and Koolwijk, P. Role of
fibrin matrix in angiogenesis. Ann. N. Y. Acad. Sci. 936: 426,
2001.
14. Kroon, M. E., Koolwijk, P., van der Vecht, B., and van Hins-
bergh, V. W. Hypoxia in combination with FGF-2 induces
tube formation by human microvascular endothelial cells in
a fibrin matrix: Involvement of at least two signal transduc-
tion pathways. J. Cell Sci. 14: 825, 2001.
15. Li, J., Zhang, Y. P., and Kirsner, R. S. Angiogenesis in wound
repair: Angiogenic growth factors and the extracellular ma-
trix. Microsc. Res. Tech. 60: 107, 2003.
16. Collen, A., Koolwijk, P., Kroon, M., and van Hinsbergh, V. W.
Influence of fibrin structure on the formation and mainte-
nance of capillary-like tubules by human microvascular en-
dothelial cells. Angiogenesis 2: 153, 1998.
17. Martinez, J., Ferber, A., Bach, T. L., and Yaen, C. H. Inter-
action of fibrin with VE-cadherin. Ann. N. Y. Acad. Sci. 936:
386, 2001.
18. Chalupowicz, D. G., Chowdhury, Z. A., Bach, T. L., Barsigian,
C., and Martinez, J. Fibrin II induces endothelial cell capil-
lary tube formation. J. Cell Biol. 130: 207, 1995.
19. Hall, H., Baechi, T., and Hubbell, J. A. Molecular properties
of fibrin-based matrices for promotion of angiogenesis in
vitro. Microvasc. Res. 62: 315, 2001.
20. Burbridge, M. F., Coge, F., Galizzi, J. P., Boutin, J. A., West,
D. C., and Tucker, G. C. The role of the matrix metallopro-
teinases during in vitro vessel formation. Angiogenesis 5: 215,
2002.
21. Gorlatov, S., and Medved, L. Interaction of fibrin(ogen) with
the endothelial cell receptor VE-cadherin: Mapping of the
receptor-binding site in the NH2-terminal portions of the
fibrin beta chains. Biochemistry 41: 4107, 2002.
22. Nehls, V., and Herrmann, R. The configuration of fibrin clots
determines capillary morphogenesis and endothelial cell mi-
gration. Microvasc. Res. 325: 1650, 1996.
23. Nohira, K., Shintomi, Y., Ikawa, H., et al. Development of skin
blood flow monitoring system using laser speckle phenom-
ena (in Japanese with English abstract). J. Jpn. Soc. Plast.
Reconstr. Surg. 6: 467, 1986.
24. Atalay, C., Kockaya, E. A., Cetin, B., and Akay, M. T. The role
of fibrin tissue adhesives in flap necrosis in rats. J. Invest. Surg.
18: 97, 2005.
25. Kulber, D. A., Bacilious, N., Peters, E. D., Gayle, L. B., and
Hoffman, L. The use of fibrin sealant in the prevention of
seromas. Plast. Reconstr. Surg. 9: 842, 1997.
26. Currie, L. J., Sharpe, J. R., and Martin, R. The use of fibrin
glue in skin grafts and tissue-engineered skin replacements:
A review. Plast. Reconstr. Surg. 108: 1713, 2001.
27. McFarlane, R. M., Deyong, G., and Henry, R. A. The design
of a pedicle flap in the rat to study necrosis and its preven-
tion. Plast. Reconstr. Surg. 35: 177, 1965.
28. Sumi, S., Inoue, K., Minote, H., et al. Effect of synthetic
Des-1-Ala-des alpha-amino chicken CGRP a derivative of cal-
citonin gene-related peptide, on ischemic skin flap in rats.
Neuropeptides 10: 55, 1991.
29. Hammond, D. C., Brooksher, R. D., Mann, R. J., and Beer-
nink, J. H. The dorsal skin-flap model in the rat: Factors
influencing survival. Plast. Reconstr. Surg. 91: 316, 1993.
1155
EXPERIMENTAL

Submucosal Injection of Micronized Acellular

Dermal Matrix: Analysis of Biocompatibility
and Durability
Jeffrey B. Wise, M.D.
David Cabiling, B.S.
David Yan, M.D.
Natasha Mirza, M.D.
Richard E. Kirschner, M.D.
Philadelphia, Pa.
Background: Posterior pharyngeal augmentation is a recognized treatment for
velopharyngeal insufficiency in selected candidates. To date, however, the pro-
cedure has failed to gain widespread acceptance because of the absence of an
implant material with sufficient safety, durability, and biocompatibility. In this
study, the use of micronized acellular dermal matrix injection for augmentation
of the posterior pharynx was investigated. Using a porcine animal model, the
safety and durability of posterior pharyngeal augmentation by micronized de-
cellularized dermis was evaluated.
Methods: Twelve Yorkshire piglets were used in this study. Under general
anesthesia, porcine-derived micronized acellular dermal matrix was injected
into the submucosa of the right side of the pharynx. At 30 days, the animals were
euthanized, and the implants and surrounding tissues were assessed grossly for
degree of augmentation and histologically to determine the extent of host cell
infiltration, vascularization, and matrix deposition and remodeling.
Results: No animal perioperative or postoperative morbidity resulted from the
operations. When the animals were euthanized and the tissue was harvested at
30 days, there existed no evidence of gross augmentation on the experimental
side of the pharynx in any of the specimens. Histologic analysis demonstrated
trace amounts of residual implant, with extensive host lymphocytic infiltration
of the material.
Conclusions: Although micronized acellular dermal matrix is a safe material
when injected into the pharyngeal wall, this study demonstrated that it is not a
durable implant at this site. The authors do not recommend its use for long-term
soft-tissue augmentation of the posterior pharyngeal wall in patients with velo-
pharyngeal insufficiency. (Plast. Reconstr. Surg. 120: 1156, 2007.)

V
elopharyngeal insufficiency is diagnosed
in 25 to 50 percent of patients following
cleft palate repair and may also result from
congenital or acquired neuromuscular disorders
or from adenoidectomy.1,2 Affected patients mani-
fest hypernasal speech and may develop compen-
satory articulation errors that further compromise
speech intelligibility. Nasal regurgitation of liquids
is also a common occurrence from velopharyngeal
insufficiency.
Many operations have been described to
provide for complete closure of the velopha-
From the Department of Otorhinolaryngology–Head and
Neck Surgery, University of Pennsylvania School of Medi-
cine, and the Division of Plastic Surgery, Department of
Surgery, The Children’s Hospital of Philadelphia.
Received for publication January 5, 2006; accepted May 12,
2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279523.58632.0f
ryngeal port, such as the posterior pharyngeal
flap and sphincter pharyngoplasty. These pro-
cedures, however, result in significant alter-
ation in nasopharyngeal air flow and may be
associated with obstructive sleep apnea. In se-
lected patients, posterior pharyngeal augmen-
tation offers a simplified approach to closing
the velopharyngeal gap.3
Historically, numerous substances have been ei-
ther implanted or injected to augment the poste-
rior pharyngeal wall, including petroleum jelly,
paraffin, silicone, Teflon, bovine collagen, autolo-
gous fat, and autologous rib cartilage. Reported
drawbacks of alloplastic materials include implant
migration, infection, embolization, and extrusion.
Moreover, the use of autologous grafts for pharyn-
geal wall augmentation is associated with unpre-
dictable volume maintenance and donor-site
morbidity.4
Micronized acellular dermal matrix (Cymetra;
LifeCell Corp., Branchburg, N.J.) is a commer-

1156 www.PRSJournal.com
Volume 120, Number 5 • Posterior Pharyngeal Augmentation
cially available injectable graft material developed
to provide soft-tissue augmentation. Its composi-
tion is similar to that of acellular dermal matrix
sheeting (AlloDerm; LifeCell), which contains col-
lagens, elastin, proteins, and proteoglycans. Mi-
cronization is achieved by homogenization in liq-
uid nitrogen to produce microfractures rather
than shredding of the ultrastructure. This process
results in an injectate with a median particle size of
123 ␮m.5 Previously, these components have been
demonstrated to promote cell repopulation and
revascularization. Reported uses of micronized
acellular dermal matrix include vocal fold
augmentation6 and cosmetic/reconstructive soft-
tissue augmentation.7 To date, however, there have
been no reports of its use in posterior pharyngeal
wall augmentation.
We hypothesized that this material could add
needed bulk to the posterior pharyngeal wall for
the simple treatment of small to moderate gap
velopharyngeal insufficiency. Because the inject-
able matrix provides for long-term soft-tissue
augmentation by promoting fibrovascular in-
growth, we anticipated that its use would be
associated with excellent biocompatibility and
volume maintenance in the posterior pharynx.
In short, the aim of this study was to assess the
safety and durability of micronized acellular der-
mal matrix for submucosal augmentation in a
porcine model.
Fig. 1. Transoral injection of micronized acellular dermal matrix into the palate. (Left) Direct laryngoscopic
visualization of the injection site. (Right) Using a 19-gauge needle loaded onto a 5-cc syringe, a total of 1.0
cc of the mixture of porcine-derived micronized acellular dermal matrix and saline is injected into the
submucosal plane at the hard/soft palate junction.
MATERIALS AND METHODS
Twelve 4-week-old Yorkshire piglets of un-
specified gender were used in this study. All
animals were housed and cared for at the large-
animal facility at The Children’s Hospital of
Philadelphia. The experimental and procedural
protocols were approved by the Institutional An-
imal Care and Use Committee of The Children’s
Hospital of Philadelphia.
The experimental injectate was prepared by
mixing 1.0 cc of lyophilized porcine acellular dermal
matrix powder with 1.4 cc of sterile, injectable saline
to form a homogenous paste. Under general anes-
thesia, a total of 1.0 cc of this mixture, loaded in a
5-cc syringe, was injected transorally with a 19-gauge
needle into the submucosal plane at the junction of
the hard and soft palate (Fig. 1). A pediatric laryn-
goscope with a Miller blade was used for direct vi-
sualization. For standardization, the injection site
was placed on the right side of midline in all animals
so that the left side of the palate could serve as a
control. The hard/soft palate junction was selected
as the site of submucosal injection rather than the
posterior pharyngeal wall, for ease of visualization.
At 30 days, the animals were euthanized by bar-
biturate overdose. The injection and control sites
were assessed in each animal both in vivo and after
tissue harvest. After fixing the samples in 10% for-
malin, the tissues were slowly dehydrated and em-
bedded in paraffin. Subsequently, they were sec-
tioned in the coronal plane at 5 ␮m and stained with
1157
 Plastic and Reconstructive Surgery • October 2007

hematoxylin and eosin. Under microscopic mea-
surement, the samples were evaluated qualitatively
for degree of pharyngeal augmentation and assessed
histologically for evidence of vascular and fibroblast
ingrowth.
RESULTS
Twelve animals underwent injections with mi-
cronized acellular dermal matrix. At the time of
injection, all animals demonstrated marked aug-
mentation at the site of injection (Fig. 2, left). All
animals survived the initial procedures and post-
operative period without complication. During
the 30-day trial, there were no signs of infection,
animal discomfort, or changes in feeding habits.
After the animals were euthanized at 30 days,
the animals’ mandibles were disarticulated to gain
clear visualization of the hard and soft palate (Figs.
2 and 3). In all animals, there was observed to be
no residual augmentation at the original injection
site. The mucosa at the site of injection appeared
to be similar to the surrounding palatal surface.

Fig. 2. Comparison of pig palates in situ immediately following micronized AlloDerm injection (left) and
at 30 days after injection (right). The significant augmentation created at the time of injection on the right
palate is not observed at 30 days.

Fig. 3. Ex vivo examination of two specimens harvested at 30 days after injection demonstrates no gross evi-
dence of tissue augmentation. There exists no perceptible difference in the experimental sides (labeled right) and
the control sides (labeled left) within each specimen.

1158
Volume 120, Number 5 • Posterior Pharyngeal Augmentation

Fig. 4. Histologic analysis of palates at 1 month after injection with micronized AlloDerm at low (left) and high power (right).
There is some evidence of fibroblast invasion of implant. At high power, there is a large host lymphocyte infiltration (hema-
toxylin and eosin, original magnification at low power, ⫻4; original magnification at high power, ⫻10).

On histologic examination, fragments of mi-
cronized dermis were present in the submucosal
plane in all of the specimens. However, the in-
jected acellular dermis was present in only trace
amounts in specimens examined 30 days after
the injection. Minimal fibrovascular ingrowth
was observed in the vicinity of the injected der-
mis. Rather, there was a significant infiltration
of lymphocytes at all of the injection sites. No
histologic changes were noted in the overlying
mucosa (Fig. 4).
DISCUSSION
Using a porcine animal model, we have inves-
tigated the use of micronized acellular dermis for
posterior pharyngeal wall augmentation in the
treatment of small to moderate gap velopharyn-
geal insufficiency. Our specific goals were to eval-
uate the safety and durability of this material when
injected into the pharynx through gross and his-
tologic analyses.
Previous studies have demonstrated the safety
of decellularized dermis in its intact and micron-
ized forms when used as an implant.8 However, to
date, there have been no studies that have evalu-
ated the safety and durability of micronized acel-
lular dermis in the oropharyngeal submucosa. All
of the animals in our study tolerated the injection
of micronized dermis in the pharynx well. There
were no postoperative infections or changes in
feeding habits.
With respect to implant durability, others have
demonstrated an early loss of soft-tissue augmen-
tation when micronized acellular dermal sheeting
is used at other sites, such as the lips and skin.9,10
Sclafani et al.7 evaluated the clinical and histologic
properties of both intact and micronized acellular
dermal grafts after subdermal/intradermal im-
plantation in 25 human subjects. The investigators
found that at 1 month, acellular dermal sheets and
micronized dermal matrix implants exhibited a
mean volume persistence of 82.8 and 24.6 per-

1159
 Plastic and Reconstructive Surgery • October 2007
cent, respectively. The authors demonstrated a
rapid loss in clinical augmentation when micron-
ized acellular dermal matrix implants were in-
jected in the subdermal plane rather than intra-
dermally. They speculated that dispersion of the
injectate within the subdermal plane may have
accounted for its rapid attenuation.
Our experience suggests that micronized acel-
lular dermis does not persist to any clinically signif-
icant degree within the oropharynx following sub-
mucosal injection. In all of the animals studied,
there was no visible soft-tissue augmentation 1
month after injection. Histologic examination at this
time demonstrated only microscopic traces of im-
plant on all samples. Moreover, there appeared to be
a cellular host immune response to the implant,
evidenced by the presence of lymphocytes at the site
of the remaining injectate.
It is uncertain why resorption of micronized acel-
lular dermis occurs so rapidly at this site. Perhaps the
pharyngeal submucosal plane allows for rapid dis-
persion of the substance, as observed in previous
studies involving subdermal injection of micronized
acellular dermal matrix. Furthermore, in the prep-
aration of commercially prepared human micron-
ized acellular dermal graft (Cymetra), micronization
of the dermal sheeting may make the injectate more
susceptible to host immunity. Specifically, the result-
ing median particle size of micronized acellular der-
mal graft is 123 ␮m (range, 59 to 593 ␮m). More
than one-fourth of these particles are 52 ␮m or less,
increasing the likelihood for host phagocytosis (S.
Griffey, Ph.D., LifeCell Corp., unpublished data,
1999).7
Absolute indications for posterior pharyngeal
wall augmentation have yet to be fully delineated.
Furlow et al.11 described a cohort of velopharyngeal
insufficiency patients in whom posterior pha-
ryngeal augmentation by Teflon injection was
attempted. In this study, successful correction
of patient velopharyngeal insufficiency was un-
related to either size of velopharyngeal gap
(range, 0 to 10 mm) or cause of velopharyngeal
insufficiency (cleft palate versus other). Rather,
velar mobility appeared most predictive of suc-
cessful outcome. Until a successful implant ma-
terial is found and tested clinically, the effective
limits of posterior pharyngeal wall augmenta-
tion will not be fully known. In those patients
who ultimately are found to be candidates for
posterior pharyngeal augmentation, there re-
main clear advantages that favor the use of an
alloplastic injectate, such as minimal patient
postoperative recovery time and the absence of
donor-site morbidity. The use of substances such
1160
as calcium hydroxylapatite for soft-tissue en-
hancement appears promising as a safe and du-
rable agent, although site-specific studies will be
required.12,13
CONCLUSIONS
From our experience with the animal trial pre-
sented in this article, we believe that although mi-
cronized acellular dermis is well tolerated when in-
jected into the oropharyngeal submucosa, it fails to
demonstrate any degree of durability at this site. We
do not advocate its use in the treatment of velopha-
ryngeal insufficiency where long-term augmentation
of the posterior pharyngeal wall is desired.
Jeffrey Wise, M.D.
1680 State Route 23, Suite 100
Wayne, N.J. 07470
jeffreywisemd@gmail.com
DISCLOSURE
The authors received financial support and mate-
rials from the LifeCell Corporation (Branchburg, N.J.),
the manufacturers of micronized acellular dermal matrix
(Cymetra).
REFERENCES
1. Furlow, L. T. Cleft palate repair by double opposing Z-plasty.
Plast. Reconstr. Surg. 78: 724, 1986.
2. Orticochea, M. A review of 236 cleft palate patients treated with
dynamic muscle sphincter. Plast. Reconstr. Surg. 71:180, 1983.
3. Wolford, L. M., Oelschlaeger, M., and Deal, R. Proplast as a
pharyngeal wall implant to correct velopharyngeal insuffi-
ciency. Cleft Palate J. 26: 119, 1989.
4. Gray, S. D., Pinborough-Zimmerman, J., and Catten, M. Pos-
terior pharyngeal wall augmentation for treatment of velo-
pharyngeal insufficiency. Otolaryngol. Head Neck Surg. 121:
107, 1999.
5. Achauer, B. M., VanderKam, V. M., and Coelikoz, B. Aug-
mentation of facial soft tissue defects with AlloDerm dermal
graft. Ann. Plast. Surg. 41: 503, 1998.
6. Pearl, A. W., Woo, P., Ostrowski, R., Mojica, J., Mandell, D. L.,
and Costantino, P. A preliminary report on micronized Allo-
Derm injection laryngoplasty. Laryngoscope 112: 990, 2002.
7. Sclafani, A. P., Romo, T., Jacono, A. A., McCormick, S.,
Cocker, R., and Parker, A. Evaluation of acellular dermal
graft sheet and injectable forms for soft tissue augmentation.
Arch. Facial Plast. Surg. 2: 130, 2000.
8. Jones, F. R., Schwartz, S. M., and Silverstein, P. Use of a non-
immunogenic acellular dermal allograft for soft tissue augmen-
tation: A preliminary report. Aesthetic Surg. J. 16: 196, 1996.
9. Maloney, B. P. Soft tissue contouring with acellular dermal
matrix grafts. Am. J. Cosmet. Surg. 15: 348, 1998.
10. Tobin, H. A., and Karas, N. D. Lip augmentation using an
AlloDerm graft. J. Oral Maxillofac. Surg. 56: 722, 1998.
11. Furlow, L. T., Williams, W. N., Esenbach, C. R., and Bzoch,
K. R. A long term study on treating velopharyngeal insuffi-
ciency by Teflon injection. Cleft Palate J. 19: 47, 1982.
12. Flaharty, P. Radiance. Facial Plast. Surg. 20: 165, 2004.
13. Tzikas, T. L. Evaluation of Radiance FN soft tissue filler for
facial soft tissue augmentation. Arch. Facial Plast. Surg. 6:
234, 2004.
 EXPERIMENTAL

Biocompatibility of Agarose Gel as a

Dermal Filler: Histologic Evaluation of
Subcutaneous Implants
Sergio Fernández-Cossı́o,
M.D.
Alvaro León-Mateos, M.D.
Francisco Gude Sampedro,
M.D., Ph.D.
Marı́a Teresa Castaño Oreja,
M.D., Ph.D.
Santiago de Compostela, Spain
Background: The search for safe and effective tissue fillers has been an ongoing
effort in plastic and cosmetic surgery over recent decades. Biocompatibility is
a prerequisite for any substance to be used as an implant material, and potential
biomaterials need to be characterized by histologic evaluation of tissue re-
sponses. Collagen is a well-known tissue filler. Agarose gel is widely used in
bioengineering. Both products are considered biocompatible. The purpose of
this study was to evaluate the bioactivity of agarose gel as a dermal filler com-
pared with collagen.
Methods: Tissue responses to agarose gel and collagen were evaluated in a rat
in vivo model (n ⫽ 96). Four groups were evaluated: group 1 (n ⫽ 24), rats with
agarose gel implants; group 2 (n ⫽ 24), rats with collagen implants; group 3, a
placebo group (n ⫽ 24); and group 4, a control group (n ⫽ 24). Responses and
biocompatibility were assessed by histopathologic and histomorphometric eval-
uation at 1 week to 8 months after implantation.
Results: Agarose gel showed marked bioactivity and biodegradation, although
the implants integrated well into tissues: newly formed collagen bands were
observed inside the implants and no granulomas were detected. Collagen im-
plants showed low cell infiltration and a significant loss of product over time.
Conclusions: Agarose gel is a biocompatible product that can be considered for
use as a tissue filler. Further investigation is required to assess its long-term
efficacy and safety. (Plast. Reconstr. Surg. 120: 1161, 2007.)

F
or over a century, the search for the ideal
tissue filler suitable for the correction of
body contour defects has been the focus of
many research studies in plastic and cosmetic
surgery. In recent decades, many substances
have been approved for use as tissue fillers, but
none can be considered ideal. The ideal filler
should be safe and effective; it should be bio-
compatible, nonimmunogenic, easily obtain-
able, nonreabsorbable, low-cost, and easily
stored1; it should look and feel natural2; and it
should be easily removed if necessary.3
The biocompatibility of a potential dermal
filler is determined by host tissue responses.4
From the Departments of Plastic and Reconstructive Surgery
and Clinical Epidemiology, Clinical University Hospital,
Santiago de Compostela, and the Departments of Experi-
mental Dermatology and Morphological Sciences, Santiago
de Compostela University, School of Medicine.
Received for publication January 11, 2006; accepted March
23, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279475.99934.71
Interaction of implanted materials with cells
leads to responses that may compromise the
long-term efficacy and safety of the implant.5
Tissue reactions are extremely variable and de-
pend on the nature of the material implanted
and on individual susceptibility. Sometimes, tis-
sue response induces degradation or even total
disappearance of the implanted product.6,7 In
other cases, the filler is replaced by newly formed
collagen.8,9 Finally, some permanent products in-
duce the formation of nodules and indurations10,11
because of a chronic inflammatory reaction with
the presence of foreign-body granulomas, giant
cells, and fibrosis.12,13
In vivo experimental analysis of tissue reac-
tions to different substances is a valuable tool for
determining the safety and efficacy of a potential
tissue filler.14 –17 In general, synthetic products
are permanent, whereas organic fillers have a
limited lifespan. Zyderm 1 is a well-known tissue
filler that is considered biocompatible and that is
regarded as the standard for all other newly
introduced injectable or implantable fillers.18,19
Agarose is also considered a biocompatible

www.PRSJournal.com 1161
 Plastic and Reconstructive Surgery • October 2007
material,20,21 and is frequently used in the labora-
tory for polymerase chain reaction and for analyt-
ical electrophoresis of DNA and RNA fragments.
Other products used as support matrixes for such
procedures, such as polyacrylamide gels, are cur-
rently being used as dermal fillers in cosmetic
surgery.3,5,9
The aim of the present study was to evaluate
the bioactivity of an agarose gel compared with
that of a collagen implant material (Zyderm 1)
to evaluate the possible application of agarose as
a dermal filler in reconstructive or cosmetic sur-
gery. To this end, histologic effects of subcuta-
neous implants in rats were evaluated after sur-
vival periods of 1 week to 8 months.
MATERIALS AND METHODS
Products
Zyderm 1 was supplied by Inamed Corp. (Ark-
low, County Wicklow, Ireland). Agarose NuSieve
3:1 agarose was supplied by Cambrex Bio Science
Rockland, Inc. (Rockland, Me.).
Zyderm 1, is a sterile suspension of highly pu-
rified bovine collagen (35 mg/ml) in phosphate-
buffered physiologic saline. It contains 0.3% lido-
caine. Zyderm was approved for use by the U.S.
Food and Drug Administration in 1981. Since
then, hundreds of thousands of patients have re-
ceived collagen implants worldwide.22 Collagen is
the major structural protein in the extracellular
matrix and consists of polypeptide chains wound
together on a triple helix. Collagen molecules are
very similar between different species, but at their
amino-terminal end they bear variable nonhelical
structures, known as telopeptides,23 that include
several dominant immunogens.24 Enzymatic hy-
drolysis of the telopeptide portions reduces the
immunogenicity of the solubilized collagen.25 Skin
testing is required before injection.
Nusieve 3:1 agarose is a standard-melting-tem-
perature agarose that consists of a blend of three
parts NuSieve agarose and one part SeaKem B
agarose (both from Cambrex Bio Science Rock-
land). Agarose is a purified linear galactan hydro-
colloid isolated from agar or agar-bearing marine
algae (class Rhodophyceae). Agar can be divided
into two principal components: agarose and aga-
ropectin. Agarose is the gelling agent, whereas
agaropectin has low gelling ability. Structurally,
agarose is a linear polymer consisting of alternat-
ing D-galactose and 3,6-anhydro-L-galactose units.
Agarose is considered to be biocompatible20,21 and
nontoxic.26 The Material Safety Data Sheet for the
agarose used in the present study (NuSieve 3:1)
1162
states that this product has not been classified as
hazardous or toxic by U.S. regulations (SARA 302,
311/312, 313) and does not meet the dangerous
preparation classification criteria under 1999/45/
EC. It is a stable product and is not carcinogenic.
For the present study, a 1.5% agarose gel was pre-
pared following the manufacturer’s instructions
under sterile conditions. The result was a trans-
parent, homogeneous gel that is stable at room
temperature and easily injectable with a 27-gauge
needle.
Animals
A total of 96 male Sprague-Dawley rats weigh-
ing 250 to 300 g were used in the experiments.
They were divided randomly into groups of 24 rats
each: an experimental group 1 of rats with agarose
gel implants, an experimental group 2 of rats with
Zyderm 1 implants, a placebo group 3 of rats in-
jected with physiologic serum, and a control group
4 of untreated rats.
Procedure
Before surgery, rats were anesthetized by in-
traperitoneal injection of 100 mg/kg of 5% so-
dium pentothal. Povidone-iodine solution was
used to prepare the surgical site, and 0.10 ml of
each product or physiologic serum was then in-
jected just below the subcutaneous level in the
interauricular region. To ensure that the implant
was at the correct depth, a pinch of skin was lifted,
the needle was inserted at the base of the crease
created, and the skin was released before injection
of the product. Animals were maintained under a
12-hour day/night cycle and fed a standard feed
with water ad libitum. At the end of each exper-
imental period (1 week, 1 month, 4 months, or 8
months), six rats per group were euthanized by
anesthetic overdose. Animal management was in
accordance with the principles of the Interna-
tional Council for Laboratory Animal Science and
Directive 86/609/EEC on the Protection of Ani-
mals Used for Experimental and Other Scientific
Purposes.
Histology and Statistical Analysis
After the animals were euthanized, both the
implant and the surrounding tissues were excised,
fixed in 10% buffered formalin, embedded in
Paraplast Plus (Sherwood Medical Co., St. Louis,
Mo.), sectioned at 6 ␮m, and stained with hema-
toxylin and eosin. Tissue reactivity to implants was
assessed by qualitative and quantitative histologic
evaluation. The qualitative analysis included his-
Volume 120, Number 5 • Agarose Gel as a Dermal Filler
topathologic examination of tissue response over
time. Migration of the product, stability or deg-
radation of implants, presence of capsule, and
type of infiltration were examined. The quantita-
tive analysis was based on measurements of cap-
sule thickness (if a capsule was present), number
of vascular openings, and counts of mononuclear
cells inside the implant. To detect possible mod-
ifications in skin structure, subcutaneous thick-
ness was also measured.
Seven stained sections were analyzed per rat.
The distance between two consecutive sections was
at least 180 ␮m. Digital photomicrographs were
taken using an Olympus BX40 microscope (Olym-
pus, Tokyo, Japan) fitted with a microphotogra-
phy attachment, and processed with MicroImage
image analysis software (MediaCybernetics, Silver
Spring, Md.). The capsule and subcutaneous tis-
sue were measured at 20⫻ and cell counts were
performed in randomly chosen 40⫻ fields. The
subcutaneous tissue was assessed considering the
connective tissue below the epidermis-dermis and
musculocutaneous levels, in normal rat skin, as
shown in Figure 1.
Single mean values for subcutaneous thickness
(in microns) and cell number were obtained for
each animal. Data are expressed as medians. The
significance of differences in measurements
among implants (collagen, agarose, and control)
was evaluated by means of the Mann-Whitney test
with Bonferroni correction for multiple compar-
isons. Values of p ⬍ 0.05 were considered statis-
tically significant. Statistical analyses were per-
formed using SPSS for Windows Version 10.0
(SPSS, Inc., Chicago, Ill.).
Fig. 1. Rat skin histology. 1, Epidermis and dermis; 2, musculo-
cutaneous layer; 3, subcutaneous tissue (hematoxylin and eosin;
original magnification, ⫻60).
RESULTS
No histologic differences were observed be-
tween tissues from control and placebo rats either
in histopathologic examination or in histomor-
phometric measurements. Both groups showed
the histologic structure of normal rat skin (Fig. 1)
in all evaluation periods. In what follows, we detail
the results obtained in rats that received Zyderm
1 or agarose implants.
Histopathologic Examination
1 Week
Tissues showed an acute inflammatory reac-
tion at the subcutaneous level surrounding the
implant, with predominance of polymorphonu-
clear leukocytes and macrophages; this reaction
was more intense around agarose implants (Fig. 2,
above, left). Infiltration of the implant was more
marked in the collagen group, with the presence
of macrophages and fibroblasts (Fig. 2, above,
right); in contrast, few cells were observed inside
agarose implants.
1 and 4 Months
The agarose implants showed an increasing
degree of cell infiltration and decreasing presence
of product over time (Fig. 2, center and below). The
predominant type of infiltration consisted of mac-
rophages and fibroblasts that migrated into the
implant and began to form a layered matrix of
collagen, which was more dense at 4 months. Gi-
ant cells were also observed. No fibrotic nodules or
foreign-body granulomas were detected. Vascular-
ization of the implant was also seen.
In contrast, collagen implants did not show
significant variations by the end of the 4-month
period (Fig. 2, below, right). The product remained
as a cohesive, amorphous mass, and only slight cell
infiltration was observed. The subcutaneous tissue
was increasingly thinner. Giant cells were not
present. The implant seemed more condensed,
showing more intense eosinophilic staining. Few
blood vessels were observed at 4 months after im-
plantation. Neither product was surrounded by a
capsule.
8 Months
Both products remained detectable at 8 months
after implantation (Figs. 3 and 4). The volume of
collagen implants had decreased significantly with
respect to the original volume. Macroscopically, col-
lagen implants appeared as thin, white masses. His-
topathologic evaluation of collagen implants
showed a mild inflammatory reaction, with infiltra-
tion of histiocytes and fibroblasts and without giant
cells. Newly formed collagen was not seen. Agarose
1163
 Plastic and Reconstructive Surgery • October 2007

Fig. 2. (Above, left) Agarose gel implant, 1 week after injection, shows acute inflammatory reaction at the subcutis and few cells
inside the implant. There is no capsule formation (hematoxylin and eosin; original magnification, ⫻110). (Above, right) Collagen
implant, 1 week after injection, shows a mild inflammatory reaction at the subcutaneous level and presence of macrophages
and fibroblasts inside the implant (hematoxylin and eosin; original magnification, ⫻120). (Center, left) Agarose gel implant, 1
month after injection, shows bands of newly formed collagen and dense cell infiltration consisting of fibroblasts and macro-
phages (hematoxylin and eosin; original magnification, ⫻95). (Center, right) Collagen implant, 1 month after injection, is visible
as a cohesive mass with slight cell infiltration (hematoxylin and eosin; original magnification, ⫻110). (Below, left) Agarose gel
implant, 4 months after injection, shows a more dense collagen matrix, with declining amount of agarose. Dense cellular
infiltration of macrophages, fibroblasts, and giant cells is also evident (hematoxylin and eosin; original magnification, ⫻120).
(Below, right) Collagen implant, 4 months after injection, shows minimal cell infiltration and a more condensed implant (he-
matoxylin and eosin; original magnification, ⫻110).

1164
Volume 120, Number 5 • Agarose Gel as a Dermal Filler
Fig. 3. (Above) Agarose implant after 8 months. A subcutaneous
mass of soft consistency is easily identifiable in all animals (arrow).
(Below) After 8 months, the collagen implant is visible macro-
scopically as a thin white mass (arrow).
implants were easily identified as subcutaneous
lumps of soft consistency.
Histopathologic evaluation of agarose implants
showed dense cellular infiltration with predomi-
nance of histiocytes and fibroblasts and the presence
of giant cells. Mature collagen bands were seen in-
side agarose implants without fibrous nodule for-
mation. The implant site was vascularized by a small
number of blood vessels, and no defined capsule was
observed around the implant (Table 1).
Histomorphometric Evaluation
Quantitative assessment of the biological be-
havior of the implant materials included counting
of mononuclear cells and blood vessels inside the
implant and measurement of subcutaneous tissue
thickness. Cell density within implants differed
significantly between the two groups at all survival
periods. Collagen implants showed low cell counts
that remained more or less constant. Agarose im-
Fig. 4. (Above) Agarose gel implant, 8 months after injection,
shows dense collagen bands within the implant, without the
presence of nodules or granuloma. Histiocytes, fibroblasts, and
giant cells can be seen, but there is no capsule (hematoxylin and
eosin; original magnification, ⫻70). (Below) Collagen implants, 8
months after injection, show minimal inflammatory reaction,
with few histiocytes and fibroblasts and no giant cells. Host col-
lagen bundles are not observed (hematoxylin and eosin; original
magnification, ⫻110).
plants showed high cell counts at 1 month that had
decreased by 8 months (Table 2).
Increased vascularization was seen in all aga-
rose-implanted rats after 1 month, decreasing by
8 months. Significant differences in vasculariza-
tion were observed between the two products at 1
month and at 4 months. At 8 months, both types
of implant showed minimal vascularization, with
no significant differences between the two groups
(Table 2).
Four months after implantation, skin from all
animals in both groups showed significantly thin-
ner subcutaneous tissue than the control group.
Subcutaneous tissue was significantly thinner in
1165
 Plastic and Reconstructive Surgery • October 2007

Table 1. Histopathologic Results for the Agarose Gel and Collagen Implants, Showing Predominant
Inflammatory Cells and Implant Histology
Inflammatory Cells Implant Histology

Agarose Gel Collagen Implant Agarose Gel Collagen Implant

Week 1 — PMN/Mac./Fib. Minimal cell infiltration Cell infiltration
Month 1 Mac./Fib. Mac./Fib. Dense cellularity Cell infiltration
Month 4 Mac./Fib./giant cells Mac./Fib. Collagen bundles Product precipitation
Month 8 Mac./Fib./giant cells Mac./Fib. Dense collagen bundles Low inflammatory reaction
PMN, polymorphonuclear neutrophils; Mac., macrophages; Fib., fibroblasts.

Table 2. Quantitative Responses over Time*

Collagen (range) Agarose (range) Control (range) p
Cells per field*
Week 1 44 (28–74) 15 (0–29) 0.004
Month 1 50 (25–55) 129 (95–170) 0.002
Month 4 54 (38–57) 130 (55–256) 0.004
Month 8 63 (57–81) 101 (86–122) 0.002
Blood vessels per field*
Week 1 0 (0–0) 0 (0–0) 1.000
Month 1 2 (0–6) 0 (0–0) 0.015
Month 4 0 (0–2) 2 (0–6) 0.041
Month 8 1 (0–3) 1 (0–2) 0.485
Subcutaneous thickness, ␮m†
Week 1 53 (30–57) 52 (38–58) 49 (42–57)
Month 1‡§ 41 (35–52) 49 (41–71) 66 (54–69)
Month 4‡§
29 (24–33) 39 (34–66) 70 (65–81)
Month 8‡§
19 (14–25) 52 (41–60) 71 (57–74)
*Cell counts and blood vessels in the agarose gel implants (week 1, n ⫽ 6; month 1, n ⫽ 6; month 4, n ⫽ 6; month 8, n ⫽ 6) and the collagen
implants (week 1, n ⫽ 6; month 1, n ⫽ 6; month 4, n ⫽ 6; month 8, n ⫽ 6). Results are expressed as medians and ranges.
†Subcutaneous thickness (in microns) in the collagen (week 1, n ⫽ 6; month 1, n ⫽ 6; month 4, n ⫽ 6; month 8, n ⫽ 6) agarose (week 1,
n ⫽ 6; month 1, n ⫽ 6; month 4, n ⫽ 6; month 8, n ⫽ 6), and control groups (week 1, n⫽ 6; month 1, n ⫽ 6; month 4, n ⫽ 6; month 8,
n ⫽ 6). Results are expressed as medians and ranges.
‡Statistical difference between collagen and agarose groups, p ⬍ 0.05.
§Statistical difference between collagen and control groups, p ⬍ 0.05.

Statistical difference between agarose and control groups, p ⬍ 0.05.

the collagen groups compared with the agarose
groups at 1, 4, and 8 months (Fig. 5 and Table 2).
DISCUSSION
Many products are available for soft-tissue aug-
mentation. However, adverse events at mid- to
long-term follow-up have been observed with
many approved filler substances.7–9,27,28 These sec-
ondary effects are typically attributable to chronic
inflammatory reactions in tissues. Histologic eval-
uation of tissue responses may thus help in pre-
dicting the biocompatibility and potential utility
of a given substance as a tissue filler.13 Histologic
monitoring of implant behavior also provides in-
formation about the stability or degradation be-
havior of the material.4 Undesirable tissue re-
sponses should be of course absent or minimal,
although according to the modern definition of
biocompatibility, a biocompatible material need
not necessarily be inert, but may be bioactive.29 In
fact, replacement by host tissue is considered by
some authors as a desired reaction to filler
implants.2
This study evaluated tissue reactions to an aga-
rose gel (Nusieve 3:1), compared with reactions to
a bovine collagen implant (Zyderm 1). Both sub-
stances are considered biocompatible but, al-
though collagen is a well-known tissue filler, as far
as we are aware there have been no evaluations to
date of the possibility of agarose gel as a dermal
filler substance. Agarose is a nontoxic26 polysac-
charide derived from agar-containing algae. Agar
has been used for a long time in food as a stabi-
lizer, thickener, humectant, surface finisher, and
flavoring agent. As a food ingredient, agar meets
the specifications of the Food Chemicals Codex.30
Agarose is widely used in the biochemistry labo-
ratory. It has no effects on cell growth or viability31
and shows good hemocompatibility.32,33 In view of
this, agarose gels in different forms are increas-
ingly being used in bioengineering roles,21,26,31,34,35
in gene therapy,29 and in extracorporeal detoxi-
fication systems.20 In our study, the agarose gel

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Volume 120, Number 5 • Agarose Gel as a Dermal Filler

Fig. 5. Box plot of the distribution of subcutaneous thickness over time: week 1 and months 1, 4,
and 8, for the collagen, agarose, and control groups. The subcutaneous tissue became thinner over
time in both experimental groups but not in the control group. Plots show median (horizontal line)
and 25th and 75th percentiles (bottom and top of box).

tested showed high bioactivity: host tissue ingrowth
was observed within implants after 1 month, and the
product was slowly degraded by macrophages. The
presence of blood vessels and giant cells indicated
the development of a chronic inflammatory reac-
tion. After 8 months, mature collagen strands could
be seen splitting up the implant, but nodules and
granuloma formation were not observed, in contrast
with previous studies of gels of similar characteristics
that have undergone full clinical evaluation.9 Like-
wise, over the 8-month monitoring period, we did
not detect any evidence of migration or histopatho-
logic indications of necrosis, calcification, tumori-
genesis, or infection at the implant sites. These find-
ings indicate that agarose gel can be considered as
a potential filler for soft-tissue augmentation.
Zyderm 1 is a bovine collagen– derived filler. It
is the most commonly used injectable filler for
soft-tissue augmentation36 and indeed is consid-
ered a reference filler. The main drawbacks to the
use of bovine collagen are the risk of allergic re-
actions (3 to 5 percent of patients) and the tem-
porary nature of the implant, which requires re-
peated injections.1 Early studies found that bovine
collagen injected beneath the forehead skin of
rats lasted for approximately 2 years,37 but it is
currently well established that bovine collagen
lasts for only approximately 3 to 6 months when
injected under human skin.1 Late granuloma for-
mation is an uncommon secondary effect.38,39
In this study, collagen implants showed a mild
inflammatory reaction with the presence of mac-
rophages and fibroblasts. After 8 months, only
small amounts of the filler were detected, as thin
white cohesive masses. This significant loss of vol-
ume is probably attributable to degradation by
macrophages and precipitation of collagen fibers
at body temperature.40 Some previous authors
have reported ingrowth of connective tissue into
collagen implants and collagen neoformation,37
whereas others have not.10 In the present study, we
did not detect collagen neoformation within Zy-
derm 1 implants.
CONCLUSIONS
As a subcutaneous implant, agarose gel is a
bioactive polymer that induces host tissue ingrowth.
We did not detect granuloma formation inside the
implants. The agarose gel tested in the present study
showed a prolonged inflammatory reaction that de-
clined after 8 months. The implants showed some
biodegradation by macrophages. Likewise, we saw

1167
 Plastic and Reconstructive Surgery • October 2007
no histopathologic indications of necrosis, calcifica-
tion, tumorigenesis, or infection over the 8-month
evaluation period. The gel did not undergo migra-
tion in tissues and the implant remained identifiable
after 8 months. Accordingly, agarose gel can be con-
sidered biocompatible. Collagen implants showed a
mild inflammatory reaction and a considerable loss
of volume after 8 months. Both substances induced
subcutaneous tissue atrophy, although this was more
marked with collagen implants.
Further research is needed using other agar
derivatives at different concentrations to identify
the best candidate product. Furthermore, im-
proved knowledge of durability and possible ad-
verse effects is necessary to assess the long-term
safety and efficacy of agarose and other agar de-
rivatives as implant materials. Clinical trials would
be mandatory before considering the use of these
substances as implant materials in humans.
Sergio Fernández-Cossı́o, M.D.
Clı́nica de Cirugı́a Estética Fernández y Fernández-Cossio
Calle Bimenes, Montecerrao
33006 Oviedo, Asturias, Spain
scossio@arrakis.es
ACKNOWLEDGMENTS
All financial support for this work was from research
funds of the University of Santiago de Compostela. The
authors thank Tomás Garcı́a Caballero, Department of
Morphological Sciences, Santiago de Compostela Medi-
cal School, for technical assistance.
DISCLOSURE
The authors have no commercial associations that
might pose or create a conflict of interest with information
presented in this article.
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1169
 RECONSTRUCTIVE

Optimal Use of Microvascular Free Flaps,

Cartilage Grafts, and a Paramedian Forehead
Flap for Aesthetic Reconstruction of the Nose
and Adjacent Facial Units
Gary C. Burget, M.D.
Robert L. Walton, M.D.
Chicago, Ill.
Background: Facial reconstruction with only free microvascular flaps has
rarely produced an aesthetic result. Menick stated, “Distant skin always
appears as a mismatched patch within residual normal facial skin.” In ad-
dition, earlier techniques using a single large nasal lining flap or bilateral
nasal lining vaults incurred a high incidence of airway obstruction.
Methods: The authors describe 10 consecutive patients requiring recon-
struction of the nasal vestibule and columella lining from October of 1997
through May of 2005. Most of them also required reconstruction of the floor
of the nose, the platform on which the alar bases and columella rest, and
defects of the facial units adjacent to the nose. Aesthetic nasal reconstruction
used two separate skin paddles to reconstruct the lining for the nasal ves-
tibule and columella, an artistically constructed nasal framework made of
cartilage, a forehead flap for cover, and other flaps and grafts to reconstruct
adjacent facial unit defects.
Results: The average patient age was 41.8 years (range, 10.4 to 65.3 years).
Follow-up (from the time of the first operative stage) averaged 26.4 months
(range, 4 to 49 months). Nine patients had functional airways, and one
required nasal airway support with internal silicone tubes. At the time of
publication, eight patients had normal-appearing noses, and two were await-
ing secondary surgery to correct persistent deformity.
Conclusions: Microvascular free flaps have proved to be highly reliable and
efficacious for restoration of missing elements of the nasal lining and ad-
jacent facial soft-tissue defects in total and subtotal nasal reconstruction.
Combined with a forehead flap, this aesthetic approach allows for recon-
struction of the center of the face layer by layer and facial unit by facial unit.
Specific attention is paid to the artistic creation of normal nasal dimensions,
proportion, and form using carved and assembled cartilage grafts and by
secondary subcutaneous contouring. In addition, this technique produces a
patent airway. (Plast. Reconstr. Surg. 120: 1171, 2007.)

U
se of free flaps for reconstruction of the
central face frequently falls short of
achieving an aesthetic result.1,2 The cause
of this failure is the use of a two-dimensional
approach in which a pattern measuring the
length and width of the defect is used to design
a free microvascular flap. The three-dimensional
From the Section of Plastic and Reconstructive Surgery, The
University of Chicago.
Received for publication August 24, 2005; accepted Septem-
ber 30, 2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000254362.53706.91
aspects of the missing central facial tissues must
be taken into account if one is to achieve a result
that has aesthetic dimensions, proportion, and
nasal contour; has a functional airway; and in-
cludes a relation to and the restoration of adja-
cent facial units. In general, in microvascular
facial reconstruction, surgeons have failed to do
the following: (1) correctly estimate the missing
deep tissue volume of the defect; (2) recreate
the plane of the floor of the nose, the nasal
platform, and the adjacent cheek and upper lip
facial units; (3) meet the lining requirements for
the nasal vestibule and columella; and (4) supply
a covering flap of correct dimensions, shape, color,

www.PRSJournal.com 1171
 Plastic and Reconstructive Surgery • October 2007
texture, and subcutaneous tissue quality optimal
for the surface of a normal, natural nose.
The current technique of aesthetic recon-
struction with microvascular free flaps developed
from our use of several different approaches to
nasal lining,3 two of which produced a less than
optimal nasal airway. In the first approach, a
large single skin paddle or flap was used for nasal
lining. This single large flap generally contracted
toward a single center and tightened like a
drumhead against the pyriform aperture, ob-
structing the patient’s airway. A second tech-
nique used bilateral flaps or skin paddles to cre-
ate symmetrical nasal lining vaults and a nasal
septum. Although anatomically correct, this
technique placed too much free flap tissue in
front of the pyriform aperture, thereby obstruct-
ing the airway.
Our current technique, although not anatom-
ically precise, is directed toward functional res-
toration of the nasal airway, nasal aesthetic unit,
and adjacent soft-tissue defects, and the provi-
sion of a stable anchorage for the visible, aes-
thetic part of the nasal reconstruction. It avoids
placement of the transferred tissues in front of
the pyriform aperture, thereby preserving a
functional airway. Also, an overly long columella
lining flap is inserted between the apex of the
main vestibule lining flap and the region of the
anterior nasal spine. This prevents collapse of
the nasal vestibule lining flap onto the face, thus
keeping the new nostrils patent. A third flap or
paddle is used, when needed, to reconstruct the
floor of the nose and the platform on which the
nose rests. Sometimes, this nasal floor flap ex-
tends onto defects of the cheek and upper lip
aesthetic units as well. Over the past 8 years, we
have used a technique of multiple microvascular
paddles or flaps, an assembled framework of
carved cartilage grafts (and in two cases, bone
grafts), and a forehead cover flap for reconstruc-
tion of subtotal and total nasal losses, often
accompanied by loss of adjacent facial units.
The microvascular transfer technique was di-
rected specifically to the restoration of the
missing nasal lining and adjacent facial ele-
ments and the creation of a patent nasal air-
way. The aesthetics of the resulting nose
evolved from the foundation provided by the
microsurgically rendered base onto which the
construction of a cartilage (or bone) frame-
work and the sartorial creation of a forehead
flap of aesthetic dimensions and shape for
nasal cover was applied. The artistic use of
secondary subcutaneous sculpting through in-
1172
cisions placed to lie in the lines of deepest
shadow on the facial surface was used to ren-
der a three-dimensional finish to the recon-
structed nose.
PATIENTS AND METHODS
Patients
From October of 1997 through May of 2005,
10 patients (five male patients and five female
patients) who had defects of the nose, the nasal
floor and platform, and the upper lip and cheek
units were treated using a multipaddle flap for
nasal lining, a nasal framework of cartilage
grafts (and in two cases, bone grafts), and a
vertical forehead flap for nasal cover. Other
flaps and skin paddles were used as well, to
reconstruct coexisting defects of adjoining fa-
cial units. The series consists of all patients in
whom this specific lining technique was used.
Two of the patients were described in an earlier
report.3 The age of the patients ranged from
10.4 to 65.3 years (mean, 41.8 years). Deformi-
ties had resulted from skin cancer extirpation
(five patients), intranasal drug use (two pa-
tients), a congenital cleft deformity (one pa-
tient), a dog bite (one patient), and an Iraqi
improvised explosive device (one patient).
Surgical Technique
Plane of the Nasal Platform
Each major reconstruction of the central face
requires two inpatient and four outpatient proce-
dures, all under general anesthesia. At an initial
operation, we excise all scar and damaged skin and
return the normal facial parts to their normal
anatomical positions, thus recreating the original
defect and opening the nasal airway. Also, at this
stage, the deep recesses of the face are filled with
free flap tissue, and a tissue plane is established to
support the nose anteriorly off the maxilla. This
plane includes the cheek, the upper lip, the floor
of the nasal airway, and the platform on which the
alar bases and columella rest. Defects involving the
maxilla are large, often extending into the max-
illary antrum. In such instances, the antrum is
obliterated and filled with flap tissue (one case).
Flap choice is based on the needs of the recon-
struction. The radial forearm free flap provides for
thin, well-vascularized tissue that is easily har-
vested, with an acceptable donor-site deformity.
Unique to the radial forearm flap is the ability to
partition this flap into separate islands for resto-
ration of specific nasal lining elements such as the
nasal vestibule, floor, and columella. Because a
Volume 120, Number 5 • Reconstruction of the Nose

Fig. 1. Case 1. (Above) The lining defect is much larger than the external nasal defor-
mity suggests. (Center and below) Operation 1. After the contracted scar was excised,
the internal defect included losses of the anterior nasal septum, the lining of the mid-
dle nasal vaults, and the anterior lining of the nasal vestibules. The large lining defect
extends from one maxilla to the other. A two-paddle right radial forearm flap carried
a large paddle to replace the anterior nasal lining and a second paddle to provide a
vascular bed and lining skin for reconstruction of the columella. Full-thickness skin
grafts were placed externally on the exposed fat of the lining paddles.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 2. Case 1, operation 2. Thirteen months later, the nose was assembled. The skin grafts were removed from the lining flap and
the flap was thinned. A cartilage framework with an aesthetic shape was constructed over the lining flaps. An unexpanded forehead
flap replaced the entire skin envelope of the nose except for small remnants at the alar bases. The flap design included extra skin to
overhang the alar margins.

radial forearm flap lacks sufficient volume for the
restoration of excessively wide and deep adjacent
facial defects, other flaps such as the anterolateral
thigh flap, scapular flap, superficial inferior epi-
gastric flap, or a named or unnamed perforator
flap may be used as a second free flap.
Nasal Lining
Nasal lining formed of a tube of skin tends to
contract, as will any circumferential scar. To avoid
this problem, we construct the nasal lining using
three separate components: the nasal floor, vesti-
bule vault, and columella. These elements are jux-

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 3. Case 1. (Above) The patient before and after operation 3, which was performed
to thin the flap and shape the upper 80 percent of the nose. (Below) In operation 4, the
pedicle was divided and the upper part of the defect contoured.

taposed to duplicate the geometric, three-dimen-
sional nasal lining anatomy. This stifles the
centripetal contraction often seen in tubed lining
flaps and helps to maintain a patent nasal air pas-
sage. In addition, the vestibular lining flaps are
often stented with matchstick-sized grafts of ca-
daver alloplast cartilage to provide interim sup-
port and resistance to shrinkage.
When the nasal platform and floor are present
or have been constructed, we then create nasal
lining with a radial forearm free flap possessing a
large nasal vestibule paddle and a separate,
smaller columella lining paddle. This is done at
the initial stage of surgery or at a separate surgical
sitting approximately 6 weeks later. This approach
aims to keep the space in front of the pyriform
aperture free of flap tissue. The resultant nasal air
passage has three skin components: a floor, an
anterior vault, and a separate columella lining
paddle. The long vascular pedicle of the radial

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 Plastic and Reconstructive Surgery • October 2007

Fig. 4. Case 1. The patient is shown before and after four operations, 18 months after
reconstruction was begun. (Left) Preoperative views. (Right) Postoperative views.

forearm flap is fed through a bluntly dissected
tunnel in the fat of the cheek and is anastomosed
to the facial artery and vein through a 1.5-cm
incision below the border of the mandible. The
raw surfaces of these free lining flaps are covered
with a temporary full-thickness skin graft.
Hard-Tissue Framework and External
Covering
At the next stage, approximately 4 weeks later,
the artistic phase of the reconstruction begins.
Cartilage from the seventh, eighth, and sometimes
sixth ribs is harvested and carved into specific
grafts to support the columella, dorsum, alae, side-
walls, and nasal tip. These grafts are sutured to-
gether to form a delicate framework of specific
shape, having the dimensions, proportion, and
form of a normal nose, but slightly reduced in all
dimensions to accommodate the forehead flap
cover. Also, at this stage, the nasal lining flaps are
thinned of excess fat in such a manner as to pre-
serve the vascular pedicle.3 At this same stage, a
forehead flap with a pedicle 1.5 cm wide, or less,
based on the supratrochlear vessels, is elevated,
thinned along its distal margins, and inset with all

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Volume 120, Number 5 • Reconstruction of the Nose
Fig. 5. Case 1. Additional preoperative (left) and postoperative (right) views of the
patient.
its layers over the cartilage framework. (Only when
the forehead skin has been destroyed, as in a burn
injury, do we resort to a microvascular free flap for
nasal cover.) As the dimensions and shape of the
forehead flap are important to aesthetic success,
we design the flap from a pattern taken from the
patient’s contralateral normal side, or from a plas-
ter and clay model using a thermally activated
plastic transfer material, Aquaplast (WFR/Aqua-
plast Corp., Wycoff, N.J.).4 We have avoided tissue
expansion of the forehead flap, as this technique
thins the dense subcutaneous tissue of the fore-
head flap, a layer essential to a smooth external
nasal contour. An artistically rendered cartilage
framework and a made-to-measure forehead flap
produce a superior aesthetic result.
Intermediate Operative Stages
Approximately 5 weeks after the new nose is
assembled, the first of two procedures is under-
taken to refine contour. The nasal flap is elevated
off its bed in the upper 75 percent of the nose; the
flap is thinned, leaving a 3- to 4-mm cushion of fat
on the flap; its bed is sculpted and detailed until
it has the dimensions and shape of the normal
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 Plastic and Reconstructive Surgery • October 2007

Fig. 6. Case 2, operation 1. (Above and center) A microvascular left radial forearm free flap is
designed for repair of the nose and upper lip. The flap has three islands: a large paddle to line the
vault of the single nasal airway; a smaller extension of the first paddle, to resurface a defect of the
nasal floor and right upper lip; and a second paddle to supply vascularized fat and skin lining for
reconstruction of the columella. (Below) Full-thickness skin grafts are applied to the exposed fat
of these paddles. The vascular pedicle is tunneled through the cheek, and its vessels are con-
nected end-to-end to the facial vessels.

nasal dorsum, supratip, and sidewalls; and the flap toured bed. These quilting sutures are removed 48
is tailored and inset using lightly tied, half-buried to 72 hours later to avoid suture marks in the skin.
mattress quilting sutures to prevent hematoma At a second operation approximately 3 weeks
and ensure contact of the flap and its newly con- later, the alar and columella margins are incised,

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 7. Case 2, operation 1. (Above) The patient had subtotal loss of the nose and loss
of a part of the right upper lip. (Center and below) A microvascular left radial forearm
free flap was designed with three skin paddles. One paddle would be the lining vault
for the nasal airway, and one would fill the defect of the right upper lip and right nasal
floor. The third paddle would be positioned with its skin side inside the nose. This
would provide lining and soft tissue that would later surround a cartilage strut support
for the columella. Full-thickness skin grafts dressed the exposed fat of the flap.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 8. Case 2, operation 2. (Above and center) The skin grafts were removed from
the outer surfaces of the lining flap. A framework of carved costal cartilage grafts
was built having the dimensions and form of a normal nose. (Below) An unex-
panded, full-thickness forehead flap was designed to fit the nasal unit precisely,
and the flap was transferred. The forehead donor site could be closed only partially.

the nasal lining flaps are further thinned, the col- Excision of the Pedicle and Sculpting and
umella is narrowed and given a normal hourglass Detailing of the Nasal Radix
shape, and the nose is shortened and its tip rotated Three weeks or more after these refining oper-
cephalad as necessary. ations, the pedicle is excised. The upper end of the

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 9. Case 2, operation 2. (Above) Skin grafts were removed from the lining skin paddles. The lining was thinned. (Center and
below) A costal cartilage framework was constructed to mimic the dimensions and form of a normal nose. An unexpanded
forehead flap with a 1.3-cm base was elevated and inset. The microvascular lining flap is visible inside the nostrils.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 10. Case 2, operation 3. (Above) The nasal flap was elevated off the upper 80 percent of the nose and thinned. Its borders were
trimmed. The nasal bed of the flap was shaped surgically to resemble a normal nasal dorsum and sidewalls. Quilting sutures held
the flap to its contoured bed. Operation 4. (Below) Incisions were made along the site of each alar and columellar margin. The nasal
lining was elevated and thinned. The lining flaps were sutured to the walls of the expanded nasal vestibules.

pedicle should be inset either in the supratip region,
where the forehead skin and nasal skin are equal in
thickness, or at the intercanthal line. If the cephalic
end of the pedicle is inset in the midportion of the
nasal dorsum, a permanent visible line will persist
where the thick forehead flap meets the thin nasal
dorsal skin. At this stage, the bed of the flap is con-
toured. The flap is trimmed to a rectilinear shape, so
that the most cephalic border scar of the forehead
flap is a straight horizontal line.
Late Secondary Refinement
The newly reconstructed nose is allowed to rest
for 4 to 6 months while chronic inflammation, col-
lagen formation, collagen contraction, and scar mat-
uration rise and subside. When necessary, and when
requested by the patient, a late refining operation is
performed. The most common late deformities are
poorly formed alar grooves, ill-defined soft triangles,
thick alar margins, and dorsal hump or overly deep
radix. Incisions to accomplish these late refinements
are placed so they will come to lie in the natural lines
of deepest shadow when the nose achieves its final
form. Incisions are not placed in existing flap border
scars, even though this means that some new scars
will be created. The lines of deepest shadow (where
incisional scars should end up) are the margins of
the aesthetic units and subunits, specifically, the
edges of the nasal dorsum, the upper borders
of the soft triangles, the borders of the nasal
tip subunit, the alar grooves, the alar-facial
grooves, the columella-labial junction, and the
nasolabial grooves.

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 11. Case 2, operation 3. The nasal flap was elevated, except for its attachment to
the alar margins and nasal tip. The flap was thinned and its bed contoured. The flap was
inset again. Note the quilting sutures, which prevent hematoma.

CASE REPORTS the columella. Struts of preserved radiated homograft cartilage

Case 1: Defect Limited to the Nasal Unit
A 37-year-old woman had suffered full-thickness loss of the
columella, nasal tip, and middle vault of her nose from chronic
ischemic injury (Fig. 1). The nasal vestibule lining, anterior
nasal septum, columella, nasal tip subunit, and nasal alae were
totally or partially missing. The alar lobules were contracted
cephalad. The nose had lost anterior projection. At an initial
operative sitting, we excised all damaged tissue and scar. A right
radial forearm flap with two paddles was designed from foil
patterns, elevated, and transferred. The larger paddle formed
a vestibule lining vault; the smaller paddle provided lining for
were inserted into these lining flaps for temporary support. The
raw external surface of these free lining flaps was dressed with
a temporary full-thickness skin graft. (The next stage was de-
layed because of the patient’s unanticipated pregnancy and
delivery.)
Thirteen months later, the skin grafts and cadaver carti-
lage were removed, the nasal lining was thinned, and a del-
icate framework of autologous costal cartilage grafts was
constructed over the lining flaps (Fig. 2). Care was taken to
ensure that the cartilage framework possessed the dimen-
sions and shape of a normal nose. Using Aquaplast as a
transfer material, we designed a vertical forehead flap from

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 Plastic and Reconstructive Surgery • October 2007

Fig. 12. Case 2, operation 4. (Above) Incisions were made along the sites of the future
alar and columellar margins. The columella was given an hourglass shape. Through
these incisions, the vestibule lining was thinned, the columella was shaped and lifted,
and the columellar-lobular angle of rotation was increased. (Left, center and below)
Preoperative views. (Right, center and below) Postoperative views.

a pattern of an idealized nose for the patient’s face. This ideal bases, which were retained. (We subsequently learned to dis-
nose had been sculpted with modeling clay on a plaster model card these contracted alar stumps, as they detract from the
of the patient’s face. The resulting flap was elevated and inset aesthetic outcome. It is better to replace the entire nasal unit.)
over the entire nasal unit, except for the stumps of the alar The forehead donor site could be closed only partially.

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Volume 120, Number 5 • Reconstruction of the Nose
Fig. 13. Case 2, operation 5. The forehead pedicle was divided. Its base was thinned and inset as a small inverted V medial to the right
eyebrow. The distal part of the flap, attached to the nose, was elevated, thinned, and trimmed. Its nasal bed was contoured. The
cephalic end of the defect was extended along rectilinear subunit lines.
At a third stage (2 months later) (Fig. 3), the flap was ele-
vated off its bed (leaving it attached only at the infratip lobule),
thinned, and trimmed. Its underlying bed was sculpted, and the
flap was replaced and held with quilting sutures (removed at 48
hours). At the fourth operation, the pedicle was divided, and
its base was replaced as a small flap medial to the left eyebrow.
The nasal defect was extended up to the intercanthal line, and
the flap was inset along subunit lines. Its upper border lay at the
intercanthal line. Figures 4 and 5 show the patient 3.5 months
after pedicle division.
Case 2: Defect of the Nasal Unit and Right Side
of the Nasal Platform/Floor
A 10-year-old girl presented 1 year after a dog traumatically
amputated her nose. The wound had healed and contracted,
obstructing both nasal airways. To hide her deformity, she wore
a small fabric shield held by two strings, tied behind. The nose
was missing, except for the nasal bones and upper nasal vault.
Portions of the right nasal floor and the platform on which the
right alar base rests were also missing.
Surgical Stages 1 through 5
At the first operative stage, we excised all scar and damaged
tissues, opening the airways and allowing normal tissues to
return to their normal positions. We transferred a left free
microvascular forearm flap having three skin paddles: one to
line the vestibule, the second to replace the right nasal plat-
form, and the third to line the columella (Figs. 6 and 7). (In
practice, paddles 1 and 2 were joined, and this permitted a
longer vascular pedicle.) The first skin paddle became the
anterior vestibule lining vault. A peninsular extension (paddle
2) of the first paddle formed a platform for the right alar base
and part of the floor of the nose. This case is unique because
the last skin paddle was fed through a buttonhole in the first
paddle to provide vascularized fat and lining skin for recon-
struction of the columella.
At stage 2 (11 weeks later) (Figs. 8 and 9), we thinned the
free lining flaps, teasing out fat locules from among the
branches of the vascular pedicle. A shapely nasal framework was
assembled of carved grafts harvested from the sixth, seventh,
and eighth costal cartilages. A forehead flap was designed with
the dimensions and shape of the normal nasal unit, a 1.3-cm-
wide base, and an extra apron of skin 1.2 cm wide along the
nostril margins. This extra apron of skin cover was folded in-
ward to meet the microvascular lining flaps so that the nostril
margins would be lined with forehead skin. Tissue expansion
was not used, as we wished to avoid thinning of the important
subcutaneous layer of the forehead flap. The forehead flap
included some hair-bearing scalp skin in its columellar and tip
portions. The alar margin and columellar parts of the flap were
thinned and depilated. The forehead defect could be closed
only partially. We used petrolatum gauze to protect the exposed
loose areolar tissue over the frontal bone from desiccation. We
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 Plastic and Reconstructive Surgery • October 2007

Fig. 14. Case 2. Final photographs were taken 16 months after reconstruction was started and immediately before the patient’s
final operation to refine nasal contour. (Above) Preoperative views. (Below) Postoperative views.

dressed the exposed raw surface of the pedicle with a split-
thickness skin graft from the gluteal region.
At operative stage 3 (8 weeks later) (Figs. 10 and 11), we
elevated the entire flap except for that portion attached to the
nasal tip; thinned it; shaped its underlying bed to resemble a
nasal dorsum, supratip, and sidewalls; and attached the flap to
its contoured bed with quilting sutures.
At operation 4 (6 weeks later) (Figs. 10 and 12), we incised
the alar margins and the borders of the columella, thinned the
vestibule lining and reattached it, narrowed the columella, and
excised a wedge of tissue from the “membranous septum” re-
gion to shorten the nose and rotate its tip upward. At stage 5
(4 weeks later) (Fig. 13), we removed the pedicle, sculpted and
detailed the upper 1.5 cm of the nose, and inset the upper part
of the forehead flap along rectilinear subunit lines. Quilting
sutures were in place for 48 hours to ensure adherence of tissue
layers and prevent hematoma.
Late Secondary Refinement
At a sixth operative session (9 months later), the dorsal line
of the nose was straightened by lowering the dorsal costal car-
tilage graft and adding a radix graft.5 Final photographs show
the patient after five surgical stages (Figs. 14 and 15).
Case 3: Defect of the Nasal Unit (Subtotal),
Right Nasal Floor and Platform, Right Upper
Lip, and Right Cheek Units
A 65-year-old medical professional presented 10 years af-
ter a basal cell carcinoma had been extirpated using the
Mohs’ technique (Fig. 16). The wound healed by secondary

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Volume 120, Number 5 • Reconstruction of the Nose
Fig. 15. Case 2. Additional preoperative (above) and postoperative (below) views of
the patient.
intention. Loss of nasal lining and scar contracture had nar-
rowed the right nasal airway to 6 mm. Dedicated to his
profession, the patient continued to work without a nose for
10 years before seeking reconstruction.
At the first operative stages (Figs. 16 and 17), we excised
the scarred defect. Releasing its edges revealed the full extent
of tissue loss. Missing were the lower two thirds of the nose,
the anterior nasal septum, the right nasal floor and platform
for the right alar base, and portions of the upper lip and right
cheek. We transferred a left radial forearm flap having three
skin paddles: a large paddle for the main vestibule lining
vault, a second paddle to repair the right nasal floor and alar
base platform, and a third paddle to provide lining for the
columella and a vascular bed for a cartilage columellar strut.
The three skin paddles, when transferred, described a coun-
terclockwise circle as they rested in the defect. Although, at
this stage, the bulky flaps seemed to obstruct the airway, the
important space directly in front of the pyriform aperture
remained open and free of flap tissue. This precaution en-
sured an eventual patent nasal airway.
At the second operation (5 months later) (Fig. 18), we
removed the temporary skin graft dressing from the external
surface of the first skin paddle and debulked the flap of
excess fat. A delicate and carefully formed framework of
costal cartilage was assembled over the thinned lining flap.
We designed a forehead flap (Fig. 19) having a 1.6-cm-wide
base, using as our model a plaster facial moulage bearing an
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 Plastic and Reconstructive Surgery • October 2007

Fig. 16. Case 3. (Above) A subtotal loss of the nose and parts of the cheek and upper lip
had been present for 10 years. (Below) Operation 1. A left radial forearm microvascular free
flap possessed three skin paddles. The proximal large paddle formed the main nasal lining
vault. A second smaller paddle lined the cheek, upper lip, and floor of the nose and pro-
vided a platform for the right alar base. A third, distal island supplied vascularized fat and
skin lining for reconstruction of the columella. The first paddle was inset with its skin side
inside the nose, whereas the distal paddle was positioned with its skin side outward. The
exposed fat of the lining paddles was covered with full-thickness skin grafts.

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 17. Case 3, operation 1. (Above, left) The defect and the scar around the defect were
excised. The wound edges retracted, showing the extent of the tissue loss. There was subtotal
loss of the nose and an associated defect of the right cheek and upper lip, the nasal platform,
and floor of the nose. (Above, right, and center and below) Operation 1. A three-paddle radial
forearm flap was designed having a large proximal paddle to line the main nasal airway; a
second paddle to resurface the cheek and the upper lip, and to serve as a platform for the
nose; and a third, distal paddle to supply a vascularized bed and lining for the columella. Note
that the columella paddle was inset with its skin surface outward. Later, the columella skin
would be turned inward as lining.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 18. Case 3, operation 2. Five months after the first stage, the nasal lining flaps were mobilized and thinned. The costal
cartilage framework built on top of the nasal lining included dorsal and columellar struts, curved alar battens, nasal sidewall grafts,
and a tip graft.

ideal clay nose. To avoid thinning the forehead flap, we did
not use tissue expansion. The dimensions and shape of the
flap were not compromised to benefit the forehead donor
site. The forehead donor site was only partially closed, yet by
10 weeks it had shrunk to 25 percent of its original size.
At a third operative stage (10 weeks later) (Fig. 19), the
forehead flap was elevated, thinned, trimmed, and inset
again over a newly contoured bed. Several months later, the
columella was narrowed and given its typical hourglass shape,
and the alar margins and vestibule lining were thinned. At a
fifth operation (4 weeks later), the pedicle was divided and
the upper one-fourth of the nose was shaped. After several
months, a final late secondary operation was performed to
shape the nasal sidewalls and further rotate the nasal tip
cephalad. The final result was a hefty nose (Figs. 20 and 21).
Because the composite tissue layers of arm skin, costal car-
tilage, and forehead skin are thicker than the native nasal
tissues, reconstructed noses generally must be made larger to
accommodate a functional airway.
Case 4: Deficiency of the Nose and Upper Lip
Units, and a Vertically Short Midface and Nasal
Platform
A 17-year-old male patient had undergone craniofacial
orbital surgery (by Dr. P. Tessier) and an Abbé flap to create
a philtrum (by B. Jones) (Fig. 22). The nose was small,
nonprojecting, and lacking a columella. The upper lip was
vertically short. Most importantly, the midface and the nasal
platform were vertically short by nearly 2 cm. There was no
space between the orbits and the upper lip to construct a
nose of normal dimensions and proportion to fit the face.
The maxilla and upper lip were displaced cephalad so that

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 19. Case 3, operation 2. (Above and center) An unexpanded forehead flap that had been de-
signed from a nasal model to replace the nasal skin cover was elevated and transferred. (Below)
Operation 3. Three months later, the flap was elevated off the nose, except along its lower edge. Its
nasal bed was contoured surgically. The flap was thinned and replaced on the nose.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 20. Case 3. Final photographs after two further refining operations and pedicle
division 3 years after the start of reconstruction. (Left) Preoperative and (right) post-
operative views.

the patient could not close his lips. The patient wished to
have a nose of normal size and appearance.
The first task was to expand the nasal platform. At an initial
operative stage (Fig. 22), the upper lip and its resident Abbé flap
were cut loose from the nose and maxilla and released 2 cm
inferiorly. We transferred a right free radial forearm flap with
two skin paddles. The first was designed twice as large as nec-
essary to fill the defect of the upper lip and floor of the nose
to allow for contraction of this unsupported tissue. This skin
paddle expanded the nasal platform vertically. The second
paddle was positioned to serve as lining and a vascularized tissue
bed for reconstruction of the columella. The patient’s lips came
together. The oversized paddle shrank to an appropriate size
over a 3-month period.
At operative stage 2 (3 months later) (Fig. 23), a pattern de-
signed from a model of the patient’s face and an idealized nose
was used to design the forehead flap. Aprons of excess skin were
added along the margins of the alae, to be folded in for additional
nostril lining. The forehead flap and local turnover flaps for lining
were delayed at this stage. Surprisingly, in this case, the forehead
possessed no frontalis muscle layer.
At a third operation (5 weeks later) (Fig. 24), we elevated and
assembled the turnover lining flaps. We constructed a cartilage frame-
work with grafts of rib cartilage that extended uninterrupted from the
alar margins and columella base to the nasal bones, had a normal
nasal shape, and possessed curved alar battens supporting patent
nasal airways. Specifically, normal nasal dimensions were achieved
with a nasolabial angle of 90 degrees, a nasofacial angle of 30 degrees,

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Volume 120, Number 5 • Reconstruction of the Nose
Fig. 21. Case 3. Additional preoperative (left) and postoperative (right) views.
and a nasal tip cartilage projection of 25 mm from the upper lip. We
inset the delayed forehead flap over this framework. We did not close
the forehead defect, fearing lagophthalmos and corneal exposure
but, rather, accepted the certain deformity of a split-thickness skin
graft on the donor site. We planned to use tissue expansion to close
the forehead at a later stage.
At the fourth operative stage (3 months later) (Fig. 25), the
pedicle was sectioned and inset at the nasal radix. Its base was
returned to the forehead.
A fifth operation (Fig. 26) was performed to raise the nasal
dorsum with diced cartilage grafts (as described by Erol6) fol-
lowing the technique of Daniel and Calvert.7 Photographs were
taken 19 months after reconstruction began (Figs. 27 and 28,
center). Subsequently, the patient declined forehead tissue ex-
pansion in favor of overgrafting of the forehead defect with a
full-thickness graft from the abdomen that was then overgrafted
with a split-thickness scalp skin graft to provide complementary
color match to the adjacent native forehead skin (by R.L.W.).
He then had single-hair transplants (by A. Barrera) to the free
flap of the upper lip and the goatee area. Final photographs
were taken 37 months after reconstruction began (Figs. 27 and
28, right).
Case 5: Secondary Addition of a Columella Lin-
ing Paddle to Restore a Collapsed Nasal Airway
In one of our earliest cases, a free columella lining skin
flap had to be installed secondarily to release a collapsed
nasal airway and restore nostril patency. The patient was a
44-year-old man who presented 1 year after an extensive
squamous cell carcinoma had been excised from his face.
The result was a large bilateral defect that included the
frontal bone, nasal bones, and nasal processes of the max-
illae, anterior nasal septum, and part of the upper lip. At the
time of extirpation, an acrylic plate had been placed in a 5-cm
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 Plastic and Reconstructive Surgery • October 2007

Fig. 22. Case 4. (Above, left) The nose and maxillae were vertically short, and the upper
lip was tethered to those structures. The patient could not close his mouth. (Above,
right, and center and below) Operation 1. The upper lip was cut loose from the nose and
brought inferiorly. A right radial forearm free flap was designed having two paddles.
The first paddle was one and a half times the size of the defect. The paddle overfilled
the secondary defect of the upper lip and floor of the nose and extended the vertical
length of the nasal platform. A second, distal paddle supplied a vascularized bed and
lining for reconstruction of the columella.

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 23. Case 4. (Above) A facial moulage having an idealized nose was the model for the forehead flap. An extra
skirt of lining was added to the alar margins of the flap. Thin Aquaplast was used to make an impression of the
nasal surface. This was flattened and transferred to aluminum suture package material, which was heat-sterilized.
(Center and below) Operation 2. Three months after operation 1, the forehead flap was delayed. The alar bases
were transferred inferiorly, and nasal turnover lining flaps were delayed.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 24. Case 4, operation 3. Five weeks later, the nose was assembled. Turnover flaps lengthened the nasal lining. A costal
cartilage framework gave the nose the dimensions and proportions of a normal nose and braced it against the force of wound
contraction. (Below, center and right) The forehead donor site was skin-grafted, an exception to our usual practice. Delayed
forehead tissue expansion and closure were planned.

defect of the frontal bone. The facial skin defect was skin-
grafted. The patient had received postoperative field radia-
tion. Four microvascular free flaps were required to create a
tissue mass that had patent airways and was of sufficient
dimensions to allow it to be sculpted into a nose.
At an initial surgical stage, the scarred defect was excised (Fig.
29). To construct bilateral anterior nasal lining vaults, we envel-
oped a nonvascularized costal cartilage graft with bilateral radial
forearm free flaps. Postoperatively, the skin-grafted floor of the
defect broke down and failed to heal to the transferred lining flaps.
Thus, at a second stage, a free anterolateral thigh flap was trans-
ferred to the floor of the defect. At a third operative stage (Fig. 30),
the anterior lining flaps were thinned and a nose was recon-
structed using a framework of costal cartilage grafts and a para-
median forehead flap designed to fit the nasal aesthetic unit.
Postoperatively, the new nose and its airways slowly collapsed
against the face. A surgical attempt (stage 4, by G.C.B.) to insert
nonvascularized cranial bone grafts into the collapsed nose,
in a previously irradiated field, ended in massive infection
and loss of the bone grafts. Again, the nose collapsed into the
facial defect. At operative stage 5 (Fig. 31), the nasal flap was
elevated off the face. A free microvascular composite flap
based on the thoracodorsal artery was installed under the
previously transferred forehead flap. The composite free flap

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 25. Case 4, operation 4. Three months later, the pedicle was divided. Its distal
portion was thinned and inset into the nasal bed, which had been extended ceph-
alad to include the dorsal subunit. In this case, the base of the pedicle was replaced
on the forehead donor site.

contained the following elements: a vascularized rib L-strut
for dorsal and columella support, a pedicled segment of
serratus anterior muscle combined with a pedicled segment
of latissimus dorsi muscle to fill nasal dead space and provide
for nasal sidewall expansion, and a skin island based on a
thoracodorsal artery perforator for lining of the columella
(to release the collapsed nasal airways). The nose was en-
larged and its airways were opened. This restored the po-
tential for a good aesthetic and functional result.
Four additional operations followed: shaping of the nasal
sidewalls; creation of alar grooves by direct incisions in the
forehead flap; contouring of the ala and columella, with con-
comitant thinning of the nasal lining; and insertion of diced
cartilage6 to raise the nasal dorsum. The nasal airways required

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 Plastic and Reconstructive Surgery • October 2007

Fig. 26. Case 4. (Above) The nose was malproportioned. The upper half was narrow
and recessed, and the lower half was thick. (Center and below) Operation 5. Three
months later, finely diced cartilage wrapped in oxidized regenerated cellulose (Sur-
gicel; Johnson & Johnson, New Brunswick, N.J.) gave strength to the dorsum. Solid
cartilage grafts improved tip projection.

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 27. Case 4. Postoperative views obtained 19 and 37 months after reconstruction was begun. (Left) Preoperative views.
(Center) Postoperative views obtained 7 months after dorsal cartilage grafting. (Right) Postoperative views obtained 1 year after
a final revision of the nose, followed by overgrafting of the forehead donor site with abdominal and scalp skin, and single-hair
grafts to the upper lip free flap and goatee area (by A. Barrera).

support with 10-mm oval silicone tubes for 2 years after the last
surgical operation (Figs. 32 and 33).
RESULTS
The average number of operations was 7.3
(range, 3 to 15). The average length of time of re-
construction (measured from the date of the first
operation) was 26.4 months (range, 4 to 49 months).
Both the patient and the surgeons judged airway
function to be normal in nine patients. At the last
follow-up, 2 years after completion of reconstruc-
tion, one patient still required the use of internal,
removable, oval silicone nasal tubes, 10 mm in larg-
est outside diameter. The patient and the surgeons
judged aesthetic facial appearance to be normal in
eight patients. The two most recent patients in the
series have residual deformity and are awaiting late
secondary refinement operations.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 28. Case 4. Additional preoperative (left), 7-month postoperative (center), and 1-year postoperative (right) views.

Three patients had complications. In one pa-
tient (patient 5), the placement of nonvascularized
cranial bone grafts into previously irradiated tissues
resulted in massive infection necessitating removal
of the grafts and hardware. Transfer of a free com-
posite microvascular flap containing a vascularized
costal bone graft corrected this problem and per-
mitted a functional and aesthetic result. A second
patient had late contracture of the floor of the nasal
airway, resulting in airway obstruction. The nose,
attached to its forehead pedicle, was lifted off the
face, and a free radial forearm flap was inserted to
create a new nasal platform. This flap expanded the
nasal lining and restored the nasal airway. A third
patient had necrosis of the columella portion of the
forehead flap and portions of the nasal lining flaps
following a secondary procedure to shape the col-
umella and thin the vestibule lining. The cartilage
framework was exposed, and parts of it were lost to
necrosis. Transfer of a dorsal metacarpal free flap to
the wound and, later, replacement of the lost carti-
lage with preserved, irradiated human allograft rib
cartilage salvaged the nose and permitted recon-
struction to resume.

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 29. Case 5. (Above) The defect resulted from excision of the nose, nasal septum,
adjacent cheeks and maxillae, upper lip, and the central part of the frontal bone for
treatment of a squamous cell carcinoma. An acrylic plug had been placed in the frontal
bone defect. (Center and below) Operation 1. Bilateral radial forearm free flaps were
transferred for nasal lining. These flaps were inadequate for volume replacement.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 30. Case 5, operation 3. (Above, left) The patient with the lining flaps in
place. (Above, right, and center and below) The skin grafts were removed from
the lining flaps and the flaps were thinned of excess fat. An unexpanded fore-
head flap was interposed over a nasal framework of costal cartilage.

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Volume 120, Number 5 • Reconstruction of the Nose

Fig. 31. Case 5, operation 3. (Above, left) The patient showing collapse and contraction of the nose following infection and extrusion
of cranial bone grafts. (Above, right, and center) Operation 5. A composite flap containing vascularized rib for the dorsum and
columella, islands of muscle for volume, and a skin island for the columella was based on the left thoracodorsal artery. (Below) The
nose has no refinement. It does have length, width, projection, and functional airways, giving it the potential for an aesthetic and
functional result.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 32. Case 5. Preoperative (above) and postoperative (below) views. Final photographs were obtained 2 years after the last
operation.

DISCUSSION each subunit can be contoured to create a normal-

The result of the microvascular transfer of a free
flap to the face often falls short in achieving an
aesthetic ideal. A free flap simply applied to fill a
defect in the face appears as a patch replacing the
normal units and subunits, with misplaced high-
lights and shadows. To ensure an aesthetic result,
microvascular free flaps must be designed to ade-
quately replace the volume and dimensions of the
missing tissues. They should be constructed and ap-
plied layer by layer as aesthetic facial units. After that,
appearing result.
Flap Volume and Skin Area
The subcutaneous volume and skin area of tissue
necessary to replace the missing tissues of the central
face are often underestimated. Deep defects involv-
ing the maxillary antrum cannot be adequately filled
with a radial forearm free flap. If maxillary ablation
is an option, flaps having a thick subcutaneous com-
ponent such as the scapular, anterolateral thigh, and

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Volume 120, Number 5 • Reconstruction of the Nose
Fig. 33. Case 5. Additional preoperative (above) and postoperative (below) views of
the patient.
superficial inferior epigastric artery flaps are used for
fill. The radial forearm flap is used for restoration of
those elements requiring skin and a relatively thin
subcutaneous component such as the nasal lining,
floor, and upper lip. The radial forearm flap design
is traced from templates of foil that duplicate the
missing nasal lining and adjacent lip and cheek el-
ements. For this purpose, patterns are derived using
adjacent normal facial anatomy, clay models of the
desired nose, and plaster moulages of the facial de-
fect. The shape and dimensions of the separate skin
elements constituting the composite defect are cop-
ied to the foil templates. The separate foil templates
are then aligned to the radial artery on the volar
forearm and joined together with tape to duplicate
the radial vascular pedicle leash. The leashed tem-
plates are then anatomically articulated to ensure
ease of placement without vascular kinking follow-
ing flap elevation. If the required skin area is insuf-
ficient for one forearm, a second free flap may be
required. Secondary shrinkage of unsupported skin
free flaps can be great, especially those of the upper
lip unit and nasal vestibule. For this reason, we de-
sign flaps of the upper lip larger than the measured
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 Plastic and Reconstructive Surgery • October 2007
defect by as much as 150 percent. Shrinkage can also
be stifled by the judicious use of cadaver cartilage
allograft stents (especially applicable for the vestib-
ular lining).
Layers
To create the foundation for a reconstructive
result with aesthetic dimensions and contour, it is
necessary to build the face in layers, from posterior
to anterior—from the bottom of the defect, up. The
deepest layer is the one that fills the deep recesses of
the defect and may include flap tissue extending into
and obliterating the maxillary antrum. This first
layer, or filler, establishes the base for the second
posterior-to-anterior layer.
This second layer is the facial plane of the cheek
and upper lip, floor of the nasal airway, and the
platform on which the new nose will rest. Although
this plane is usually reconstructed with a single,
large, free microvascular flap, two separate flaps are
sometimes necessary. In some cases, the free micro-
vascular flap that forms the facial plane of the cheek
and upper lip has been allowed to flow over into the
nasal cavity to line the floor of the nose. The plane
of the cheeks, upper lip, nasal floor, and nasal plat-
form should be well established before the new nose
is reconstructed on it.
The third layer of reconstruction, installed of-
ten at a separate surgical stage, is the lining flap for
the nasal vestibule and columella. In this series, it
was most often a radial forearm free flap having
two skin paddles: one to line the large, single nasal
vestibule and one to line the columella. In most
cases, a third paddle was added for defects of the
nasal floor, nasal platform, or adjacent facial units.
In case 5, the lining for the columella was inserted
secondarily to open a collapsed airway. In another
case, the nasal floor and platform were inserted to
correct a secondary contracture of the airway. We
have allowed this free flap lining to heal in place
for 4 weeks or more before constructing the more
aesthetically important superficial layers of the
nose at a separate stage.
The fourth and fifth layers of the central face,
reconstructed at the next surgical stage, are (1) the
framework of carved cartilage grafts possessing the
dimensions and shape of a normal nose, and (2) a
sartorially correct paramedian forehead flap de-
signed to fit over this framework. Although the car-
tilage grafts are usually harvested from the sixth,
seventh, and eighth costal cartilages, in some cases
we have used auricular conchal cartilage to recon-
struct the nasal tip and alae. When the nasal bones
are missing, we use a structure of three pieces of
1206
cranial bone joined together and fixed to the max-
illae and frontal bone with microplates and screws.
We use a carefully designed, unexpanded forehead
flap for the fifth, or skin cover, layer of the recon-
struction, except when the forehead has been de-
stroyed in the initial disease process. Then, a micro-
vascular free flap (radial forearm, lateral arm, or
anterolateral thigh) is our second choice. In either
case, the cover flap is designed to fit the nasal unit
and not flow onto adjacent facial units.
Facial Units
To the greatest degree practical, we build the
new center of the face aesthetic unit by aesthetic
unit. The nose and the lip-cheek-nasal floor units are
always constructed with two separate flaps. This ap-
proach maintains the normal segmentation of the
face, each facial unit contracting centripetally to-
ward its separate center. However, facial units can
also be carved out of a single large flap after it has
been transferred, if the flap is designed sufficiently
large. Most often, we carve the upper lip and cheek
units out of a single large flap after the flap has been
established in the defect. Patterns used for this pur-
pose are taken from the contralateral normal side of
the patient’s face or from an ideal plaster and clay
model of the face.
Fine Contouring (Nasal Subunits)
After the defect has been built up layer on layer,
and after facial aesthetic units have been divided one
from another, fine surface contouring can be added.
The fine features of the nose and adjacent facial
units include the following: a straight and narrow
dorsum, flat or “ski-slope” nasal sidewalls that blend
subtly with the cheek unit, a small projecting nasal
tip, a narrow columella possessing Sheen’s angle of
rotation,5 alar grooves, thin alar margins, alar-facial
grooves (where the alar bases rest on the upper lip),
and nasolabial grooves.
We perform one or two stages of fine contouring
with the nasal pedicle intact, as first described by
Millard.8 At the first stage of contouring, we lift the
forehead flap cover off the upper three-fourths of
the nose, thin the flap, sculpt its underlying bed, and
replace the flap on the bed. When necessary, a sec-
ond “intermediate” operation is performed with the
pedicle intact. At this stage, we narrow and shape the
columella and thin the alar margins and vestibule
lining. When the forehead pedicle is divided, we use
that exposure to shape the nasal radix and redesign
the cephalic end of the defect along subunit lines.
When necessary, late secondary cartilage grafts are
added into the nasal tip, to increase projection9; at
Volume 120, Number 5 • Reconstruction of the Nose
the radix, to straighten the dorsal line5; and along
the alar margin, to correct upward retraction or a
notch.
The key to all contouring procedures before or
after pedicle division is to approach the central facial
features through incisions that will come to lie in the
lines of deepest facial shadow. These shadowed lines
are as follows: the lateral lines of the nasal dorsum,
the border of the tip subunit, the alar grooves, the
superior borders of the soft triangles, and the naso-
labial grooves. Through these precisely placed inci-
sions, the skin is elevated, the subcutaneous tissue is
sculpted or augmented with cartilage grafts, and the
skin is replaced and held to its newly contoured bed
with temporary quilting sutures.
CONCLUSIONS
The use of multipaddle, microvascular, free na-
sal lining flaps allows the creation of a nasal tissue
mass possessing functional airways and with normal
or greater than normal dimensions. This, in turn,
permits the application of a cartilage framework and
covering flap that can be sculpted to an aesthetic
result. Visual and artistic concepts distinguish aes-
thetic facial reconstruction on a foundation of mi-
crovascular free flaps from simple wound filling.10
Unadorned with the aesthetic concepts presented
here, straightforward microvascular flap transfer
produces a blob in a hole. The flap spans and covers
up facial units and subunits. It obliterates normal
contours. In contrast, reconstruction performed tis-
sue layer by tissue layer, and facial unit by facial unit,
with the added touch of fine contouring of subunits,
produces an aesthetic result having the dimensions,
proportion, and surface contour of a natural normal
nose, upper lip, and cheek.
Gary C. Burget, M.D.
2913 North Commonwealth Avenue, Suite 400
Chicago, Ill. 60657-6224
gburget@hotmail.com
DISCLOSURE
The authors have no commercial associations that
might pose or create a conflict of interest with infor-
mation presented in this article. Such associations
include consultancies, stock ownership or other equity
interests, patent licensing arrangements, and pay-
ments for conducting or publicizing any study de-
scribed in the article.
REFERENCES
1. Burget, G. C., and Menick, F. J. Aesthetic Reconstruction of the
Nose. St. Louis: Mosby, 1994. Pp. 431–461.
2. Menick, F. J. Facial reconstruction with local and distant
tissue: The interface of aesthetic and reconstructive surgery.
Plast. Reconstr. Surg. 102: 1424, 1998.
3. Walton, R. L., Burget, G. C., and Beahm, E. K. Microsurgical re-
construction of the nasal lining. Plast. Reconstr. Surg. 115: 1813, 2005.
4. Murrell, G. L., and Burget, G. C. Aesthetically precise tem-
plates for nasal reconstruction using a new material. Plast.
Reconstr. Surg. 112: 1855, 2003.
5. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty, 2nd Ed.
St. Louis: Mosby, 1987. Pp. 808–825.
6. Erol, O. O. The Turkish delight: A pliable graft for rhino-
plasty. Plast. Reconstr. Surg. 105: 2229, 2000.
7. Daniel, R. K., and Calvert, J. W. Diced cartilage grafts
in rhinoplasty surgery. Plast. Reconstr. Surg. 113: 2156, 2004.
8. Millard, D. R., Jr. Reconstructive rhinoplasty for the
tk;4lower half of a nose. Plast. Reconstr. Surg. 53: 133, 1974.
9. Peck, G. C. The onlay graft for nasal tip projection. Plast.
Reconstr. Surg. 71: 27, 1983.
10. Millard, D. R., Jr. Aesthetic aspects of reconstructive surgery
(Preface). Clin. Plast. Surg. 8: 165, 1981.
1207
DISCUSSION
Optimal Use of Microvascular Free Flaps, Cartilage
Grafts, and a Paramedian Forehead Flap for Aesthetic
Reconstruction of the Nose and Adjacent Facial Units
Frederick J. Menick, M.D.
Tucson, Ariz.
I n this fascinating article, skilled surgeons share
their experience in the repair of composite
defects of the central face. Frequently, facial
wounds lie entirely within one facial unit. Often,
defects encompass parts or all of multiple adja-
cent units, creating a composite defect. Because
units vary in aesthetic priority, volume, dimen-
sion, position, skin quality, outline, and contour,
such reconstructions are more complicated. Too
frequently, traditional approaches fail to restore
the three-dimensional form of the face with two-
dimensional flaps or transfer distant mismatched
skin to provide facial cover. Burget and Walton’s
success is attributable to their appreciation of
the aesthetic consequences of anatomical loss,
their ability to identify and replace the “true”
tissue loss in correct dimension and position,
and their skill in restoring the complex subtle
three-dimensional contour of the lip and cheek
that serves as a platform for a nose that projects
from the face and has a subtly contoured sur-
face. Over six to seven operations, they coordi-
nate the steps of their repair, as follows:
1. They recreate the defect and establish a
lip/cheek platform on which to build a
nose. Because local or regional tissue is in-
sufficient to restore such large complex de-
fects, distant tissue is transferred by micro-
vascular technique. In large deep losses,
only the facial platform is restored using a
superficial inferior epigastric flap, a latissi-
mus flap, a scapular flap, or an anterior
lateral thigh flap of sufficient volume and
dimension. The maxillary antrum is obliter-
ated, if necessary.
2. Once the midface platform is present or
restored, a radial forearm flap with separate
paddles for the nasal vault, nasal floor, and
columella lining is transferred as a free flap.
In smaller defects, the lip, cheek, and nasal
requirements can be simultaneously re-
stored with a single free flap and the recon-
Received for publication November 14, 2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000254345.98806.47
1208 www.PRSJournal.com
struction can begin without a preliminary
“bulk” flap. A full-thickness skin graft is
placed externally to resurface the raw sur-
face of the lining flap.
3. Some months later, the external full-
thickness skin graft and underlying excess
fat are excised from the radial free forearm
lining. Individually designed rib grafts are
shaped to emulate the external form of
each subunit and are fixed with sutures to
each other and to the reconstructed lining
to create a subsurface architecture. A fore-
head flap of exact dimensions is designed
and transferred to supply nasal skin cover,
thinning the flap distally of subcutaneous
tissue and frontalis. The distal 1.5 cm is
folded inward to meet the arm skin of the
lining flap so that the nostril margin will be
lined with forehead skin and not mis-
matched arm skin.
4. Before forehead flap pedicle division, two
intermediate operations are performed.
Initially, the forehead is reelevated over its
proximal two-thirds with 3 mm of subcuta-
neous fat. The underlying excess bulk, con-
sisting of subcutaneous fat and frontalis, is
excised to sculpt the dorsum, supratip, and
sidewalls into a “nasal shape.” The forehead
flap is maintained intraoperatively as a bi-
pedicle, vascularized from the brow and in-
set into the tip, columella, and ala.
5. Some weeks later, a second intermediate
operation is performed to define the nostril
rim, thin the nostril lining and open the
airway, shape the external columella, and
shorten the nose, as needed. This is per-
formed through peripheral marginal inci-
sions, leaving the proximal flap adherent to
the recipient site.
6. The forehead flap pedicle is divided some
weeks later.
7. Four to 6 months later, revision is under-
taken. Disregarding old scars, direct inci-
sions are made in the ideal depressions be-
tween subunits and excess soft tissue
sculpted to define the alar crease, soft tri-
angle, and dorsal lines. The nostril margins
Volume 120, Number 5 • Discussion
are reopened and further debulked, if
needed. Profile imperfections are ad-
dressed with additional radix or dorsal car-
tilage augmentation, if appropriate.
The ultimate importance of this article, in my
opinion, lies less in the specific details of micro-
vascular transfer or free flap design and more on
the fascinating integration of regional unit prin-
ciples, operative stages, the requirements of facial
platform, and the three-dimensional reconstruc-
tion of the central face and nose. It illustrates the
consummate use of local, regional, and distant
tissue to restore multiple, different yet interde-
pendent facial units. Just as a patient undergoing
a nasal reconstruction is not “the forehead flap I
did on Wednesday,” such complex repairs are not
solved by assuming that free tissue transfer is “na-
sal reconstruction.” It is only a donor material,
which any surgeon can use to “fill the hole.” How-
ever, only a few can integrate the material into a
“nose.”
The authors clearly define their principles of
repair:
1. Restore normal to normal. Recreate the de-
fect if distorted by scar, previous repair, or
congenital deficiency.
2. The facial platform of the lip and cheek
projects the nose and must be restored to
create the expected proportion, position,
and volume of the midface.
3. Build on a stable platform. Only when
edema, local anesthesia, tension, gravity,
and scar contraction subside and stabilize
should a nose be rebuilt on the lip and
cheek platform. This prevents shifting of the
nasal base and nasal distortion.
4. Missing tissue must be replaced exactly. Any
excess will bulge, displacing adjacent land-
marks outward. If the defect is replaced with
tissues of inadequate volume, adjacent land-
marks will be distorted as they are pulled
inward by the repair.
5. Use exact templates to design flaps in di-
mension and outline.
6. Use surgical stages to advantage. Create a
platform. Position materials to the face.
Modify donor materials so that they are the
correct thinness and contour to match facial
requirements.
7. Recreate a three-dimensional shape by resto-
ration of the rigid three-dimensional cartilag-
inous framework and subcutaneous sculpture.
8. Facial units vary in character: skin quality
(color, texture, thickness, hair characteris-
tics) subcutaneous bulk, muscle function,
outline, and contour. The expected charac-
ter of each unit must be restored by using or
modifying tissues to resupply the unit. This
often requires the use of separate grafts or
flaps. Careful analysis of the anatomical and
aesthetic loss pinpoints the deficiencies that
require replacement— cheek, lip, nasal floor
and nasal vault, columella, and support. Tis-
sues must be replaced in layers—skeleton,
facial soft tissue, cover, lining, and support.
In reality, it is impossible to recreate the hu-
man face. We can only assemble bits and pieces of
expendable tissue to create a facsimile that ap-
pears to be normal but is not. The technical steps
described in this excellent article are worthy of
discussion, as follows.
USE OF DISTANT TISSUE FOR FACIAL
DEFECTS
The choice of donor material depends on the
tissue requirements of the defect, donor availabil-
ity, and the surgeon’s ability to transfer it to the
recipient site. In large central facial defects, local
tissue is absent. Regional tissue is often insufficient
in dimension and volume. Thus, distant tissue be-
comes the first choice for large complicated
wounds.1 Unfortunately, it does not match facial
skin in color, texture, or thickness or have a facial
shape. Logically, free flaps should be used to pro-
vide bulk, protect vital structures, revascularize
local tissue, restore facial platform, or provide lin-
ing. At a later stage, only local tissues are used for
aesthetic cover. Distant tissue is invaluable for pro-
viding “invisible requirements” (bulk, support, lin-
ing) but is not used to replace surface facial skin.
Only local facial skin is used to resurface the face.
Although modern techniques of microvascular
transfer are more efficient and reliable than older
methods that have used delayed or pedicle flaps
and axial, myocutaneous, or tube flaps, the impli-
cations of distant tissue transfer remain the same.
The ultimate aesthetic result depends primarily
on the surgeon’s choice and design of donor ma-
terials, his or her ability to modify it into a facial
shape, and his or her ability to suit the recipient
needs. The method of tissue transfer is irrelevant
if regional unit expectations are achieved.
ADVANTAGES OF SURGICAL STAGING
Surgeons often fail to appreciate the many
advantages of surgical stages. Time permits a
wound to “mature,” ensuring a stable platform.
Staging allows the surgeon to recreate the defect
1209
 Plastic and Reconstructive Surgery • October 2007

Fig. 1. Cocaine-damaged nose after failed closed cartilage grafting. The skin and lining are contracted, a septal fistula is present, and
the upper lip is retruded.

in layers, verify vascular viability, use excess tissue size, and a thin columella— can be vexing in any
for secondary hinge-over flaps, or to delay or pre- nasal reconstruction. Too often, the donor tissues
fabricate transferred tissue. Intermediate soft-tis- used to restore the cover, lining, and support are
sue sculpting procedures allow the surgeon to too thick and bulge into the airway. Frequently,
modify transferred tissue into a more “nasal” char- the dimensions of the nasal vault lining “cupola”
acter. Too often, surgeons seek to use “one flap in or the length of the columella are inadequate.
one hole in one operation” (or as few operations Inadequate support of cover and lining with a
as possible), which severely limits the result. rigid middle framework leads to collapse. Circum-
ferential nostril rim scar contraction can create
RECONSTRUCTION OF NASAL LINING: 360-degree nostril stenosis. The authors recom-
RADIAL FREE FOREARM FLAP DESIGN mend the use of a separate columellar paddle to
The authors clearly define the elements of
nasal lining loss—nasal vault, floor, columella, and
septum. The axial vascular leash of a radial fore-
arm flap allows the design of individual paddles, in
continuity, which can supply tissue to each of these
deficient areas, if needed. However, restoration of
the septal partition is unnecessary. Excessive bulk
within the nasal airway partition causes nasal ob-
struction. Although a single combined nasal vault
and floor pattern was used in case 2, certainly the
flexibility of orientation achieved by the use of
separate nasal vault and nasal floor paddles may be
helpful in more complex and larger nasal floor de-
fects. Once the floor is repaired, they recommend a
large nasal vestibular paddle and a separate “overly
long columella lining flap . . . inserted between the
apex of the main vestibule lining flap and the region
of the anterior nasal spine” to “keep the space in
front of the pyriform aperture free of flap tissue” and
prevent the collapse of the vestibular lining flap onto Fig. 2. Scarred tissues are discarded in the inferior one-half of
the face, narrowing the nostril. nose. Normal is returned to normal. The nasal floor is released and
Certainly, the restoration of patent airways— resurfaced with bilateral flaps of scarred external alar skin based
necessitating thin nostril rims, adequate nostril laterally to reposition the retracted lip.

1210
Volume 120, Number 5 • Discussion

maintain nostril patency. This ensures adequate
columella length but also necessitates temporary
nasal obstruction and a somewhat complex sec-
ondary debulking. Although its axial pedicle en-
sures an initial robust blood supply, the radial
artery may be ablated during later columella thin-
ning, making the columella dependent on a ran-
dom blood supply through scars at both the nasal
vault and nasal floor. This creates the potential for
devascularization of the columella lining (as seen
in one of the 10 patients). At present, my own
preference is to include the columella component
of the nasal lining repair into a single nasal vault
flap. A wider radial forearm flap is positioned skin
inward to provide nasal vault lining and then
folded on itself to cover its raw external surface. At
the time of forehead flap transfer and framework
reconstruction, the external surface of the radial
flap is hinged over, using the external skin as a
columella extension. The radial flap can also be
initially folded inward to simultaneously restore
both ala and columella lining (Figs. 1 through 9).

Fig. 3. A free radial forearm flap is folded to create alar and columellar lining and supply temporary
external cover.

Fig. 4. Two months later, the external forearm skin is hinged inferiorly and the columellar lining
split. Excess soft tissue is excised to create a thin, supple lining sleeve. A dorsal rib graft has been
positioned.

1211
 Plastic and Reconstructive Surgery • October 2007

Later, at the time of forehead flap transfer, exter-
nal skin is discarded.
Regardless of method, widely patent nostrils in
such complex repairs remain elusive.
FOLDING THE FOREHEAD FLAP TO
PROVIDE ADDITIONAL ALAR RIM LINING
The authors recommend folding inward an
extra 1.2-cm apron of distal forehead flap to meet
the previously positioned microvascular lining
flaps. This lines the nostril margins with forehead
skin, avoiding the possibility of exposed nonfacial
skin being visible within the reconstructed nostril.
Although the modified folded forehead flap
technique2,3 for nasal lining is the workhorse for
routine reconstructions in my everyday practice, I
would hesitate to supplement the microvascular
lining as they suggest. Folding an extension of a
forehead flap to provide additional lining could
be extremely useful if the microvascular flap was
deficient in width from side to side and extra
lining was required to prevent inadequate nostril
size. By necessity, however, such a folded method
initially creates a thicker, less defined nostril rim
and might best be avoided if used to simply “hide”
lining skin. Although this can be revised with ex-
cellent results, it adds an extra degree of difficulty
in an already complex repair. Close examination
of the intraoperative photographs suggests that
the authors were similarly cautious in the infold-
ing of the forehead flap in the cases illustrated.
THE INTERMEDIATE OPERATION:
MODIFICATION OF THE PRELIMINARY
NASAL RECONSTRUCTION BEFORE
FOREHEAD FLAP DIVISION
A successful nasal reconstruction requires
an outer layer of thin, conforming skin and an

Fig. 5. A framework of primary rib cartilage grafts restores a middle supportive framework. A full-thickness forehead flap is trans-
ferred for cover. With all its layers, no distal thinning is performed.

1212
Volume 120, Number 5 • Discussion
Fig. 6. One month later, the forehead flap is physiologically delayed. Forehead skin and 3 mm
of subcutaneous fat are completely elevated, maintaining the proximal pedicle. The flap is put
to the side of the defect. The underlying reconstruction is completely exposed.
inner layer of thin vascular and supple lining,
separated by an artistically shaped middle sup-
portive framework, which supports, shapes, and
braces the transferred tissues against gravity,
tension, and scar contracture. Unfortunately,
transferred cover and lining donor tissues are
thicker than normal nasal skin and lining and
must be debulked while their vascularity is main-
tained. Simultaneously, the integrity and rigidity
of cartilage grafts must be maintained while
their thinness and moldability are ensured. In-
dividual cartilage pieces must be pieced together
into an artistic construction, which will simulate the
volume, dimensions, position, symmetry, and con-
tour of multiple nasal subunits. They mold the over-
lying external skin and underlying lining into a nasal
shape. Remember the principles of Gillies and Mil-
lard4: “Plastic surgery is a perpetual battle of beauty
versus blood supply.” Too often, surgeons fail to
acknowledge the need for donor modification or
remain frozen by the fear of tissue necrosis. This
leads to a bulky, amorphous external nose, and thick
obstructed nostrils.
The skin, subcutaneous fat, and frontalis of
the forehead make it thicker than nasal skin. (Just
as a radial free forearm flap containing various
amounts of subcutaneous fat and fascia is thicker
than normal nasal lining.) Traditionally, a fore-
head flap is transferred in two stages. At the initial
flap transfer, the proximal aspect is “thinned” and
positioned over a flimsy construction of cartilage
grafts fixed together with sutures. Three weeks
later, the proximal flap is “debulked” at the time
of pedicle division. Such staged thinning is limited
and piecemeal. Because of gravity or tension, car-
tilage grafts may also shift or settle, requiring further
augmentation, reduction, or repositioning. Tradi-
tionally, multiple revision operations have been per-
formed months later. As described by the authors,
the angle, height, and shape of the dorsum and
radix may need to be altered by excision or aug-
mentation. Tip projection or definition may need to
be increased. The sidewalls may require debulking.
The nostril rims must be thinned and the airways
opened. The columella must be shaped and nar-
rowed. The nasal surface must be sculpted to re-
create the alar creases, dorsal lines, soft triangles,
and nasolabial folds by further so⬙ft-tissue excision.
To minimize these problems, the authors
combine initial distal forehead flap thinning at
the time of transfer with two intermediate
“sculpting” operations before pedicle division,
as first described by Millard.5 First, with the pedi-
cle intact, the proximal flap is elevated off the
1213
 Plastic and Reconstructive Surgery • October 2007

Fig. 7. Subunit designs are marked with ink on the underlying excess of fat and frontalis. This solid,
healed construction of primary cartilage grafts and free flap lining is sculpted by soft-tissue excision
into a nasal shape, like a bar of soap.

superior two-thirds of the repair and the under-
lying recipient bed is modified, maintaining a
bipedicle between the brow and the distal inset
of the tip, columella, and ala. Some weeks later,
the alar margins, nostrils, and columella are
further modified through marginal incisions.
Exposure is poor and meticulous manipulation
difficult.
Over the past 15 years,2,3 I have approached
the reconstructive problem in another way. A
forehead flap is initially transferred with all of its
layers (skin, subcutaneous fat, frontalis, and a
deep areola layer) without distal thinning (Figs.
1 through 5). Such a flap retains its maximal
blood supply (random through the skin, myocuta-
neous through the frontalis, and axial through the
supratrochlear vessels). Three weeks after trans-
fer, it is also physiologically delayed. Because its
subcutaneous fat and frontalis layer have not been
injured or excised, it remains soft and supple. Scar

1214
Volume 120, Number 5 • Discussion
Fig. 8. Thin, supple, conforming forehead skin resurfaces the
three-dimensional framework and is replaced on the recipient
site with peripheral and quilting sutures. One month later, the
pedicle is divided.
fibrosis does not occur. Thus, at 3 weeks, the pe-
ripheral borders of the transferred forehead flap
Fig. 9. Nasal shape and function are significantly restored at 9 months, shortly after revision
surgery to further define the alar creases by direct incision and soft-tissue sculpture.
can be incised (Fig. 6). Forehead skin and 3 mm
of subcutaneous fat can be elevated over the entire
recipient site while the proximal pedicle is main-
tained intact. Routinely, the flap is temporarily
placed to the side of the defect, although a small
columella inset can be maintained if desired. This
exposes an underlying bed of residual forehead
subcutaneous fat, frontalis, and primary cartilage
grafts now unified and healed together into a
strong construction (Fig. 7). Excess soft tissues can
be excised and additional cartilage grafts posi-
tioned, if needed. A shaped three-dimensional
midlayer framework can be carved like a bar of
soap. A nasal shape can be sculpted from soft and
hard tissue to shape the dorsum, tip, sidewalls, ala,
and columella during one intermediate opera-
tion. Old cartilage grafts can be repositioned if
shifted or additional grafts added, if needed. With
such exposure, the surgeon can position himself
or herself to visualize the nose from 360 degrees,
maximizing the opportunity to create the appro-
priate volume, position, symmetry, and propor-
tion of a nose. Then, thin supple forehead skin with
a few millimeters of subcutaneous fat is replaced
on the remodeled recipient bed and fixed with
peripheral and quilting sutures (Fig. 8). The pedi-
cle is divided three to four weeks later. Later scar
revision of any secondarily healed forehead de-
fect and further direct incision of the alar crease
or rim may be helpful. The number of stages is
1215
 Plastic and Reconstructive Surgery • October 2007

decreased and the ease of repair and overall
results improved (Fig. 9). This approach adds a
level of precision and safety not previously seen
in my practice. The full-thickness forehead flap
technique also permits a modified use of the
folded forehead flap or skin grafts for lining.2,3
genital absence of the frontalis, significant
scarring within the flap territory, or the flap is
required in a severe smoker. In summary, this
excellent article exemplifies the “best” of plastic
surgery—its intellect, its skill, and its ability to
reconstruct patient lives.

TISSUE EXPANSION AND DELAY OF Frederick J. Menick, M.D.

THE FOREHEAD DONOR SITE
I agree with the authors that tissue expan-
sion should be avoided. They suggest that tissue
expansion “thins the dense subcutaneous tissue
of the forehead flap, a layer essential to a smooth
external nasal contour.” In reality, this layer is
partially excised during nasal repair. A parame-
dian forehead flap based on a narrow su-
pratrochlear pedicle allows primary closure of
the inferior forehead and positions any residual
defect high under the hairline to heal second-
arily. Tissue expansion is avoided because it is
unnecessary. It delays the nasal repair; adds un-
necessary morbidity; can be complicated by de-
flation, infection, or extrusion; and increases
social isolation. It is occasionally useful in the
very short forehead (⬍4 cm) or a very tight or
scarred forehead (past forehead flap). Tissue
expansion is not used because it does not need to
be used. In routine cases, an initial delay of a
forehead flap by peripheral outlining weeks be-
fore transfer is unnecessary, unless the su-
pratrochlear blood supply is in question— con-
1102 North El Dorado Place
Tucson, Ariz. 85715
drmenick@drmenick.com
ACKNOWLEDGMENT
The author acknowledges the invaluable assistance
of Arthur Salibian, M.D., of Santa Ana, California, in
the microvascular transfer of the radial forearm flap.
DISCLOSURE
The author has no financial interest in any of the
products, devices, or drugs mentioned in this article.
REFERENCES
1. Menick, F. J. Facial reconstruction with local and distant tissue:
The interface of aesthetic and reconstructive surgery. Plast.
Reconstr. Surg. 102: 1424, 1998.
2. Menick, F. J. A ten year experience in nasal reconstruction with the
three stage forehead flap. Plast. Reconstr. Surg. 109: 1839, 2002.
3. Menick, F. J. Nasal reconstruction: Forehead flap. Plast. Re-
constr. Surg. 113: 100E, 2004.
4. Gillies, H., and Millard, D. R., Jr. The Principles and Art of Plastic
Surgery. Boston: Little, Brown, 1957.
5. Millard, D. R., Jr. Reconstructive rhinoplasty for the lower half
of the nose. Plast. Reconstr. Surg. 53: 133, 1974.

American Society of Plastic Surgeons Mission Statement

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

1216
 RECONSTRUCTIVE

Aesthetic and Functional Outcome following

Nasal Reconstruction
Marc A. M. Mureau, M.D.,
Ph.D.
Sanne E. Moolenburgh,
M.D.
Peter C. Levendag, M.D.,
Ph.D.
Stefan O. P. Hofer, M.D.,
Ph.D.
Rotterdam, The Netherlands
Background: Few reports on outcome of aesthetic nasal reconstruction exist.
Therefore, subjective and objective aesthetic and functional outcome following
nasal reconstruction was assessed.
Methods: Outcome was assessed in 38 consecutive patients treated for subtotal
nasal defects using standardized semistructured interviews. Standardized phys-
ical examination forms and photographs were used.
Results: In six patients, one aesthetic subunit was involved; in 14, two; and in
18, three or more. Defects were classified as skin only (13 percent), skin/
cartilage (21 percent), and full thickness (66 percent). Some defects (32 per-
cent) involved adjacent aesthetic units. Inner lining was reconstructed with local
mucosa or turnover skin flaps. Support was provided with regional cartilage
grafts and/or composite septal flaps. Skin defects were reconstructed with
forehead, nasolabial, cheek advancement, Abbé, facial artery perforator, or free
radial forearm flaps. Nasal reconstructions required 116 procedures. Thirty-
three patients participated in the follow-up study. Mucosal crusting was noted
in 36 percent, passage difficulties in 31 percent, and worse olfaction in 16
percent. Phonation was unchanged. Eighty-one percent were very satisfied with
nasal function. Flap color match was moderate to good in 97 percent; hair
growth occurred in 61 percent. At critical inspection, a thicker flap (58 percent),
smaller ostium nasi (77 percent), thicker alar rim (86 percent), and minor alar
rim retraction (46 percent) were noted. Seventy-nine percent were very satisfied
with total nasal appearance.
Conclusion: Although objective functional and aesthetic outcome following nasal
reconstruction sometimes shows impairment compared with the normal situation,
it gives high subjective patient satisfaction with function and aesthetics. (Plast.
Reconstr. Surg. 120: 1217, 2007.)

P
robably the first nasal reconstruction using a
cheek flap was published in the Sushruta Sam-
hita in India between 700 and 600 BC.1 Many
centuries later, different techniques using other
donor sites to reconstruct the nose such as the
forehead,1 the upper arm,2 or retroauricular area3
were published. The forehead, however, eventually
became the most popular donor site for nasal re-
construction because of its excellent vascularization,
skin color, and texture match.4 The forehead flap has
been brought close to perfection by different contrib-
utors improving each others’ techniques.4
Nasal reconstruction is more than meets the
eye with respect to the need for structural sup-
From the Departments of Plastic and Reconstructive Surgery
and Radiotherapy, Erasmus Medical Center Rotterdam.
Received for publication January 6, 2006; accepted April 5,
2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279145.95073.ed
port and inner lining. Concepts involving ade-
quate structural support and inner lining were
slowly accepted.5,6 Once these concepts were
combined with the aesthetic subunit principles,7
as popularized by Burget and Menick,8,9 predict-
ably good aesthetic results of nasal reconstruc-
tion could be achieved.
In the literature, emphasis exists on technical
refinements to optimize aesthetic results following
nasal reconstruction; however, little has been pub-
lished on long-term aesthetic or functional out-
come (PubMed search for “outcome,” “nasal or
nose reconstruction”).10 –16 Only four outcome
studies of nasal reconstruction actually presented
any data on subjective aesthetic results: one with-
out any statistical analyses,11 one without finding
any statistically significant results because of small
sample sizes,12 one with subjective nasal functional
ratings by 32 patients and subjective aesthetic rat-
ings by a panel,14 and one for nasal alar defects
only.15 A PubMed search found no studies address-

www.PRSJournal.com 1217
 Plastic and Reconstructive Surgery • October 2007
ing objective functional outcome after subtotal na-
sal reconstruction.
In conclusion, to date there is still a shortage
of studies on function and appearance after na-
sal reconstruction. The aim of the present study
was to investigate subjective and objective func-
tional and aesthetic follow-up results after recon-
struction of subtotal nasal defects.
PATIENTS AND METHODS
Patient Sample Characteristics
A total of 38 consecutive patients treated be-
tween November of 2001 and May of 2005 for
subtotal nasal defects by one surgeon (S.O.P.H.)
were included. There were 22 men and 16 women;
their ages ranged from 35 to 87 years (mean, 62
years). Thirty-three patients had a defect following
radical tumor resection (mainly squamous and
basal cell carcinoma) and five patients had a de-
fect caused by miscellaneous conditions requiring
nasal reconstruction (Table 1).
According to the aesthetic subunit principles,8,9
in six patients (16 percent) the defect involved one
aesthetic subunit, in 14 cases (37 percent) two, and
in 18 subjects (47 percent) three to seven. Most
typically, the ala nasi (63 percent), nasal tip (47
percent), lateral sidewall (47 percent), or nasal dor-
sum (42 percent) was affected. In 11 subjects (29
percent), the columella was missing; in three cases
(8 percent), both alae nasi were involved; and in two
patients (5 percent), both lateral sidewalls had to be
reconstructed. Some defects also involved adjacent
aesthetic facial units such as cheek (seven cases) or
upper lip (five patients). Defects were classified as
skin only (13 percent), skin and cartilage (21 per-
cent), and full thickness (66 percent).
Local and Systemic Risk Factors
A total of 23 cases (61 percent) had a history
of previous nose surgery: tumor excision and pri-
Table 1. Causes of Subtotal and Total Nasal Defects
in 38 Patients
Cause No. of Patients (%)
Basal cell carcinoma 15 (39.5)
Squamous cell carcinoma 12 (31.6)
Lymphoma 3 (7.9)
Keratoacanthoma 1 (2.6)
Lentigo maligna 1 (2.6)
Sweat gland carcinoma 1 (2.6)
Trauma 2 (5.3)
After meningococcal sepsis 1 (2.6)
Burns 1 (2.6)
After radiotherapy 1 (2.6)
Total 38 (100.0)
1218
mary closure (n ⫽ 12 times); tumor excision and
skin graft (n ⫽ 7); tumor excision and local or
regional flap (n ⫽ 4); and ethmoidectomy and
dorsal onlay cartilage graft (n ⫽ 1). Fourteen pa-
tients (37 percent) had received local radiother-
apy or brachytherapy in the past (40 to 60 Gy), and
14 cases (37 percent) had one or more systemic
risk factors (hypertension, diabetes mellitus, or
systemic lupus erythematosus; or a history of myo-
cardial infarction, percutaneous transluminal cor-
onary angioplasty, or open heart surgery). In sum-
mary, seven cases (18 percent) had none of the
above-mentioned risk factors, 22 patients (58 per-
cent) had one such a risk factor, and nine subjects
(24 percent) had two.
Nasal Reconstruction Techniques
Nasal reconstructions were performed using
the basic principles of aesthetic nasal reconstruc-
tion as comprehensively described by Burget and
Menick.9
Intranasal Lining
Intranasal lining was reconstructed with ipsi-
lateral mucoperichondrial flaps anterocaudally
based on the septal branch of the superior labial
artery5,6 in 14 patients. Turnover skin flaps sur-
rounding the defect4,10 were used to provide inner
lining in 12 cases where the size of the defect had
to be enlarged to the total size of the involved
aesthetic subunit. Five subjects required a hemi-
nose reconstruction and a cranially based com-
posite septal swing flap5,6 was used for inner lining
and sidewall cartilage support. In two patients,
after a total nose amputation, an anterocaudally
based composite septal pivot flap with laterally
peeled mucoperichondrial flaps5,6 was used for
lining of both nasal vestibules and cartilage sup-
port. One of these latter two patients required a
folded paramedian forehead flap for additional
inner lining coverage.
Cartilage Framework Support
For restoration of a cartilage framework, con-
chal, septal, or rib cartilage grafts were used 26, 13,
and four times, respectively, in 31 patients. These
cartilage grafts were used as alar batten grafts,
nasal supratip and columellar strut grafts, dorsal
onlay or cantilever grafts, and lateral sidewall sup-
port grafts.
Nasal Cover
Using the aesthetic subunit principles,8,9 skin
defects were reconstructed with 32 paramedian
forehead flaps in 30 patients. In one patient, two
forehead flaps were used simultaneously after it
appeared that the first flap had been designed
Volume 120, Number 5 • Outcome after Nasal Reconstruction
without the alar unit and in another patient a
second forehead flap was used for reconstruction
of an ala nasi defect after necrosis of the first
forehead flap following flap thinning. Ala nasi skin
defects were reconstructed with cranially based
nasolabial flaps in six patients. Paranasal cheek
defects were covered using cheek advancement
flaps in seven cases. Upper lip defects were recon-
structed with facial artery perforator flaps17 (three
times) or Abbé flaps (three times). In two of these
latter patients, an extended Abbé flap was used to
simultaneously reconstruct the missing columella
in one case and to cover the nasal floor in the
other patient. One patient with basal cell nevus
syndrome required a free radial forearm flap for
total nasal skin coverage because of multiple pre-
vious basal cell carcinoma excisions followed by
skin graft and local/regional flap reconstructions.
Second and Third Stages of Nose
Reconstruction
Paramedian forehead flaps were typically di-
vided and inset 3 weeks later in a second stage in
the first 16 patients of the current series, followed
by flap thinning in a third stage in 10 of these
cases. In the remaining six patients, flap thinning
was either not deemed necessary (two times) or
refused by the patient (four times). With increas-
ing experience, a three-stage approach according
to Menick’s later reports4,18 was followed in the
remaining 14 patients in whom a forehead flap was
used. After 3 weeks, the forehead flap was vigor-
ously thinned and the cartilage framework was
sculptured in the right shape while the flap re-
mained attached distally and to its pedicle. An-
other 3 weeks later, in a third stage, the forehead
flap was divided and inset in all 14 cases. Forehead
flaps were further thinned during additional aes-
thetic improvements as scar revisions or cartilage
tip grafts in eight patients. Nasolabial and Abbé
flaps were divided and inset 3 weeks after the first
stage in all nine patients.
Procedure
A letter was mailed to all patients explaining the
study and asking them to participate. All consenting
patients were invited to the outpatient clinic for a
standardized interview, physical examination, and
clinical photographs of their face. The study was
approved by a medical ethics committee.
Measures
Medical Data
All patient files were retrieved, and patient
characteristics, medical history, surgical data, and
complications were scored meticulously on a stan-
dardized form.
Subjective Nasal Function and Satisfaction
with Appearance
To assess subjective nasal function and sat-
isfaction with appearance, we developed a stan-
dardized semistructured interview with prefor-
mulated questions. Reported problems of nasal
functioning19 (airway passage, snoring, olfaction, dry
mucosa, epistaxis, and phonation) were scored. Sat-
isfaction with the appearance of different nasal char-
acteristics was measured using a five-point scale (1 ⫽
very dissatisfied; 5 ⫽ very satisfied), as was satisfaction
with donor-site scars (forehead, nasolabial fold, ear,
and chest).
Objective Nasal Function and Appearance
To determine objective nasal function and ap-
pearance, we developed a standardized physical
examination form. Nasal function was assessed by
scoring the occurrence of alar collapse during
forced inspiration and nasal whistling during pho-
nation or respiration. In addition, anterior rhi-
noscopy was performed in all patients to look for
mucosal dryness, crusts, ulceration, adhesions, or
synechiae. Nasal appearance was assessed by an
independent investigator (M.A.M.M.) through scor-
ing flap color match (good, moderate, or poor), flap
hair growth (yes or no), flap thickness (too thick,
adequate, or too thin), ostium nasi size (smaller,
equal, or larger), alar rim thickness (too thick, equal,
or too thin), alar rim retraction (yes or no), and
satisfaction with total nasal appearance (1 ⫽ very
dissatisfied; 5 ⫽ very satisfied). Standardized
preoperative and postoperative clinical photo-
graphs of the face and nose were taken by a
medical photographer.
Statistical Analysis
Data were analyzed as frequencies and percent-
ages or means and ranges. To detect possible dif-
ferences between groups, Fisher’s exact and Mann-
Whitney U tests were used. Two-tailed values of p ⬍
0.05 were accepted as statistically significant.
RESULTS
Postoperative Complications and Results
Requiring Revision Surgery
Twenty-one patients (55 percent) had a totally
uneventful postoperative course following every
procedure. Seven postoperative complications
(18 percent) and 19 results requiring revision
surgery occurred in 15 patients (39.5 percent)
(Table 2). In addition, two patients (5 percent)
had a complication that resolved following con-
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 Plastic and Reconstructive Surgery • October 2007

Table 2. Postoperative Complications and Results Requiring Revision Surgery in 15 Patients

Procedure
Paramedian forehead flap*
Extended Abbé flap
Mucoperichondrium flap
Cheek advancement
Dorsal onlay rib graft
Conchal tip grafts
Full-thickness alar
reconstruction
FH, forehead; NL, nasolabial; FTSG, full-thickness skin graft.
*Flap tip necrosis occurred twice following flap thinning.
Postoperative Complication or
Result Requiring Revision Treatment Patient No.
Flap tip necrosis with exposed One cartilage removal and closure 9
and/or infected cartilage and secondary cartilage tip graft
Flap tip necrosis with exposed One necrotectomy and second FH flap 34
and/or infected cartilage
Flap tip necrosis with exposed One necrotectomy and NL flap 5
and/or infected cartilage
Flap tip necrosis with exposed One necrotectomy and FTSG 31
and/or infected cartilage
Flap tip necrosis with exposed Two inner lining transpositions 6, 38
and/or infected cartilage
Lower eyelid ectropion One medial canthopexy 29
Unstable rib graft fixation One screw fixation to nasal bone 23
Insufficient tip support One rib cartilage strut graft 14
17 instances of a too-small Four caudally based paranasal 14, 15, 24, 31
ostium nasi in 10 patients transposition flaps and lateral alar
base transpositions
Four instances of ostium nasi 2, 4, 24, 34
widening and FTSG
Two Z-plasties 34, 35
Two cases of ala nasi thinning 24, 36
Four alar batten cartilage grafts 5, 14, 34, 36
One case of alar cartilage graft thinning 4

servative treatment. One patient with persistent
bleeding from intranasal mucosal wound edges
was successfully treated with a Merocel tampon
(Medtronic Xomed, Jacksonville, Fla.) for 48 hours.
Another case had a temporary lower eyelid ectro-
pion following a cheek advancement procedure that
resolved spontaneously.
Flap tip necrosis occurred three times follow-
ing 32 paramedian forehead flaps (9 percent), of
which two resulted from flap thinning during the
second stage, once after two extended Abbé flaps,
and twice following 14 mucoperichondrium flaps
(Table 2). Five of six patients with flap tip necrosis
had a risk factor compromising flap circulation
(smoking, n ⫽ 3; local radiotherapy, n ⫽ 1; and
diabetes mellitus, n ⫽ 1). Forehead flap tip ne-
crosis resulted in infected cartilage, which had to
be removed in one patient who developed insuf-
ficient tip projection caused by retraction that was
treated later with a secondary conchal cartilage tip
graft (case 9) (Table 2 and Fig. 1).
A too-small ostium nasi (i.e., smaller than the
unaffected side) was the most encountered and
resistant postoperative problem that had to be
surgically corrected in 10 patients, sometimes on
multiple occasions (Table 2). A caudally based
paranasal flap transposed into the nasal floor
while the alar base was transposed laterally was
performed four times to correct the stenosis (e.g.,
case 14) (Table 2 and Fig. 2). Furthermore, ostium
nasi widening using a full-thickness skin graft, ala
nasi thinning in combination with quilting su-
tures, Z-plasties, alar batten cartilage grafts, and
alar cartilage graft thinning were used (Table 2).
In total, 116 procedures were needed in 38 pa-
tients (mean, three operations per patient). Postop-
erative complications occurred in two of seven pa-
tients without risk factors (smoking, radiotherapy, or
systemic disease) and in five of 31 cases with one or
more of these risk factors (Fisher’s exact test, p ⫽
0.592). A total of 24 percent of the patients in whom
a paramedian forehead flap was used compared with
none of the cases in whom a nasolabial flap was used
had complications (Fisher’s exact test, p ⫽ 0.311).
Results indicating revision surgery occurred in 14
percent of patients without risk factors and in 32
percent with one or more risk factors (Fisher’s exact
test, p ⫽ 0.644).
Follow-Up Results
Thirty-three patients (87 percent) participated
in the follow-up study. Three patients refused to
participate and two had died (one because of distant
tumor metastasis). The mean follow-up period was
12 months (range, 6 to 35 months).
Subjective Nasal Function and Satisfaction with
Appearance
Compared with before tumor resection and
nasal reconstruction, 31 percent reported having

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Volume 120, Number 5 • Outcome after Nasal Reconstruction

Fig. 1. (Above, left) Nasal tip and partial dorsum skin and cartilage defect after radical
basal cell carcinoma resection in a 52-year-old man (case 9) (Table 2). (Above, right) Im-
mediate postoperative result after reconstruction with a paramedian forehead flap in
combination with conchal cartilage tip and strut grafts. (Below, left) Paramedian forehead
flap tip necrosis with infected cartilage grafts 28 days postoperatively. (Below, right) Final
result at 14-month follow-up after infected cartilage graft removal, flap inset and thin-
ning, and a secondary conchal cartilage strut graft for tip projection improvement. The
patient was satisfied with nasal appearance and very satisfied with nasal function.

more airway passage difficulties, 22 percent re- often, and 6 percent reported having spontaneous
ported having mucosal crusts or dry mucosa more nose bleeding more often. Phonation was un-
often, 16 percent reported having more difficulty changed in all 33 patients. Eighty-one percent
smelling odors, 13 percent reported snoring more reported being very satisfied with nasal function-

1221
 Plastic and Reconstructive Surgery • October 2007

Fig. 2. (Above, left) Full-thickness defect including the nasal tip, both alae nasi, and col-
umella 5 months after radical excision of an aggressive keratoacanthoma that did not
regress spontaneously in a 58-year-old woman (case 14) (Table 2). (Above, right) Left-sided
ostium nasi stenosis, high-riding left alar base, and lack of tip projection 11 months after
reconstruction with mucoperichondrial and turnover skin flaps, septal and conchal car-
tilage grafts, and a paramedian forehead flap. (Below, left) A caudally based paranasal flap
was transposed into the nasal floor and the alar base was transposed laterally to correct
the stenosis. (Below, right) Final result at 6 1⁄2-month follow-up. The patient was very
satisfied with nasal appearance and satisfied with nasal function.

ing (mean, 4.4; where 1 ⫽ very dissatisfied and and donor-site scars. In general, patients were
5 ⫽ very satisfied). most satisfied with flap color match and appear-
Table 3 shows satisfaction results with the ap- ance of the reconstructed nasal tip and least sat-
pearance of different reconstructed nasal units isfied with ostium nasi size and flap hair growth

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Volume 120, Number 5 • Outcome after Nasal Reconstruction
Table 3. Satisfaction with Appearance of
Reconstructed Nasal Subunits and Donor-Site Scars
in 33 Patients
No. of
Very Satisfied with Appearance of Patients (%)*
Reconstructed nasal tip 17/21 (81)
Reconstructed ala nasi 17/25 (68)
Reconstructed nasal dorsum 11/15 (73)
Reconstructed ostium nasi size 14/27 (52)
Flap color match 27/33 (82)
Flap hair growth 6/19 (32)
Total nasal appearance 26/33 (79)
Donor-site
Forehead/nasolabial fold scar 25/31 (81)
Ear scar 21/22 (96)
Chest scar 9/9 (100)
Brow appearance 20/25 (80)
*Total number of patients in whom the item is applicable.
(Table 3). A total of 19 (10 male and nine female
patients) of 31 patients with a forehead, nasola-
bial, or free radial forearm flap showed flap hair
growth. Eight of these 19 patients were treated
with ruby laser hair removal therapy. Satisfaction
with flap hair growth was lower following nasola-
bial flap reconstruction (mean, 2.0; range, 1 to 5)
compared with forehead flap reconstruction (mean,
3.7; range, 1 to 5; Mann-Whitney U test, Z ⫽ –2.0,
p ⫽ 0.046). Seventy-nine percent reported being
very satisfied with total nasal appearance. Subjective
satisfaction with donor-site scars was generally very
high (Table 3). There was no statistically significant
difference in satisfaction with total nasal appear-
ance, flap color match, or flap donor-site scars be-
tween the forehead and nasolabial flap reconstruc-
tion patients (Mann-Whitney U test, p ⫽ 0.457, p ⫽
0.457, and p ⫽ 0.595, respectively).
Objective Nasal Function and Appearance
Six of 22 patients (27 percent) with a recon-
structed ala nasi showed alar collapse during
forced inspiration, compared with two of 10 pa-
tients (20 percent) with a normal ala nasi (Fisher’s
exact test, p ⫽ 1.000). Only one of these patients
had unilateral airway passage difficulties during
normal nasal respiration. None of the patients had
symptoms of nasal whistling during phonation or
respiration. Anterior rhinoscopy revealed dry mu-
cosa in 15 percent, mucosal crusts in 36 percent,
and mucosal adhesions/synechiae in none of 33
patients.
Flap color match was good in 20 patients (61
percent), moderate in 12 patients (36 percent),
and poor in one patient (forehead flap in severely
damaged skin following previous irradiation).
Flaps were considered too thick in 19 of 33 pa-
tients, six of whom had already been scheduled for
further flap thinning. Fifty-six percent of the fore-
head flaps compared with 80 percent of the na-
solabial flaps were considered too thick (Fisher’s
exact test, p ⫽ 0.622). Nasal scars were on the
aesthetic subunit border in 21 patients (64 per-
cent). When looked at critically, reconstructed os-
tium nasi size was smaller compared with the con-
tralateral normal situation in 17 of 22 patients (77
percent), one of whom was treated for ostium nasi
stenosis (10 patients in total) (Table 2). Critical
analysis also showed a thicker reconstructed alar
rim and minor alar rim retraction in 19 (86 per-
cent) and 10 (46 percent) cases, respectively (for
typical examples, see Figs. 3 through 5). Satisfac-
tion with total nasal appearance (mean, 3.6; range,
1 to 5) as scored by the independent investigator
was statistically significant lower compared with
mean patient satisfaction (mean, 4.2; range, 1 to
5; Mann-Whitney U test, Z ⫽ –2.4, p ⫽ 0.015).
DISCUSSION
The present study assessed subjective and ob-
jective aesthetic and functional outcome following
subtotal nasal reconstruction in 38 patients with a
mean follow-up of 12 months. To overcome meth-
odologic flaws from previously published reports
on aesthetic and functional outcome after nasal
reconstruction,10 –16 we analyzed our results criti-
cally and objectively using semistructured, stan-
dardized questionnaires and physical examina-
tion forms.
In the current series, the flap tip necrosis
rate was six of 85 flaps (7 percent), which is
comparable to earlier reported rates ranging
from 0 to 12 percent.10,12–16 Seven patients (18
percent) had postoperative complications re-
quiring revision. Compared with earlier re-
ported postoperative complication rates (1 to 20
percent),10,12–16 this seems slightly high. How-
ever, in the present series, nasal defects that had
to be reconstructed were extensive and included
all three layers in the majority of patients, in
contrast to earlier studies in which a consider-
able portion of patients had small to moderate
skin-only or skin and cartilage defects10,11,13–15 or
where only alar defects were present.12 Another
explanation could be the high prevalence of
previous nose surgery, local radiotherapy, or sys-
temic risk factors compromising wound healing,
which proved to be related to the occurrence of
inner lining or skin flap tip necrosis in five of six
cases.
Two cases from the present series were treated
for insufficient cartilage support and 10 patients
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 Plastic and Reconstructive Surgery • October 2007

Fig. 3. (Left) Full-thickness nasal defect including the right ala nasi and lateral sidewall after radical excision of a recurrent
squamous cell carcinoma in a 75-year-old man. (Right) Immediate postoperative views after reconstruction with a paramedian
forehead flap combined with a composite septal swing and mucoperichondrium flap and conchal cartilage grafts.

for a small ostium nasi, sometimes on multiple
occasions. In addition, alar rim retraction and a
thickened alar rim were findings addressed during
revision surgery. The ostium nasi is a very difficult
landmark to reconstruct because of the combina-
tion of often barely sufficient inner lining with a
skin cover flap under slight tension and the need
for very firm structural support, even in areas
where previously no support was present, to with-
stand circular scar contraction. Numerous tech-
niques are available to add skin-only or cartilage
support in a second stage9,18; however, few fol-
low-up data on improvement through these tech-
niques are available.
In our opinion, the most common cause for
nostril stenosis and alar rim retraction is inade-
quate inner lining. In our personal evolution of
nasal reconstruction techniques, we have slowly
shifted away from the regular use of intranasal
lining flaps. We feel that circulation in these frail
flaps is somewhat unreliable, especially when com-
bined with cartilage grafts. Transposition of these
flaps is often disappointing. In cases where small
inner lining requirements exist, a full-thickness
skin graft or turn-down lining flap with delayed
primary cartilage grafting at the intermediate
stage currently is our preference.18 In cases where
medium to larger inner lining requirements exist,
the folded forehead flap with delayed primary car-
tilage grafting at the intermediate stage is our
preferred technique.18 For subtotal nasal recon-
struction with very large lining requirements, we
would now consider a vascularized free lining tis-
sue transfer.20 Another factor that is important in
prevention of alar rim retraction is acceptance of
the extension of the forehead flap into the hair-
bearing scalp to prevent a too-short forehead flap
pulling on the nose. This has to be combined with
liberal proximal dissection of the flap base beyond
the brow.

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Volume 120, Number 5 • Outcome after Nasal Reconstruction
Fig. 4. Final result at 9-month follow-up after forehead flap inset and thinning during two separate proce-
dures. At critical analysis, the right-sided reconstructed alar rim was scored as thicker than the contralateral
normal one. The patient reported being very satisfied with nasal appearance and function.
Another challenging problem is alar rim thick-
ness. This problem improved in our series when
we changed from a two-stage to a three-stage fore-
head flap approach, which allowed safer and more
radical thinning. This needs to be combined with
strategically positioned quilting sutures.
A mean of three operations per patient were
necessary to reach an acceptable aesthetic and func-
tional result, which is comparable to other investi-
gators reporting a mean of 2.5 operations per
patient,12 necessary secondary revisions in 11 to 54
percent,13,16 and one to three operations in 81 per-
cent of all patients to reach optimal results.10 It is
important to emphasize that most of our patients
were satisfied with their reconstructive outcome and
refused further surgery after their forehead flap
pedicle had been severed. This was somewhat to our
discontent, because we sought perfection in our sur-
gical results. In general, we feel it is difficult to reach
perfection in just a three-stage operation. A number
of more critical patients, however, still desired fur-
ther nasal improvement. These patients usually will
need one or more additional operations to reach a
better result.
Eighty-one percent of the patients reported
being very satisfied with nasal function (mean,
4.4), which is in accordance with other investiga-
tors who also reported a mean satisfaction of 4.4
using comparable five-point Likert scales.12,14 Pho-
nation was unchanged in all patients, 31 percent
experienced more airway passage problems, and
22 percent reported having mucosal crusts more
often compared with before surgery. These results
are in line with a previous study on subjective nasal
function after reconstruction.15 Twenty-seven per-
cent of the patients with a reconstructed ala nasi
showed alar collapse during forced inspiration,
compared with 20 percent with a normal ala nasi.
Only one of these patients had unilateral airway
passage difficulties during normal nasal respira-
tion. These findings cast doubt on the clinical
usefulness of this test, which together with the
Cottle test is promoted for detecting nasal valve
abnormality.19 It may be better to use cotton-tip
applicators to look for internal valve abnormality.21
We feel that objective measures for nasal valve
patency still do not exist and that using self-report
visual analogue scales may be more reliable. Al-
though composite septal transposition flaps were
used in seven instances resulting in a monolocular
intranasal cavity, which may be a risk factor for
nasal whistling sounds during phonation or res-
piration, none of the patients showed such symp-
toms. The relatively high incidence of dry mucosa
and crusts, however, shows that the nasal air hu-
midification mechanism may sometimes be af-
fected or even impaired despite these efforts to
reconstruct nasal lining.
1225
 Plastic and Reconstructive Surgery • October 2007

Fig. 5. (Above, left) Skin and cartilage defect of the left ala nasi, nasal floor, cheek, hemiphiltrum, and upper lip after radical excision
of a basal cell carcinoma in a 64-year-old man (case 31) (Table 2). (Above, center) Immediate result after a paramedian forehead flap
and conchal cartilage alar batten grafts for reconstruction of the ala nasi, an extended Abbé flap for the hemiphiltrum, and a facial
artery perforator flap for the upper lip. (Above, right and below) Final result at 11-month follow-up after flap inset and thinning and
correction of a left-sided ostium nasi stenosis in two separate stages. At critical analysis, left-sided alar rim retraction was noted, as
was a thicker alar rim compared with the right one. The patient was very satisfied with nasal function and appearance.

A total of 79 percent of all patients were very
satisfied with their nasal appearance, which is com-
parable to earlier reports in the literature.12,13,15
Other investigators either provided no data10 or
stated that “high aesthetic and functional goals were
met in all patients,” without further clarification.16 In
the present series, patients were most satisfied with
flap color match and appearance of the recon-
structed nasal tip, and they were least satisfied
with the occurrence of flap hair growth, ostium nasi
size, and ala nasi shape. These results corroborate
the results from an earlier report where patients
reported being least satisfied with nostril size and
alar notching,12 which is another indication that
these structures are most difficult to reconstruct
successfully.
Flap color match was poor in one patient in
whom a forehead flap was used to reconstruct a
nasal defect in severely damaged and discolored
paranasal skin following previous radiotherapy.
Flaps were considered too thick in 58 percent,
without a statistically significant difference be-
tween the flaps used. Especially when the nasal
skin is very thin in combination with delicate nasal
cartilage contours, obtaining an adequate flap
thickness is very challenging, and often involves

1226
Volume 120, Number 5 • Outcome after Nasal Reconstruction
two or more additional flap-thinning procedures.
When looked at critically, reconstructed ostium
nasi size, reconstructed alar rim thickness, and
minor alar rim retraction were recurrent prob-
lems as discussed above. Moderate to severe alar
notching was also previously found in 46 and 65
percent of all patients following ala nasi recon-
structions using nasolabial and forehead flap,
respectively.12 Despite the liberal use of alar batten
cartilage grafts in the current series, preventing
the circular scar contraction forces from retracting
and narrowing the ala nasi remains very difficult.
In the current study, no statistically significant
differences were found in satisfaction with total nasal
appearance, flap color match, or flap donor-site
scars between the forehead and nasolabial flap re-
construction patients. These results contradict ear-
lier results of two articles investigating a possible
difference in aesthetic results between nasolabial
and forehead flap reconstructions: both studies con-
cluded that better results were obtained with naso-
labial flap reconstructions.11,12 Uchinuma et al. spec-
ulated that anatomical differences of the face
between Caucasians and Asians may be an explana-
tion for this difference, because their study popula-
tion consisted only of Japanese patients.11 Another
more general explanation may be that defects re-
constructed with forehead flaps are typically larger
and more complex, which makes any comparison
difficult. Ideally, for a valid and reliable comparison
between forehead and nasolabial flap reconstruc-
tions, size, depth, and location of defects should be
standardized or statistically controlled for.
Similar to Drisco and Baker,15 mean satisfaction
with total nasal appearance as scored by the inde-
pendent investigator was statistically significantly
lower compared with mean patient satisfaction in
our series. Apparently, nasal reconstruction patients
generally seem to be less critical about the aesthetic
result compared with professionals.
CONCLUSION
Although objective functional and aesthetic
outcome following nasal reconstruction some-
times shows impairment compared with the nor-
mal situation, it leads to a high subjective patient
satisfaction with function and aesthetics.
Stefan O. P. Hofer, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Erasmus Medical Center Rotterdam
P.O. Box 2040
3000 CA Rotterdam, The Netherlands
sophofer@hotmail.com
DISCLOSURE
None of the authors has a financial interest in any
of the products, devices, or drugs mentioned in this
article.
REFERENCES
1. McDowell, F. The classic reprint: Ancient ear-lobe and rhi-
noplastic operations in India. Plast. Reconstr. Surg. 43: 512,
1969.
2. Tagliacozzi, G. De Curtorum Chirurgia per Insitionem. Venice,
Italy: Bindoni, 1597.
3. Washio, H. Retroauricular-temporal flap. Plast. Reconstr. Surg.
43: 162, 1969.
4. Menick, F. J. Nasal reconstruction: Forehead flap. Plast.
Reconstr. Surg. 113: 100e, 2004.
5. Burget, G. C., and Menick, F. J. Nasal support and lining:
The marriage of beauty and blood supply. Plast. Reconstr.
Surg. 84: 189, 1989.
6. Burget, G. C., and Menick, F. J. Nasal reconstruction: Seeking
a fourth dimension. Plast. Reconstr. Surg. 78: 145, 1986.
7. Millard, D. R. Aesthetic reconstructive rhinoplasty. Clin.
Plast. Surg. 8: 169, 1981.
8. Burget, G. C., and Menick, F. J. The subunit principle in
nasal reconstruction. Plast. Reconstr. Surg. 76: 239, 1985.
9. Burget, G. C., and Menick, F. J. Aesthetic Reconstruction of
the Nose. St. Louis: Mosby, 1994.
10. Rohrich, R. J., Griffin, J. R, Ansari, M., et al. Nasal recon-
struction: Beyond aesthetic subunits. A 15-year review of 1334
cases. Plast. Reconstr. Surg. 114: 1405, 2004.
11. Uchinuma, E., Matsui, K., Shimakura, Y., et al. Evaluation of
median forehead flap and the nasolabial flap in nasal re-
construction. Aesthetic Plast. Surg. 21: 86, 1997.
12. Arden, R. L., Nawroz-Danish, M., Yoo, G. H., et al. Nasal alar
reconstruction: A critical analysis using melolabial island and
paramedian forehead flaps. Laryngoscope 109: 376, 1999.
13. Singh, D. J., and Bartlett, S. P. Aesthetic considerations in
nasal reconstruction and the role of modified nasal subunits.
Plast. Reconstr. Surg. 111: 639, 2003.
14. Quatela, V. C., Sherris, D. A., and Round, M. F. Esthetic
refinements in forehead flap nasal reconstruction. Arch. Oto-
laryngol. Head Neck Surg. 121: 1106, 1995.
15. Drisco, B. P., and Baker, S. R. Reconstruction of nasal alar
defects. Arch. Facial Plast. Surg. 3: 91, 2001.
16. Boyd, C. M., Baker, S. R., Fader, D. J., et al. The forehead
flap for nasal reconstruction. Arch. Dermatol. 136: 1365, 2000.
17. Hofer, S. O. P., Posch, N. A. S., and Smit, X. The facial artery
perforator flap for reconstruction of perioral defects. Plast.
Reconstr. Surg. 115: 996, 2005.
18. Menick, F. J. A 10-year experience in nasal reconstruction
with the three-stage forehead flap. Plast. Reconstr. Surg. 109:
1839, 2002.
19. Howard, B. K., and Rohrich, R. J. Understanding the nasal
airway: Principles and practice. Plast. Reconstr. Surg. 109:
1128, 2002.
20. Walton, R. L., Burget, G. C., and Beahm, E. K. Microsurgical
reconstruction of the nasal lining. Plast. Reconstr. Surg. 115:
1813, 2005.
21. Khosh, M. M., Jen, A., Honrado, C., et al. Nasal valve recon-
struction: Experience in 53 consecutive cases. Arch. Facial
Plast. Surg. 6: 167, 2004.
1227
DISCUSSION
Aesthetic and Functional Outcome following
Nasal Reconstruction
Fredrick J. Menick, M.D.
Tucson, Ariz.
T his article is a significant contribution from
motivated surgeons serious about facial repair.
They evaluate their techniques with the hope of
improving the lives of their patients. Thirty-eight
consecutive reconstructions of subtotal defects—
both superficial (skin or skin and support loss) and
full thickness—were examined. All required the
repair of one or multiple nasal subunits and adja-
cent cheek and lip. Subjectively, their patients were
satisfied (79 percent) despite objective functional
and aesthetic imperfections.
In reality, this article examines how success is
measured in a facial reconstruction— objectively
or subjectively, or by the surgeon or the patient. In
general, provided that the overall facial gestalt is
correct, the patient appears normal at conversa-
tional distance and there are no distracting abnor-
malities, the surgeon and patient should be happy.
Success in facial reconstruction is not measured by
the presence of scars. It is determined by the cor-
rectness of dimension, outline, symmetry, contour,
and position of facial landmarks. The repair must
blend into the adjacent normal tissue. As a rule, if
the surgeon reestablishes the basic elements of the
missing part, minimizes the deficiencies, and avoids a
jarring abnormality, the result will be good. The au-
thors identified several technical deficiencies that lim-
ited their results: growth of hair on the forehead, flap
necrosis, infection, and airway stenosis.
THE PRESENCE OF HAIR ON A NASAL
RECONSTRUCTION
The hair-bearing scalp and glabrous forehead
are one anatomical region. They have similar an-
atomical layers, a peripheral blood supply, and sim-
ilar skin quality except for the presence or absence
of hair. Forehead height varies. It can be high or low
or its effective height limited by an old scar. Most
foreheads permit a forehead flap to be transferred
with little or no hair-bearing skin. The template,
which defines the dimension and outline of skin
required to resurface the defect, is positioned just
under the hairline above the supratrochlear vessels.
It is vascularized by vertically oriented vessels that
Received for publication June 2, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279146.17203.9f
1228 www.PRSJournal.com
anastomose with the multiple adjacent territories of
the angular, supraorbital, infratrochlear, and infe-
rior orbital vessels. The proximal pedicle is designed
vertically and extended inferiorly through the me-
dial eyebrow toward the medial canthus, releasing
restricting fibrous bands or corrugator muscle fibers
and maintaining the visible vessels. Because the
pivot point drops closer to the defect as the pedi-
cle extends inferiorly through the brow, the flap
length and its reach are effectively lengthened.
Under most circumstances, hair-bearing skin need
not be transferred. However, the nose is the first
priority. If the forehead is extremely low and hair
must be transferred to reach the defect, the flap
should be designed with a hairy distal extension.
Any transferred hair can be removed by shaving,
plucking, depilation, electrocautery, or laser as
appropriate. In clinical practice, if a nose looks
normal, the patient will be happy, even if hair is
transferred. Remember that either the right or left
pedicle can be used to resurface a midline defect,
but an ipsilaterally based flap should be used for
a unilateral defect—reaffirming that the shortest
distance between the pedicle base and the defect
is a straight line. Rotate a paramedian flap inward
toward the midline to minimize an acute “twist.”
Because the forehead vessels are oriented verti-
cally, an obliquely designed flap transects its feed-
ing vessels and decreases its blood supply. Closure
of an oblique flap also increases the risk of brow
asymmetry and permanent distortion on donor
closure. A vertical design is best.
Forehead expansion is almost never needed
in a “virgin” forehead. It is never used to help
close the donor site, although it could be used
secondarily in unusual cases. Very rarely, if signifi-
cant scarring is present in the donor area, an ex-
pander can increase available skin, both vertically
and horizontally, in more complicated cases. An ex-
pander is occasionally helpful in a patient who has
already undergone one or more previous forehead
flaps. Occasionally, skin distal to a horizontal fore-
head scar is delayed, in stages, before flap transfer.
FLAP NECROSIS AND INFECTION
The authors noted a 7 percent rate of flap tip
necrosis after transfer. Flap necrosis and infection
may occur together.
Volume 120, Number 5 • Discussion
A forehead flap is highly vascular. However, it
is thicker and stiffer than normal nasal skin. Dur-
ing transfer, frontalis and subcutaneous tissue
must be excised to modify the forehead into skin
of “nasal thinness.” I perform almost all forehead
flaps under general anesthesia as full-thickness
forehead flaps.1 Local anesthesia with epineph-
rine is not injected into the flap or the recipient
site, to avoid intraoperative contour distortion or
diminished vascularity. During reconstruction,
the flap should remain pink and well perfused.
Epinephrine vasoconstriction prevents intraoper-
ative evaluation of impending tissue ischemia and
should be avoided.
Forehead flaps do not die unless they are un-
der excessive tension or radically thinned into the
dermis. To avoid tension, they must be of ade-
quate size and reach (an exact template should be
used, the pivot point lowered, the flap lengthened
into the hairline, and the flap based on the ap-
propriate pedicle). Individual sutures are placed
with care. If the flap blanches, the suture is re-
moved and replaced more gently or in another
area. Occasionally, the flap seems “too tight,” mo-
tivating the surgeon to remove or limit the size of
cartilage support which can temporarily be banked
and replaced in a delayed primary fashion during
a later intermediate operation (i.e., a tip graft).
Once the distal flap is sutured to the columella
and along the alar rims, suturing continues along
the lateral margins of the defect. However, if the
repair seems tight and the flap becomes white,
the flap should be left to dangle from the brow
to the rim. Although the underlying cartilage
grafts might seem at risk for infection or necro-
sis, within 1 week, the wound closes spontane-
ously and heals by secondary intention.
The flap should appear well vascularized and
uniformly pink during each operative stage. Note
that the intraoperative photographs of cases 2 and
3 show “white” flaps— epinephrine should be
avoided to permit intraoperative evaluation and
tension should be avoided that creates ischemia.
If ischemia with impending necrosis is noted post-
operatively, wound tension should be eliminated
(remove sutures and possibly return the patient to
the operating room to remove the tip graft). A
treatable cause should be identified. In my limited
experience, leeches or hyperbaric oxygen are not
helpful. If necrosis seems inevitable in the early
postoperative period, the surgeon has several
options. Although tempted to use “watchful wait-
ing,” too often spontaneous debridement of isch-
emic tissue leads to cartilage exposure, necrosis,
and infection, which puts the entire framework at
risk. Even if secondary healing closes the wound
without further incident, the reconstructed nose
will be distorted by scar contraction and will re-
quire complicated late revisions to place new car-
tilage grafts and missing skin. In most instances, a
few days postoperatively, once the area of tissue
loss has demarcated but before suppuration, the
necrotic area should be debrided and resurfaced.
When designing a vertical forehead flap, position
the cover template at or within the hairline and
then the proximal aspect tapered downward to-
ward the pedicle base, which narrows to 1.2 to 1.5
cm. If the distal flap dies, the taper may allow the
surgeon to reelevate the flap and advance it infe-
riorly to resurface a small skin loss without distor-
tion of the repair. If necrosis is more significant,
a second flap should be transferred from the fore-
head or cheek to cover the deficient area. If part
of the ala is missing, resurfacing an entire subunit
should be considered.
It is important that the surgeon avoid carti-
lage graft infection and late scar contracture.
The entire repair must not be placed in jeopardy
by failing to act. The problem must be corrected
early to achieve a good result. If death of the
entire flap seems inevitable, the patient should
be returned to the operating room. If all cor-
rectable causes have been ruled out, the flap
should be elevated, grossly necrotic tissue de-
brided conservatively, and the flap returned to
the forehead donor site. The forehead will heal
well. Reusable cartilage should be banked. Try
again once the donor and recipient sites have
matured. Harvest a second forehead flap from
an uninjured area and start over.
INFECTION
Infection may occur when lining is lost in pa-
tients with a history of multiple operations, prior
alloplastic foreign implant, or infection. If lining
necrosis is noted early after repair, it may be pos-
sible to debride unhealthy tissue and apply new
lining before the cartilage framework becomes
infected. The skin graft lining technique should
be considered.1,2 A full-thickness forehead flap will
vascularize a full-thickness skin graft. If a limited
area of lining is necrotic, it can be debrided, un-
derlying cartilage grafts removed, and a full-thick-
ness skin graft placed onto the raw surface of the
overlying full-thickness forehead flap. Later, at an
intermediate stage, the forehead flap can be reel-
evated from the skin graft. Lining skin grafts in-
tegrate into the adjacent residual lining and will
survive without the overlying forehead flap at an
intermediate stage. Delayed primary cartilage grafts
1229
 Plastic and Reconstructive Surgery • October 2007
are then placed to support and shape the lining. The
forehead flap is returned to the recipient site. A
turned-in nasolabial flap or intranasal lining flap
might also be considered to replace missing lining.
Three weeks later, the flap pedicle is divided.
If a significant lining loss and infection have
occurred and the repair is lost, save the forehead
flap. Return it to the forehead. The framework
and lining should be debrided as needed. If the
forehead flap was initially transferred as a full-
thickness flap, flap fibrosis will not occur. Some
months later, after wound maturation, the same
flap can be reelevated and transferred during a
second attempt at nasal repair.
In summary, forehead flap necrosis, lining loss,
and infection must be prevented. If problems occur,
the framework should be protected by restoring vas-
cularized cover or lining, if possible. Under all cir-
cumstances, the forehead skin must be preserved.
NOSTRIL STENOSIS
Nostril stenosis is a vexing problem. All wounds
heal with scar, and all scars contract. Circumferential
nostril rim scars tend to stenose. Obviously, the first
admonition must be prevention. Thick lining stuffs
the airway. Bulky support grafts push the lining in-
ward. A poorly designed covering flap, under ten-
sion, will collapse both. Lining and cover must be
thin, supple, and conformable. Lining must be re-
placed accurately—not too much and certainly not
too little. Intranasal lining flaps revolutionized mod-
ern nasal reconstruction. However, they are limited
in size and the dynamics of their rotation. They are
highly vascular but flimsy. Even if supported by a
rigid primary support framework, gravity, tension,
and myofibroblast contraction can have negative
effects.
All patients should be advised preoperatively
that most major defects (large or full-thickness
defects) will require one or two revisions 4 to 6
months after pedicle division.3 Once the tissues
have matured, the definition of the alar crease can
be improved by direct incision and soft-tissue
sculpting, or the forehead scar can be revised in
the area of secondary healing, if desired. Simul-
taneously, the alar rim is incised at the junction of
cover and lining, the lining thinly elevated, and
excess soft tissue excised between the lining and
the undersurface of the cartilage grafts to open
1230
the airway and debulk the rim. If tight, the cir-
cumference of constricted lining can be incised
and expanded by incisions made vertically to the
rim. The gap created by reexpansion of the lining
is filled with a transposition flap of excess rim skin,
if available, or with a full-thickness or composite
skin graft fixed with quilting sutures and a stent.
Rarely is the alar base significantly displaced me-
dially, but excess skin lateral to the repaired ala can
be transposed as a flap, if appropriate. This moves
the alar base laterally and provides additional lining
as the alar base is positioned to a more ideal position.
In difficult cases that are likely to be recalcitrant, I
use stents for weeks or months.
In summary, the authors have carefully ana-
lyzed their results and found ways to modify their
techniques to improve their success. This article
supports plastic surgery—improving patient hap-
piness by restoring acceptable appearance and
function. It focuses our attention on our limita-
tions and provides motivation for all surgeons to
analyze results and define technical maneuvers to
avoid and treat complications. Their clinical shift
away from the two-stage forehead flap with intra-
nasal lining flaps to a three-stage forehead flap
transfer for nasal cover replacement and the mod-
ified folded flap for nasal lining1,2 with primary
and delayed primary support grafts reflects my
own practice. A free flap is occasionally used to
line total and subtotal defects.4
Fredrick J. Menick, M.D.
University of Arizona
1102 North El Dorado Place
Tucson, Ariz. 85715
drmenick@drmenick.com
DISCLOSURE
The author has no financial interest in any of products,
devices, or drugs mentioned in this article.
REFERENCES
1. Menick, F. A 10-year experience in nasal reconstruction with
the three stage forehead flap. Plast. Reconstr. Surg. 109: 1839,
2002.
2. Menick, F. Nasal reconstruction: Forehead flap. Plast. Reconstr.
Surg. 113: 100e, 2004.
3. Burget, G. C., and Menick, F. J. Aesthetic Reconstruction of the
Nose. St. Louis: Mosby, 1994.
4. Menick, F. Facial reconstruction with local and distant tissue:
The interface of aesthetic and reconstruction surgery. Plast.
Reconstr. Surg. 102: 1424, 1999.
 RECONSTRUCTIVE

Reconstruction of the Lower Lip: Rationale to

Preserve the Aesthetic Units of the Face
J. Camilo Roldán, M.D.,
Background: The boundaries of the aesthetic units of the face are often crossed
D.M.D. after lower lip cancer surgery. The aim of this study was to compare the aesthetic
Marcus Teschke, M.D., and functional outcome after use of different operative techniques based on the
D.M.D. concept of the aesthetic units of the face.
Elfriede Fritzer, M.Sc. Materials: Sixty-three patients were evaluated after lower lip reconstruction.
Anton Dunsche, M.D., The aesthetic outcome was recorded by standard photography evaluating the
D.M.D., Ph.D. disruption of the boundaries of the aesthetic units of the face, lip projection,
Franz Härle, M.D., D.M.D., and the resulting facial expression. The functional outcome consisted of the
Ph.D. evaluation of mouth opening, pouting, and lips at rest for the evaluation of
Jörg Wiltfang, M.D., mouth continence. Three techniques were used: wedge excision, the Webster-
D.M.D., Ph.D. Fries method, and the step technique. The step technique was combined with an
Hendrik Terheyden, M.D., Abbé or an Estlander flap in defects involving more than two-thirds of the lip.
D.M.D., Ph.D. Results: In defects involving up to one-third of the lip, the aesthetic outcome was
Regensburg, Bonn, Karlsruhe, and
better for the step technique than for wedge excision (a statistical trend was ob-
Kiel, Germany served, p ⫽ 0.088). In defects involving two-thirds of the lip, the aesthetic and
functional outcome was better using the step technique than the Webster-Fries
method (p ⫽ 0.002), because the boundaries of the aesthetic units are respected.
In defects involving more than two-thirds of the lip, the result was better using the
step technique combined with the Abbé flap.
Conclusion: The authors have shown that the step technique alone or combined
with a flap of the opposite lip is a rational approach for preserving the aesthetic units
of the face and its function. (Plast. Reconstr. Surg. 120: 1231, 2007.)

D
efects of the lower lip result predomi-
nantly from ablative oncologic surgery.
The prognosis for lip cancer patients is
favorable, with a 5-year survival rate between
80 and 98 percent.1,2 The goals of plastic re-
construction of the lip are an excellent aes-
thetic and functional result.3,4
Since the middle of the nineteenth century,
more than 200 different techniques for recon-
struction of the lower lip have been described.5
The concept of the aesthetic units of the face,
introduced by Gonzalez-Ulloa in 1956 for recon-
struction in burn surgery,6,7 has become an im-
From the Departments of Oral and Maxillofacial Surgery,
University of Regensburg and University of Bonn, Depart-
ment of Oral and Maxillofacial Surgery, Institute of Medical
Informatics and Statistics, University Schleswig-Holstein,
Campus Kiel, and Department of Oral and Maxillofacial
Surgery, General Hospital Karlsruhe.
Received for publication December 9, 2005; accepted May 18,
2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279147.73273.e9
portant tool for a systematic approach in facial
reconstruction, mainly for surgery of the nose.8
In the treatment of lip cancer, the concept of the
aesthetic units of the face has not been taken
into account systematically. This is a very impor-
tant aspect when choosing the right operative
technique.
Defects involving less than one-third of the
lip are usually closed primarily after wedge exci-
sion; this concept is widely accepted.3,4 The
method according to Webster is one of the most
accepted techniques for defects involving two-
thirds or more of the lip. This technique consists of
cheek advancement after excision of nasolabial tri-
angles, paramental triangles, and a rectangular ex-
cision of the lower lip,9 and has been modified by
many authors10,11 and was recently presented as the
first choice in lip reconstruction.12,13 A less com-
mon technique, the step technique, was originally
proposed for defects involving up to two-thirds of
the lip.14 An advantage of this technique is the
preservation of the commissure. This technique
consists of a rectangular excision of the lip, which

www.PRSJournal.com 1231
 Plastic and Reconstructive Surgery • October 2007

Fig. 1. Preoperative views of a lower lip carcinoma (above). Operative markings ac-
cording to the Webster-Fries method show an involvement of more than two-thirds
of the lower lip. Burow triangles in the nasolabial folds and in the submental region
allow cheek advancement; the musculature remains intact. The commissure is

1232
Volume 120, Number 5 • Lower Lip Reconstruction
Table 1. Symmetry by Pouting and Profile after Reconstruction
No. of
Procedure Cases
Symmetry by pouting after reconstruction of defects involving one-third of the lower lip
Wedge excision 17 6 (35.3%)
Step technique 21 17 (81.0%)
Total 38 (100%) 60.5%
Symmetry of profile after reconstruction of defects involving two-thirds of the lip
Webster-Fries method 8 0
Step technique 4 4
Total 12
*1 ⫽ good, 2 ⫽ moderate, and 3 ⫽ poor.
is closed after a horizontal stepwise advancement
of a lateral flap above the labiomental fold.1,14 The
aim of this study is to evaluate the aesthetic and
functional outcome using the three techniques for
lip reconstruction based on the concept of the
aesthetic units of the face.
PATIENTS AND METHODS
Between January of 1980 and August of 2004,
137 patients underwent primary resection of the
lip as a consequence of squamous cell carcinoma
at the Department of Oral and Maxillofacial Plas-
tic Surgery at the University Schleswig-Holstein,
Campus Kiel, Germany. In this study, we included
63 patients who underwent lip reconstruction us-
ing the techniques chosen to be evaluated and in
whom a complete documentation was available.
Operative and Oncologic Management
The defect was classified in thirds of the lip.14
The surgical margin for resection was 5 mm; for
tumors larger than 20 mm, the resection margin
was 10 mm. The histologic margin was controlled
three-dimensionally.15 Defects involving less than
one-third of the lip were closed primarily after
wedge excision (n ⫽ 17), which was combined
with a Z-plasty in the labiomental fold to avoid a
notch in the lip.16 Defects involving two-thirds or
more of the lip were closed according to the Web-
ster-Fries method (n ⫽ 14). The Webster modifi-
cation according to Fries11 consists of a curved
incision in the labiomental fold and an excision of
Burow triangles in the submental region and not
paramental as proposed by Webster9 (Fig. 1, cen-
ter). The step technique was also used for defects
involving one-third, two-thirds, and more than
two-thirds of the lip (n ⫽ 32). In defects involving
more than two-thirds of the lip, the step tech-
disrupted (center). Postoperative view at 2 years shows a change in the facial expression (below, left). The upper lip is disproportionally
large and the lower lip is collapsed in the oral cavity. The commissures are not well defined and a macrostomia is seen (below, right).
Score*
1 2 3 p (␹2 test)
0.016
6 (35.3%) 5 (29.4%)
2 (9.5%) 2 (9.5%)
21.1% 18.4%
0.002
0 8
0 0
nique was supplemented with an Abbé17 or an
Estlander flap,18 depending on the involvement
of the commissure.
A vermilionectomy according to von Esmarch
was performed in almost all the cases simulta-
neously in the presence of actinic cheilitis as de-
scribed previously.19 The lower lip excision and
the reconstruction were carried out under local
anesthesia, unless the procedure was combined
with a neck dissection.
Follow-Up and Examination of the Patients
The aesthetic and functional analysis was eval-
uated at least 1 year after surgery; on average, after
5 years. The examination consisted of the evalu-
ation of the function of the orbicular ring (open-
ing the mouth, pouting the lips, and lip at rest for
lip continence). The aesthetic outcome was re-
corded, basically evaluating the disruption of the
boundaries of the aesthetic units of the face, the
disruption of the natural folds (i.e., nasolabial,
labiomental, and commissural fold), symmetry,
scars,4 and lip projection in profile and the result-
ing facial expression. In edentulous cases, the den-
ture was set to support the lower lip. The aesthetic
and function were recorded by standardized pho-
tography and rated by two of the authors as 1
(good), 2 (moderate), or 3 (poor). We evaluated
the sensibility of the lip by asking patients about
their sensation, differentiating the involvement in
thirds of the lip. A pilot study regarding two-point
discrimination test at a distance of 2 cm from the
scar1,20 did not provide accurate information about
patient discomfort.
Statistical Analysis
To evaluate the aesthetic and functional out-
come of the techniques used, the defects were
1233
 Plastic and Reconstructive Surgery • October 2007

Fig. 2. Preoperative views of a lower lip carcinoma in the presence of a cheilitis

actinica (above). Operative markings according to the step technique combined with
a vermilionectomy according to von Esmarch showing involvement of two-thirds of
the lip. The nasolabial fold, the labiomental fold, and the commissural fold are

1234
Volume 120, Number 5 • Lower Lip Reconstruction

Fig. 3. Preoperative view of a lower lip carcinoma (above, left). Operative markings according to the step technique combined
with a cuneiform Abbé flap showing involvement of more than two-thirds of the lip. No natural folds are crossed (below, left).
The postoperative result at 1 year shows a harmonious upper lip/lower lip length. The facial expression has not changed
(above, right). No microstomia is seen (below, right).

classified in thirds of the lip and analyzed sepa-
rately. The chi-square test and the Fisher’s exact
test were used to evaluate the aesthetic and func-
tional outcome. Statistical significance was defined
as p ⬍ 0.05. No adjustment of the error probabilities
for multiple testing was performed because of the
explorative nature of the study.
RESULTS
Defects Involving One-Third of the Lip
Wedge excision (n ⫽ 17) and the step tech-
nique (n ⫽ 21) were performed in patients having
defects involving up to one-third of the lip. Lip
competence and sensibility were observed in all
cases 1 year after surgery. The labiomental fold was
crossed in 29.4 percent of the cases (five of 17)
treated by wedge excision, which is statistically
significant compared with the step technique (p ⫽
0.012). Using wedge excision, the scar was more
pronounced by pouting, forming a notch (p ⫽
0016) (Table 1). The aesthetic outcome compar-
ing wedge excision to the step technique showed
better results for the latter, but this is only a sta-
tistical trend (p ⫽ 0.088).

outlined to show that these natural folds are not crossed. The excision of the rectangles above the labiomental fold allows
advancement for closure (center). Postoperative view at 1 year shows no change in facial expression. The length of the lower lip
is harmonious with the upper lip (below).

1235
 Plastic and Reconstructive Surgery • October 2007

Fig. 4. Preoperative views of a lower lip carcinoma (above). Operative markings ac-
cording to the step technique combined with a rectangular Abbé flap showing in-
volvement of more than two-thirds of the lip. The steps following the labiomental
fold are curved as proposed by Grimm (Schubert, J. Modified Grimm-Johanson

1236
Volume 120, Number 5 • Lower Lip Reconstruction
Defects Involving Two-Thirds of the Lip
The Webster-Fries method (n ⫽ 8) and the
step technique (n ⫽ 4) were performed in patients
having defects involving up to two-thirds of the lip.
Lip competence was present in all cases. The sen-
sibility was normal in 30 percent of the patients
treated with the Webster-Fries method, and 40
percent had a hypesthesia of one-third of the lip
1 year postoperatively. All patients treated with the
step technique had normal sensibility at that time
point. In patients treated with the technique ac-
cording to Webster-Fries, the nasolabial fold and
the commissural fold were always disrupted; the
labiomental fold was not disrupted but showed a
very pronounced scar above the mental muscle,
giving an unnatural aspect of the chin. The upper
lip was disproportionally prominent compared
with the reconstructed lower lip. The lower lip was
also collapsed in the oral cavity; this discrepancy,
compared with the step technique, is statistically
significant (p ⫽ 0.002) (Fig. 1 and Table 1). The
facial expression in the cases treated with the Web-
ster-Fries method was usually distorted because of
the scar in the commissure perpendicular to the
natural release lines of the face. The aesthetic
outcome compared with the step technique was
scored as poor (p ⫽ 0.002). Pouting and mouth
opening were not symmetrical in the cases treated
by the Webster-Fries method, showing unbalanced
commissures. There was no microstomia (Fig. 1).
However, in contrast, a tendency to macrostomia
was observed, and two patients needed surgical
correction of the commissures. Patients treated
with the step technique alone, bilateral or unilat-
eral, did not show disruption of natural folds. The
scar following the labiomental fold was not as ob-
vious as when using the Webster-Fries technique,
because the scars were broken because of the
stairs. The function did not show any impairment.
No microstomia was seen (Fig. 2).
Defects Involving More than Two-Thirds of
the Lip
The method according to Webster-Fries (n ⫽ 6)
and the step technique (n ⫽ 7) were performed in
patients with defects involving more than two-
surgery for lower lip reconstruction (in German). Dtsch. Z. Mund Kiefer Gesichtschir. 9: 141, 1985); a straight step as originally described
by Johanson et al. (Surgical treatment of non-traumatic lower lip lesions with special reference to the step technique: A follow-up on
149 patients. Scand. J. Plast. Reconstr. Surg. 8: 232, 1974) would invade the check region. No natural folds are crossed. A rectangular Abbé
flap matches better with the rectangular defect in the lower lip (center). The postoperative result at 1 year shows a harmonious upper
lip/lower lip length. The facial expression has not changed (below, left). The lower lip in profile is prominent (below, right). No micros-
tomia is seen.
thirds of the lip. The step technique was combined
with an Abbé flap (n ⫽ 4) and, in cases with in-
volvement of the commissure, an Estlander flap
(n ⫽ 3). Lip competence was present in all cases.
The sensibility was normal in 60 percent of the
patients treated with the step technique. None of
patients treated with the Webster-Fries method
had a normal sensibility; 16.7 percent had a hyp-
esthesia of one-third of the lip, and 66.7 percent
had a hypesthesia of two-thirds of the lip 1 year
after surgery. Patients treated using the Webster-
Fries method showed a distorted symmetry of the
lips in pouting and at rest. The upper lip was seen
as disproportionately large and the lower lip col-
lapsed in the oral cavity as observed in the men-
tioned patients with involvement of up to two-thirds
of the lip. In cases treated with the step technique
combined with an Abbé flap, the sphincter function
was restored with mouth competence and symmetry.
The commissure remained balanced, with minor
cheek asymmetry, and the nasolabial fold was re-
spected. The aesthetic appearance was affected
mostly by deep scars. No microstomia was seen (Figs.
3 and 4). Reconstructions combining the step tech-
nique with an Estlander flap resulted frequently in
microstomia, depending on the extension of the
tumor in the upper lip. The stretching effect on
the remaining lip was limited compared with the
Abbé flap. Mouth competence was always possible
and the aesthetic result was acceptable, considering
a change in the facial expression that was attribut-
able to a flattened nasolabial fold.
DISCUSSION
The wedge excision with primary closure is a
rational approach for treating defects involving up
to one-third of the lip if the labiomental fold is not
compromised. In cancer surgery, considering a
5-mm resection margin on both sides and the size
of the tumor, the preservation of the labiomental
fold is hardly possible when using this technique.1
Even in the few cases in which this was possible
without compromise of the natural folds, a notch
resulted as a consequence of the disorientation of
the orbicular muscle seen in pouting.1,14,21 The
rectangular excision, when using the step tech-
nique, allowed horizontal advancement of the re-
1237
 Plastic and Reconstructive Surgery • October 2007
maining lip, preserving the orientation of the or-
bicular muscle. Direct closure after wedge excision,
despite its simplicity, showed a less satisfactory aes-
thetic result than that achieved with the step tech-
nique. The step technique is usually recommended
for defects of up to two-thirds of the lip; according
to our experience and considering the advantages
mentioned above, it is also an alternative for defects
involving up to one-third of the lip.
The lip function achieved when using the
Webster-Fries technique in defects involving up
to two-thirds of the lip was acceptable. Webster-
related techniques are currently proposed as
methods of first choice in major lip recon-
struction.12,13 Our experience showed a very poor
aesthetic result. The most negative aspect was the
change of facial expression. Natural folds, such as
the nasolabial or commissural fold, are systematically
involved. This technique did not produce microsto-
mia, but the upper lip was always disproportionately
large, and in profile, the lower lip was commonly
collapsed in the oral cavity. The step technique is
not commonly used outside Europe.22–24 Only a
few groups have reported their experience in Euro-
pean countries.21,25–28 The step technique, according
to Johanson and modified by Blomgren, allowed
reconstructing of up to two-thirds of the lower
lip without any compromise of the commissure.1,14
The excellent results achieved with the step tech-
nique are attributable to the reconstruction of the
orbicular muscle in the original direction and the
preserved vascular, motoric, and sensory nerve
supply.14,23,26,28 This technique implies a lip and chin
advancement, whereas the fan flap and related tech-
niques imply a cheek advancement.22 The step tech-
nique respects the natural folds of the face, namely,
the nasolabial, commissural, and labiomental folds.
The experience in the present study proved the
versatility of this technique, where no bound-
aries of aesthetic units had to be crossed. Be-
cause of this, the aesthetic units of the face are
preserved. The stepwise incision of the labio-
mental fold gives a more natural impression in
comparison with the straight incision lines com-
monly used in Webster-related techniques. The
modification of the step technique by Grimm27
consists of curved steps following the labiomen-
tal fold. This is ideal for major defects, in which
the conventional straight stair step could invade
the cheek, crossing the commissural fold. The
curved incision seems to be more natural than
the straight incision proposed by Johanson. Ac-
cording to the best of our knowledge, this mod-
ification has not been published in the interna-
tional literature yet.
1238
The major challenge in lip reconstruction is
the defect involving more than two-thirds of the
lip. Salgarelli et al. recommend the step technique
for defects involving up to 60 percent of the lip; for
defects involving more than 60 percent of the lip,
they recommended the Bernard-Freemann-Fries
technique.25 From our point of view, the most
important task is reconstruction of the lip with
functional tissue that matches the lost one. The
most appropriate tissue with which to achieve this
task is the remaining upper lip as the donor site;
the lip is simply reconstructed with a full-thickness
switch flap. Electromyographic evidence of rein-
nervation of free autogenous muscle in the face
for reanimation in facial palsy had been demon-
strated previously.29 The same phenomenon was
studied and confirmed for the Abbé plastic and
fan flap.30 This explains why the sphincter func-
tion of the new orbicular muscle following an
Abbé flap improved constantly in the first year
postoperatively. Mouth competence was seen im-
mediately after reconstruction using this tech-
nique. Because of the postoperative stretching of
the lip, we did not find microstomia associated
with the Abbé flap.
In our experience, we have not seen any in-
dication for disruption of the commissure if it is
not involved. If this was the case, the most satis-
factory result was achieved combining the step
technique with an Estlander flap as proposed by
Blomgren et al.1 The full-thickness flap of the up-
per lip matched well with the remaining lower lip.
We have seen a tendency for microstomia to occur;
the aesthetic result was clearly better than when
using the Webster-Fries technique.
In contrast to other descriptions,1 we prefer a
rectangular to a cuneiform Abbé or Estlander flap.
It provides much more mucosa for reconstruction
of the vestibulum oris, and also matches better
with the rectangular defect in the lower lip.
CONCLUSIONS
The aesthetic and functional outcomes dif-
fered substantially according to the operative tech-
nique used. Surgical planning, oriented to pre-
serve the aesthetic units of the face, proved to be
very valuable. According to our results, we propose
the following concept to reconstruct the lower lip:
the chosen technique has only to involve the peri-
oral tissues. Incisions should not cross boundaries
of the aesthetic units. If the closure of the defect
is primarily not possible by advancement of the
remaining lower lip, a full-thickness flap of the
opposite lip should be used; this matches better
with the lost tissue than others. If the commissure
Volume 120, Number 5 • Lower Lip Reconstruction
is not involved, there is no technical reason to
disrupt it for lip reconstruction. A disrupted com-
missure changes the facial expression. As a con-
sequence of the conditions described in this arti-
cle, the step technique alone or combined with a
full-thickness flap of the opposite lip such as an
Abbé or Estlander flap, is a rational approach for
preserving the aesthetic units of the face and its
function.
J. Camilo Roldán, M.D., D.M.D.
Department of Oral and Maxillofacial Surgery
University of Regensburg
Franz-Josef-Strauß-Allee 11
D-93053 Regensburg, Germany
roldan.schack@gmx.de
ACKNOWLEDGMENT
This article is dedicated to our teacher, Franz Härle,
professor emeritus of the University of Kiel, who inspired
us in the art of facial plastic surgery.
DISCLOSURE
None of the authors has a financial interest in any
of the products, devices, or drugs mentioned in this
article.
REFERENCES
1. Blomgren, I., Blomqvist, G., Lauritzen, C., Lilja, J., Peterson,
L. E., and Holmström, H. The step technique for the recon-
struction of lower lip defects after cancer resection: A fol-
low-up study of 165 cases. Scand. J. Plast. Reconstr. Surg. 22:
103, 1988.
2. Schubert, J., and Grimm, G. Lippenkarzinome (I): Primäre
Lippenkarzinome. Dtsch. Z. Mund Kiefer Gesichtschir. 8: 387,
1984.
3. Coppit, G., Lin, D., and Burkey, B. Current concepts in lip
reconstruction. Curr. Opin. Otolaryngol. Head Neck Surg. 12:
281, 2004.
4. Schubert, J., Grimm, G., and Tischendorf, L. Functional and
esthetic aspects of therapy for lip cancer (in German).
Fortschr. Kiefer Gesichtschir. 37: 75, 1992.
5. Brusati, R. Reconstruction of the labial commissure by sliding
U-shaped cheek flap. J. Maxillofac. Surg. 7: 11, 1979.
6. Gonzalez-Ulloa, M. Restoration of the face covering by means
of selected skin in regional aesthetic units. Br. J. Plast. Surg.
9: 212, 1956.
7. Gonzalez-Ulloa, M. Regional aesthetic units of the face. Plast.
Reconstr. Surg. 79: 239, 1987.
8. Fattahi, T. T. An overview of facial aesthetic units. J. Oral
Maxillofac. Surg. 61: 1207, 2003.
9. Webster, R. C., Coffey, R. J., and Kelleher, R. E. Total and
partial reconstruction of the lower lip with innervated mus-
cle-bearing flaps. Plast. Reconstr. Surg. 25: 360, 1960.
10. Grimm, G. New method of flap plastic surgery for the sub-
stitution of total lower lip defects caused by tumors (in Ger-
man). Zentralbl. Chir. 44: 1621, 1966.
11. Fries, R. Advantages of a basic concept in lip reconstruction
after tumor resection. J. Maxillofac. Surg. 1: 13, 1973.
12. Wechselberger, G., Gurunluoglu, R., Bauer, T., Piza-Katzer,
H., and Schoeller, T. Functional lower lip reconstruction
with bilateral cheek advancement flaps: Revisitation of the
Webster method with minor modification in the technique.
Aesthetic Plast. Surg. 26: 423, 2002.
13. Zilinsky, I., Winkler, E., Weiss, G., Haik, J., Tamir, J., and
Orenstein, A. Total lower lip reconstruction with innervated
muscle bearing flaps: A modification of the Webster flap.
Dermatol. Surg. 27: 687, 2001.
14. Johanson, B., Aspelund, E., Breine, U., and Holmström, H.
Surgical treatment of non-traumatic lower lip lesions with
special reference to the step technique: A follow-up on 149
patients. Scand. J. Plast. Reconstr. Surg. 8: 232, 1974.
15. Dunsche, A. Operative Therapie epithelialer Tumoren der
Übergangsschleimhäute im Kopf-Hals-Bereich. In R.
Rompel and J. Petres (Eds.), Operative onkologische Derma-
tologie. Berlin: Springer, 1999. Pp. 171–177.
16. Steinhilber, W., Deutschländer-Wolff, J., and Schmelzle, R.
Principles and technic of reconstruction of the red portion of
the lip (in German). Fortschr. Kiefer Gesichtschir. 23: 27, 1978.
17. Abbé, R. A new plastic operation for the relief of deformity
due to double hare lip. Med. Rec. 53: 477, 1898.
18. Estlander, J. Eine Methode aus der einen Lippe Substanzver-
luste der anderen zu ersetzen. Arch. Klin. Chir. 14: 622, 1872.
19. von Terheyden, H., Fleiner, B., and Koch, G. Contour of the
lower lip after von Esmarch reconstruction of lower lip ver-
million (in German). Mund Kiefer Gesichtschir. 1: 113, 1997.
20. Fogel, M. L., and Stranc, M. F. Lip function: A study of
normal lip parameters. Br. J. Plast. Surg. 37: 542, 1984.
21. Langdon, J. D., and Ord, R. A. The surgical management of
the lip cancer. J. Craniomaxillofac. Surg. 15: 281, 1987.
22. Dado, D. V., and Angelats, J. Upper and lower lip recon-
struction using the step technique. Ann. Plast. Surg. 3: 204,
1985.
23. Sullivan, D. E. “Staircase” closure of lower lip defects. Ann.
Plast. Surg. 1: 392, 1978.
24. Calhoun, K. Reconstruction of small- and medium-sized de-
fects of the lower lip. Am. J. Otolaryngol. 13: 16, 1992.
25. Salgarelli, A. C., Sartorelli, F., Cangiano, A., and Collini, M.
Treatment of the lower lip cancer: An experience of 48 cases.
Int. J. Oral Maxillofac. Surg. 34: 27, 2005.
26. Kuttenberger, J. J., and Hardt, N. Results of modified stair-
case technique for reconstruction of the lower lip. J. Crani-
omaxillofac. Surg. 25: 239, 1997.
27. Schubert, J. Modified Grimm-Johanson surgery for lower
lip reconstruction (in German). Dtsch. Z. Mund Kiefer Ge-
sichtschir. 9: 141, 1985.
28. Salgarelli, A. C., Persia, M., Ciancio, P., and Pagani, R. The
staircase technique for treatment of cancer of the lower lip:
A report of 36 cases. J. Oral Maxillofac. Surg. 59: 399, 2001.
29. Hakelius, L., and Stalberg, E. Electromyographical studies of
free autogenous muscle transplants in man. Scand. J. Plast.
Reconstr. Surg. 8: 211, 1974.
30. DePalma, A. T., Leavitt, L., and Hardy, B. Electromyography
in full thickness flaps rotated between upper and lower lips.
Plast. Reconstr. Surg. 21: 448, 1958.
1239
RECONSTRUCTIVE

Incomplete Excision of Basal Cell Carcinoma:

A Prospective Trial
Shirley Y. Su, M.B.B.S.
Francesco Giorlando,
M.B.B.S., B.Med.Sci.
Edmund W. Ek, M.B.B.S.
Tam Dieu, F.R.A.C.S.
Melbourne and Dandenong, Victoria,
Australia
Background: As a measure of the standard of surgical care, incomplete excision
of skin malignancy is an important clinical indicator, developed by the Royal
Australasian College of Surgeons and the Australian Council on Healthcare
Standards. Reported rates of incomplete excision of basal cell carcinoma vary
widely (5 to 25 percent) among centers worldwide. This prospective study
reports on the incidence of incomplete excision at a tertiary referral public
hospital and determines the factors that may influence this.
Methods: From January of 2001 to December of 2002, 1214 basal cell carcino-
mas were excised at Peter MacCallum Cancer Centre. Data were collected
prospectively and analyzed using the FileMaker Pro program and SPSS software.
Results: The overall percentage of incomplete excision was 11.2 percent for
primary excisions. Risk factors for incomplete excision are the head site; mor-
pheic, superficial, and infiltrative subtypes; lesions larger than 20 mm in diam-
eter; the presence of multiple lesions; repair by skin graft; and recurrent and
previously incompletely excised basal cell carcinomas. The type of anesthetic
used did not affect outcome. There was no significant difference in the per-
centage of incomplete excision between consultants, registrars, and the clinical
assistant, but this was probably attributable to the small number of cases per-
formed by consultants at Peter MacCallum Cancer Centre.
Conclusions: This is the largest prospective study of incomplete excision of
basal cell carcinomas. The authors’ result is within the range reported in the
current literature but is higher than anticipated. Preoperative “red-flagging” of
basal cell carcinomas most at risk of incomplete excision may lead to a better
result. (Plast. Reconstr. Surg. 120: 1240, 2007.)

B
asal cell carcinoma is the most common
skin cancer in Australia, with an incidence
of 788 per 100,000 persons annually—
substantially higher than in many parts of the
world, including the United Kingdom, the
United States, and Holland.1–3 Compared with
other treatment modalities, surgical excision re-
mains the accepted standard. It has a cure rate of
95 to 99 percent4 –9 and the advantages of sim-
plicity, economy, and the availability of a histo-
logic diagnosis. In a retrospective study at the
same center, Dieu and MacLeod reported in-
complete excision of 6.3 percent of lesions from
a series of 3558 basal cell carcinomas excised
during a 42-month period.10 In this large pro-
spective study, the authors aimed to verify the
From the Departments of Plastic Surgery of Peter MacCallum
Cancer Centre and Dandenong Hospital.
Received for publication February 13, 2006; accepted June
1, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279148.67766.e1
percentage of incomplete excision of the Plastic
Surgery Unit at Peter MacCallum Cancer Cen-
tre, a major tertiary referral center for cancer
management in Victoria, Australia. Comparison
has been made with similar reported series from
the world literature.
PATIENTS AND METHODS
From January of 2001 to December of 2002,
2582 skin tumors were excised from 1223 patients.
The Plastic Surgery Unit consists of a plastic sur-
gery trainee registrar (usually a first-year registrar
on 6-month rotation), a clinical assistant, and
three consultant surgeons. All pathology speci-
mens were examined and reported by the Depart-
ment of Pathology at the same center. Incomplete
excision was defined by the pathologist as the pres-
ence of tumor at the surgical margin.
The processing of specimens involves fixation
in formalin, macroscopic examination by a pa-
thologist or supervised pathology trainee, mark-
ing of margins with black ink or silver nitrate,
selection of blocks, processing through alcohol to

1240 www.PRSJournal.com
Volume 120, Number 5 • Incomplete Excision of Carcinoma
wax, sectioning, and staining with hematoxylin
and eosin. Other special stains were performed as
required. Small specimens were processed in their
entirety or near entirety so that margins were ex-
amined thoroughly. Large specimens were sliced
transversely at 3- to 5-mm intervals and blocks
selected to best assess tumor and adjacent margins
on the basis of the macroscopic appearance. Ad-
ditional blocks and/or levels were examined if
there was any doubt about the status of a margin.
Data were collected prospectively on standard-
ized forms and collated using the FileMaker Pro
program (FileMaker, Inc., Santa Clara, Calif.).
Variables collected by the operating surgeon were
the patient’s age and sex, tumor site and size,
preoperative diagnosis, surgical margin of exci-
sion, method of reconstruction, and type of an-
esthetic. The experience of the surgeon, number
of lesions excised at the operation, and history of
previous treatment were also recorded.
The histologic subtype and the margin of ex-
cision were documented. Basal cell carcinomas
with mixed features were classified according to
the most dominant type (i.e., nodular/superficial
and nodular/infiltrative were classified as nodu-
lar, and superficial/infiltrative was classified as su-
perficial).
SPSS (SPSS, Inc., Chicago, Ill.) was used to
analyze results and perform statistical tests (chi-
square test or Fisher’s exact test). A value of p ⬍
0.05 was considered significant. A multivariate lo-
gistic regression analysis was performed and the
model was assessed for goodness of fit using the
Hosmer-Lemeshow test. The categorical variable of
incomplete excision (yes or no) was used as the
outcome variable. Other variables fitted to the
model were the site of the lesion, histologic sub-
type, diameter of the lesion, margin of excision,
presence of multiple lesions, method of repair,
type of anesthetic, and experience of the surgeon.
Table 1. Percentage of Incomplete Excision for Basal Cell Carcinomas
Type of Excision
Primary excision
Recurrent lesions
Previous surgery
Previous radiotherapy
Previous cryotherapy
Previous surgery plus cryotherapy
Previous surgery plus radiotherapy
Lesions for wider excision
Incomplete at PMCI
Incomplete from elsewhere
Total
BCCs, basal cell carcinomas; PMCI, Peter MacCallum Cancer Institute.
Variables were tested for interdependence by as-
sessment of correlation between variables and by
further step-wise removal of variables likely to be
cross-related, in particular, method of repair and
tumor size. A number of models were performed
and the variables that were nonsignificant were
excluded in a step-wise fashion. The odds ratios of
significant variables and goodness of fit were con-
sistent across all models tested.
Punch, shave, or incisional biopsies and pal-
liative excisions were excluded. Incomplete or in-
correctly entered data forms were excluded [79
patients (6 percent), 96 lesions (3.7 percent)].
RESULTS
From a total of 2582 lesions excised, 1214 (47
percent) were basal cell carcinomas. Of the 1214
basal cell carcinomas, 93 percent (1129) were pri-
mary excisions, 4.6 percent (n ⫽ 56) were recur-
rent, and 2.4 percent (n ⫽ 29) were reexcisions for
incompletely excised lesions (Table 1). The inci-
dence of incomplete excision for primary lesions
is 11.2 percent. Unless otherwise specified, results
in this article are based on primary excisions. Re-
current lesions and wider excisions are discussed
later in the article.
Age and Sex
The median age was 73.4 years (range, 23 to
100 years); 28.3 percent were women and 71.7
percent were men. The incidence of incomplete
excision was 11.3 percent for women and 11.2
percent for men.
Anatomical Site
Most basal cell carcinomas were located on the
head (52.1 percent). There was a statistically sig-
nificant difference (p ⬍ 0.005) in the proportion
of incompletely excised lesions from the head
Total No. of No. Incompletely Percentage of
BCCs Excised Incomplete Excision
1129 (93%) 127 11.2%
56 (4.6%) 15 26.8%
37 10
4 3
11 1
1 0
3 1
29 (2.4%) 11 37.9%
22 9
7 2
1214 (100%) 153 12.6%
1241
 Plastic and Reconstructive Surgery • October 2007
Fig. 1. Percentage of incomplete primary excisions by site.
(14.5 percent), trunk (8.5 percent), neck (7.7 per-
cent), and limbs (7.0 percent) (Fig. 1).
Although not statistically significant, the areas
most at risk on the head were the chin (20 percent
incompletely excised), periorbital region (17.9
percent), periauricular area (17 percent), and
forehead and temple (15.7 percent) (Fig. 2).
Histologic Subtypes of Primary Excisions
There were significant (p ⬍ 0.001) differences
in the percentage of incomplete excision for mor-
pheic basal cell carcinomas (50 percent), super-
ficial basal cell carcinomas (16.1 percent), infil-
trative basal cell carcinomas (12.8 percent), and
nodular basal cell carcinomas (7.3 percent) (Fig. 3).
Diameter of Lesion
Basal cell carcinomas larger than 20 mm had
a significantly (p ⬍ 0.03) higher percentage of
incomplete excision (20.4 percent) than lesions of
less than or equal to 10 mm (11 percent) or lesions
between 10 and 20 mm (10.6 percent) (Table 2).
Margin of Excision
The percentage of incomplete excision was
11.2 percent and 17.6 percent for lesions excised
with surgical margins of 2 to 5 mm and 5 to 10
mm, respectively (p ⫽ 0.427) (Table 3). Margins
greater than 10 mm were not used.
1242
Site of Tumor Infiltration and Invasion
The lateral margin was involved in 81.9 per-
cent of incomplete excisions; the deep margin, in
13.4 percent; both margins, in 3.9 percent; and
nerve invasion, in 0.8 percent. The ratio of lateral
to deep margin involvement was 5:1.
Presence of Multiple Lesions
Most patients (62 percent) had more than one
lesion excised at the same operation. The per-
centage of incomplete excision was 8.9 percent for
a single lesion and ranged from 8.3 to 13.6 percent
if two to six lesions were present (average, 12.7
percent). This was of borderline significance
(p ⫽ 0.05). Basal cell carcinomas in patients with
seven or eight lesions were all excised com-
pletely (Table 4).
Method of Repair
There was a significant difference (p ⬍ 0.001)
in the percentage of incomplete excision between
direct closure, graft repair (full-thickness or split-
thickness skin graft), and flap repair (10.5, 28.3,
and 9.9 percent, respectively) (Table 5).
Type of Anesthetic
Incomplete excision was 13.6 percent for use
of a general anesthetic, 10.8 percent for a local
anesthetic, 12.3 percent for local anesthetic with
Volume 120, Number 5 • Incomplete Excision of Carcinoma
Fig. 2. Percentage of incomplete primary excisions from the head.
intravenous sedation, and 25 percent for regional
blocks (Table 6). These results were not statisti-
cally significant (p ⫽ 0.39).
Experience of Surgeon
There was no significant difference in the per-
centage of incomplete excisions between opera-
tors (p ⫽ 0.11): 4.5 percent for consultant sur-
geons, 11.1 percent for the clinical assistant, and
9.1 percent for the trainee registrar operating
alone. When a consultant assisted the registrar, it
was 16.1 percent; if the roles were reversed, it was
14.7 percent. The registrar or clinical assistant was
the chief operator in 92 percent of operations
(Fig. 4).
Recurrent Lesions and Wider Excisions
Compared with primary excisions, the per-
centage of incomplete excision for recurrent basal
cell carcinomas and lesions requiring wider exci-
sion were significantly higher (p ⬍ 0.05): 11.2,
26.8, and 37.9 percent, respectively (Table 1). Of
the 2582 lesions, 56 were wider excisions of pre-
viously incompletely excised basal cell carcinomas,
and 58.1 percent (n ⫽ 29) of these had residual
tumor on histologic examination.
Multivariate Analysis
Variables that were significant predictors for
incomplete excision are head location; nodular,
superficial, and morpheic subtypes; diameter
greater than 20 mm; the presence of multiple (two
or more) lesions; and graft repair (Table 7). Le-
sion size and type of repair remained significant
when each was removed step-wise from the model,
suggesting independence.
DISCUSSION
The incidence of incomplete excision of basal
cell carcinoma reported in retrospective studies is
in the range of 6.3 to 25 percent.10 –19 An exception
to this is the study by Emmett and Broadbent, who
reported a rate of 0.7 percent (10 of 1411).20 This
excellent result was achieved by two experienced
operators, from a sample of private patients, using
excision margins (3 to 10 mm) wider than those
1243
 Plastic and Reconstructive Surgery • October 2007

Fig. 3. Histologic subtypes of incomplete primary excisions.

currently practiced and very high percentages of carcinomas excised from three different catego-
flap and graft reconstruction (70 and 22 percent, ries of hospitals in the United Kingdom. Their
respectively). “supraregional cancer hospital,” a tertiary institu-
The incidence of incomplete excision in pro- tion more comparable to Peter MacCallum Can-
spective studies range from 2 to 18.2 percent (Ta-
ble 8).21–25 Notably, the only large prospective au-
Table 4. Multiple Lesions and Incomplete Excision
dit of recent years, that by Kumar et al.,23 reported
an overall result of 4.5 percent in 757 basal cell No. of No. Percentage of
No. of Primary Incompletely Incomplete
Lesions Excisions (%) Excised Excision
Table 2. Diameter of Incomplete Excisions 1 428 (38.0) 38 8.9
2 337 (29.9) 46 13.6
No. of No. Percentage of 3 221 (19.6) 27 12.2
BCC Primary Incompletely Incomplete 4 97 (8.6) 12 12.4
Diameter Excisions (%) Excised Excision 5 15 (1.3) 2 13.3
6 24 (2.1) 2 8.3
ⱕ10 mm 684 (60.6) 75 11 7 6 (0.5) 0 0
10–20 mm 396 (35.1) 42 10.6 8 1 (⬍0.01) 0 0
⬎20 mm 49 (4.3) 10 20.4 Total 1129 (100) 127
Total 1129 (100) 127
BCC, basal cell carcinoma.
Table 5. Method of Repair
Table 3. Surgical Margins of Incomplete Excisions No. of No. Percentage of
Type of Primary Incompletely Incomplete
No. of No. Percentage of Repair Excisions (%) Excised Excision
Primary Incompletely Incomplete
Margin Excisions (%) Excised Excision Direct closure 975 (86.4) 102 10.5
FTSG/STSG 53 (4.7) 15 28.3
2–5 mm 1112 (98.5) 124 11.2 Flap 101 (8.9) 10 9.9
5–10 mm 17 (1.5) 3 17.6 Total 1129 (100) 127
Total 1129 (100) 127
FTSG, full-thickness graft; STSG, split-thickness skin graft.

1244
Volume 120, Number 5 • Incomplete Excision of Carcinoma

Table 6. Type of Anesthetic In a previous retrospective series at the same

No. of Percentage center, looking at a 3-year period immediately be-
Primary No. of fore our study (1997 to 2000), Dieu and MacLeod
Excisions Incompletely Incomplete reported an incomplete excision rate of 6.3
Anesthetic (%) Excised Excision percent.10 This series’ result of 11.2 percent is
General anesthetic 22 (1.95) 3 13.6 much higher and may have been influenced by
Local anesthetic 846 (74.9) 91 10.8 several factors. First, as head of the unit and busiest
Local anesthetic
with sedation 253 (22.4) 31 12.3 consultant, the late Professor MacLeod’s untimely
Regional 8 (0.7) 2 25 illness and death during the course of the study
Total 1129 (100) 127 left trainees inadequately supervised. This is re-
flected by the lower proportion of consultant-led
operations in this audit, in comparison with the
cer Centre, had an incidence of 7.5 percent, or previous series and with Kumar’s audit23 (8, 22.9,
double that reported at their “regional plastic sur- and 14.3 percent, respectively). Second, there
gery unit” (3.2 percent) and “district general hos- were variations in experience and technique
pital” (3.1 percent). Peter MacCallum Cancer among the rotating registrars. Third, in the ret-
Centre is a tertiary referral cancer hospital with a rospective study, some reports of incomplete ex-
catchment area that includes the surrounding me- cision were excluded after review of the pathologic
tropolis and all of the state of Victoria. Skin lesions findings—the same review process did not occur
are usually referred to our unit because they are in this study.
deemed to be difficult and beyond the treatment Incomplete excision was highest in the head
capacity of the primary referring doctor. As such, (14.5 percent), with only marginal differences at
our result of 11.2 percent incomplete excision is other sites (7 to 8.5 percent). The chin (20 per-
at least in part a reflection of the complexity of cent), periorbital (17.9 percent) and periauricu-
tumors presenting to our institution. lar regions (17 percent), and forehead and tem-

Fig. 4. Experience of operating surgeon and percentage of incomplete excision.

1245
 Plastic and Reconstructive Surgery • October 2007

Table 7. Multivariate Analysis pared with an overestimation of 1.6 mm for the

Variable Odds Ratio p limbs.24 Head and neck lesions constitute 60 per-
cent of all basal cell carcinomas excised at Peter
Site
Trunk 1.00 MacCallum Cancer Centre, compared with 80 to
Head 3.46 0.00 90 percent at other centers.12,19,23
Limbs 0.95 0.88 The percentage of incomplete excision for
Neck 1.20 0.71
BCC subtype morpheic basal cell carcinomas was significantly
Nodular 1.00 higher than all other subtypes. This finding has
Morpheic 14.33 0.00
Superficial 3.45 0.00 been confirmed in several studies.23,27 Morpheic
Infiltrating 1.82 0.03 basal cell carcinomas classically are white-yellow-
NOS 1.31 0.421 ish, flesh colored, and with ill-defined borders
Tumor size
ⱕ10 mm 1.00 and induration—all contribute to difficulty in
10–20 mm 1.22 0.39 diagnosis and in delineating the macroscopic
⬎20 mm 2.14 0.02 margins. Burg et al. also found a much wider sub-
Margin of excision
2–5 mm 1.00 clinical extension in large and morpheic basal cell
5–10 mm 0.71 0.66 carcinomas.28 Superficial basal cell carcinomas
No. of lesions have poorly defined margins as they spread within
1 1.00
2–8 1.83 0.00 the epidermis, again contributing to a higher per-
Repair method centage of incomplete excision. A subtype of mul-
Direct closure 1.00 tifocal superficial basal cell carcinomas is even
FTSG/STSG 2.80 0.01
Flap 0.84 0.66 more difficult clear.
Anesthetic type There were no incomplete excisions in pa-
Local anesthetic 1.00
General anesthetic 0.74 0.70 tients having seven or eight lesions excised in the
Local anesthetic with sedation 0.62 0.16 same operation, and there was no difference with
Regional 1.33 0.77 having between two and five lesions excised. How-
Experience of surgeon
Consultant 1.00 ever, the risk of incomplete excision was signifi-
Registrar 0.56 0.19 cantly higher in the multivariate analysis if more
Fellow 0.64 0.34 than one lesion was present, perhaps because of
Consultant/registrar 0.01 0.67
Registrar/consultant 1.05 0.91 the increased complexity of tumors in patients
BCC, basal cell carcinoma; NOS, not otherwise specified; FTSG, with multiple lesions and a subgroup with “syn-
full-thickness skin graft; SSG, split-thickness skin graft. dromal lesions.”
The majority (60.6 percent) of basal cell car-
Table 8. Percentage of Incomplete Excision in the cinomas were smaller than 10 mm in diameter
Prospective Literature and, overall, 95.7 percent were smaller than 20
Total Percentage of mm. Tumors larger than 20 mm were twice as
No. of Incomplete likely to be incompletely excised (20.4 percent
Authors Year Lesions Excision versus 10 to 11 percent), which is consistent with
Lawrence et al.21
1986 58 17.2 published reports that the subclinical extension of
Kumar et al.23 2002 757 4.5 basal cell carcinomas increased with the size of the
Bisson et al.22 2002 100 4
Thomas et al.24 2002 71 2.8 tumor.28
Hsuan et al.25 2004 55 18.2 Graft reconstructions had a higher percentage
of incomplete excision and were associated with
larger lesions (24 percent of all lesions ⬎20 mm
poral regions (15.7 percent) had above average required a skin graft, and 4 percent used flap
proportions of incomplete excision. The inner repair). However, graft repair and lesions larger
canthus (23.5 percent) and the ear (19.7 percent) than 20 mm were independent risk factors for
were particularly difficult to treat. Our findings incomplete excision on multivariate analysis. We
are comparable with those of many published attribute this to the preference for skin grafts
series.12,13,23,26 This can be attributed to the scarcity rather than local flaps if clinical margins are un-
of tissue, proximity to vital structures, and cos- certain for various reasons. Direct closure, clearly
metic considerations that must be taken into ac- associated with smaller lesions, has low rates sim-
count in treating lesions on the face. Thomas et al. ilar to those achieved with flap repair, a technique
found that surgeons underestimated margins by usually used when the operator is confident of
0.17 mm, on average, for the head and neck, com- surgical margins.

1246
Volume 120, Number 5 • Incomplete Excision of Carcinoma
Most published studies concur that a 2- to
4-mm margin would completely excise more than
95 percent of basal cell carcinomas, provided that
they are small (⬍2 cm in diameter) and well
defined.8,22,24,28 A 5- to 10-mm margin has been
suggested for morpheic and infiltrative basal cell
carcinomas and those larger than 2 cm in
diameter.28 In our study, larger basal cell carcino-
mas (⬎2 cm) accounted for 4.3 percent of all
primary excisions, but only 1.5 percent of basal
cell carcinomas were excised with margins larger
than 5 mm. In comparison, the lower percentage
of incomplete excision (4.5 percent) reported by
Kumar et al.23 was associated with an excision mar-
gin of greater than 5 mm in 20.6 percent of basal
cell carcinomas overall and in 32.4 percent of
basal cell carcinomas at their supraregional cancer
hospital. This is reflected by a much higher pro-
portion of graft and flap repair (35.1 percent ver-
sus 13.6 percent at Peter MacCallum Cancer Cen-
tre) and a lower ratio of lateral versus deep margin
involvement (3:1 versus 5:1).
The choice of anesthetic type depends on pa-
tient and tumor factors. Regional anesthesia was
associated with the highest percentage of incom-
plete excision (25 percent), but the numbers
treated were too small to be significant. It was used
on eight occasions: seven were on the limb and
one was on the eyelid. Although the differences
were not significant among local anesthesia, local
anesthesia with sedation, and general anesthesia
(10.8, 12.3, and 13.6 percent, respectively), there
were small increases in the percentage of incom-
plete excision, perhaps associated with the com-
plexity of the tumor.
Other studies have shown an inverse correla-
tion between the experience of the surgeon and
incomplete excision of basal cell carcinomas.10,23
In our study, the percentage of incomplete exci-
sion was 4.5 percent for consultant surgeons,
which is markedly lower than 9.1 percent for reg-
istrars and 11.1 percent for the clinical assistant.
However, this was not statistically significant be-
cause of the small number of operations per-
formed by the consultant. Because Peter MacCal-
lum Cancer Centre is a teaching hospital, the
surgical trainee or clinical assistant operating
alone performs the majority of cases that are
deemed to be “clear-cut” (76.6 percent), and the
consultant is the sole operator only on the rare
occasions when junior staff are unavailable [22
cases (2 percent) of basal cell carcinomas ex-
cised]. The high proportion of incomplete exci-
sion (15 to 16 percent) for combined registrar/
consultant operations reflects the deliberate
selection of difficult cases for the purposes of reg-
istrar teaching (combined cases account for 81
percent of excisions under general anesthesia, 100
percent of regional block, 50 percent of lesions
⬎20 mm, and 62 percent of lesion requiring full-
thickness/split-thickness skin graft repair). The
clinical assistant always operated alone.
There is continuing debate on whether in-
completely excised lesions should be managed
conservatively or reexcised. Histologic examina-
tion of previously incompletely excised basal cell
carcinomas reveals 51.8 percent to have residual
tumor, a figure on par with several published
series.11,12 Given a 5-year recurrence rate of 35 to
39 percent9,11,29,30 and further recurrence between
5 and 10 years,31 reexcision is favored at Peter
MacCallum Cancer Centre. The percentage of in-
complete excision is also significantly higher in
recurrent lesions and wider excisions (26.8 per-
cent and 37.9 percent, respectively), a trend re-
ported by several studies.11,16,20,23 A follow-up study
looking at recurrence rates could be informative.
CONCLUSIONS
This is the largest prospective study to date of
incomplete excision of basal cell carcinomas. Our
study emphasizes the role of ongoing audits in
maintaining clinical standards and the impor-
tance of trainee supervision. Incomplete excision
of 11.2 percent is acceptable given the constraints
and referral patterns of a tertiary teaching hospital
and is comparable to figures published in the cur-
rent literature. However, this result is higher than
anticipated and can improve. Some risk factors
have been identified—these lesions can be pre-
operatively “red-flagged” and managed with more
caution.
Shirley Su, M.B.B.S.
14 Nottingham Street
Kensington, Victoria 3031, Australia
shirleysu108@hotmail.com
ACKNOWLEDGMENTS
This article would not have been possible without the
support of the late Allan MacLeod. The authors thank
the Skin Surgery Unit secretary, Celia Marra, for help in
compiling the study data, and Drs. Raewyn McDonald,
Dean White, Natasha Van Zyl, Naveen Somia, and
Nigel Mann for their contributions. They are also grate-
ful to Dr. John Reynolds and Dr. Bill Murray (of Peter
MacCallum Cancer Centre’s statistics and pathology de-
partments, respectively) for advice and assistance.
DISCLOSURE
The authors have no financial associations or in-
terests in relation to this article.
1247
 Plastic and Reconstructive Surgery • October 2007
REFERENCES
1. Staples, M., Marks, R., and Giles, G. Trends in the incidence
of non-melanocytic skin cancer (NMSC) treated in Australia
1985–1995: Are primary prevention programs starting to
have an effect? Int. J. Cancer 78: 144, 1998.
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ventions for basal cell carcinoma of the skin (Cochrane Re-
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3. Diepgen, T. L., and Mahler, V. M. The epidemiology of skin
cancer. Br. J. Dermatol. 146 (Suppl. 61): 1, 2002.
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Plast. Reconstr. Surg. 65: 656, 1980.
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Plast. Reconstr. Surg. 5: 87, 1971.
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rates of basal cell carcinomas. J. Dermatol. Surg. Oncol. 18: 471,
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8. Wolf, D. J., and Zitelli, J. A. Surgical margins for basal cell
carcinoma. Arch. Dermatol. 123: 340, 1987.
9. Park, A. J., Strick, M., and Watson, J. D. Basal cell carcinomas:
Do they need to be followed up? J. R. Coll. Surg. Edinb. 39: 109,
1994.
10. Dieu, T., and MacLeod, A. Incomplete excision of basal cell
carcinomas: A retrospective audit. Aust. N. Z. J. Surg. 72: 219,
2002.
11. Richmond, J. D., and Davie, R. M. The significance of in-
complete excision in patients with basal cell carcinoma. Br.
J. Plast. Surg. 40: 63, 1987.
12. Griffiths, R. W. Audit of histologically incompletely excised
basal cell carcinomas: Recommendations for management
by re-excision. Br. J. Plast. Surg. 52: 24, 1999.
13. Sussman, L. A. E., and Liggins, D. F. Incompletely excised
basal cell carcinoma: A management dilemma? Aust.
N. Z. J. Surg. 66: 276, 1996.
14. Mak, A. S. Y., and Poon, A. M. S. Audit of basal cell carcinoma
in Princess Margaret Hospital, Hong Kong: Usefulness of
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Plast. Reconstr. Surg. Hand Surg. 29: 149, 1995.
15. Schreuder, F., and Powell, B. W. E. Incomplete excision of
basal cell carcinomas: An audit. Clin. Perf. Qual. Health Care
7: 119, 1990.
16. Rippey, J. J., and Rippey, E. Characteristics of incompletely
excised basal cell carcinomas of the skin. Med. J. Aust. 166:
581, 1997.
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17. Hauben, D. J., Zirkin, H., Mahler, D., et al. The biologic
behavior of basal cell carcinoma: Analysis of recurrence in
excised basal cell carcinoma. Part II. Plast. Reconstr. Surg. 69:
110, 1982.
18. Hussain, M., and Earley, M. J. The incidence of incomplete
excision in surgically treated basal cell carcinoma: A retro-
spective clinical audit. Ir. Med. J. 96: 18, 2003.
19. Bogdanov-Berezovsky, A., Cohen, A., Glesinger, R., et al.
Clinical and pathological findings in reexcision of incom-
pletely excised basal cell carcinomas. Ann. Plast. Surg. 47: 299,
2001.
20. Emmett, A. J. J., and Broadbent, G. G. Basal cell carcinoma
in Queensland. Aust. N. Z. J. Surg. 51: 576, 1981.
21. Lawrence, C. M., Comaish, J. S., and Dahl, M. G. C. Excision
of skin tumours without wound closure. Br. J. Dermatol. 115:
563, 1986.
22. Bisson, M. A., Dunkin, C. S. J., Suvarna, S. K., et al. Do plastic
surgeons resect basal cell carcinoma too widely? A prospec-
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Plast. Surg. 55: 293, 2002.
23. Kumar, P., Watson, S., Brain, A. N., et al. Incomplete excision
of basal cell carcinoma: A prospective multicentre audit. Br.
J. Plast. Surg. 55: 616, 2002.
24. Thomas, D., King, A., and Peat, B. Excision margins for
nonmelanotic skin cancer. Plast. Reconstr. Surg. 112: 57, 2002.
25. Hsuan, J. D., Harrad, R. A., Potts, M. J., et al. Small margin
excision of periocular basal cell carcinoma: 5 year results. Br.
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26. Freidman, H. I., Williams, T., Zamora, S., et al. Recurrent
basal cell carcinoma in margin-positive tumour. Ann. Plast.
Surg. 38: 232, 1997.
27. Nagore, E., Grau, C., Mollnero, J., et al. Positive margins in
basal cell carcinoma: Relationship to clinical features and
recurrence risk. A retrospective study of 248 patients. J. Eur.
Acad. Dermatol. Venereol. 17: 167, 2003.
28. Burg, G., Hirsch, R. D., Konz, B., and Braun-Falco, O. His-
tographic surgery: Accuracy of visual assessment of the mar-
gins of basal-cell epithelioma. J. Dermatol. Surg. 1: 21, 1975.
29. Gooding, C. A., White, G., and Yatsuhashi, M. Significance of
marginal extension in excised basal cell carcinoma. N. Engl.
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30. Dellon, A. L., DeSilva, S., Connolly, M., et al. Prediction of
recurrence in incompletely excised basal cell carcinoma.
Plast. Reconstr. Surg. 75: 860, 1985.
31. Rowe, D. E., Carroll, R. J., and Day, C. L., Jr. Long-term
recurrence rates in previously untreated (primary) basal cell
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Surg. Oncol. 15: 315, 1989.
 RECONSTRUCTIVE

Immediate, Optimal Reconstruction of Facial

Lentigo Maligna and Melanoma following Total
Peripheral Margin Control
Sameer S. Jejurikar,
Gregory H. Borschel,
Timothy M. Johnson,
Lori Lowe,
David L. Brown,
New York City, N.Y.; Toronto, Ontario,
Canada; and Ann Arbor, Mich.
M.D.
Background: Peripheral margin control of lentigo maligna and melanoma on
M.D. the head and neck can be problematic. Frozen sections are unreliable, and
M.D. conventional histopathology cannot examine the entire margin. Customary
M.D. treatment involves wide excision and dressing care or skin graft coverage until
M.D. histopathologic evaluation is complete, as reexcision is frequently required
because of positive margins. Wound contraction, donor-site morbidity, and
additional procedures before reconstruction are inherent disadvantages to this
approach.
Methods: After excisional biopsy of facial lentigo maligna and thin (⬍1 mm)
lentigo maligna melanoma, peripheral margin control was performed in the
office by means of excision of 2-mm-wide linear strips of skin, 5 to 10 mm from
the biopsy site, combined with simple wound closure. Total margins were eval-
uated by means of permanent sections. Repeated margin excision was per-
formed until clear. Definitive excision of the lesion was then performed and,
with confidence of negative peripheral margins, the optimal reconstructive
option was pursued immediately.
Results: Fifty-one lesions underwent “square” peripheral margin control, with
lentigo maligna melanoma present in nine lesions (average Breslow depth, 0.65
mm). Margins required for clearance of lentigo maligna and lentigo maligna
melanoma averaged 1.0 and 1.3 cm, respectively. No recurrences were identified
with long-term follow-up. Reconstruction using the optimal procedure was
performed immediately in all cases.
Conclusions: Use of the square technique in the management of lentigo ma-
ligna and lentigo maligna melanoma improves the certainty of peripheral mar-
gin control before definitive excision. Immediate reconstruction can be per-
formed, thereby avoiding temporizing procedures or open wounds and
providing for optimal aesthetic and functional results. (Plast. Reconstr. Surg.
120: 1249, 2007.)

A
lthough melanoma represents a small por-
tion of all skin cancers, it is responsible for
the majority of skin cancer–related deaths.1
Lentigo maligna represents in situ melanoma on
sun-damaged skin, whereas lentigo maligna mel-
anoma is invasive melanoma with a lentigo ma-
ligna histologic subtype. Both lentigo maligna
From the Department of Plastic Surgery, Manhattan Eye,
Ear and Throat Hospital; Division of Plastic Surgery,
Department of Surgery, University of Toronto; and Section
of Plastic Surgery, Department of Surgery, and Depart-
ments of Dermatology, Otolaryngology, and Pathology,
University of Michigan Health Systems.
Received for publication December 22, 2005; accepted May
3, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279324.35616.72
and lentigo maligna melanoma most commonly
occur in older individuals on sun-damaged skin of
the head and neck.
Numerous modalities have been used to treat
lentigo maligna and lentigo maligna melanoma,
including wide local excision, variations of Mohs’
surgery using permanent sections, and standard
Mohs’ surgery.2– 4 For lentigo maligna, other mo-
dalities have been attempted, including cryosur-
gery, radiation therapy, electrodesiccation and cu-
rettage, laser treatment, topical 5-fluorouracil, and
imiquimod.5–9 These nonsurgical techniques are
generally associated with unacceptable local recur-
rence rates.10 –13 For these reasons, most surgeons
treat lentigo maligna and lentigo maligna mela-
noma with wide local excision and proceed with
definitive reconstruction only after histopathologic

www.PRSJournal.com 1249
 Plastic and Reconstructive Surgery • October 2007
evaluation of permanent sections has revealed
clear margins.
Although wide local excision remains the
standard for treatment of both lentigo maligna
and lentigo maligna melanoma, it has its lim-
itations. Recommended surgical margins are
0.5 to 1 cm for lentigo maligna and 1 to 2 cm
for lentigo maligna melanoma, depending on
tumor thickness.14 –17 These recommended mar-
gins may be insufficient, however, as lesions of-
ten have subclinical extension beyond the visible
pigment.10,11,18,19 This occult extension can be
missed on routine histologic examination. Con-
ventional “bread loaf” sectioning of specimens
allows only a small percentage of the actual pe-
ripheral margin to be evaluated.20 With an in-
complete assessment of the total margin, a re-
port indicating clear surgical margins could be
erroneous, leading to an increase in local recur-
rence because of inadequate tumor clearance.
Although recurrences may present as in situ le-
sions, invasive local recurrences may also occur
and are associated with a worse prognosis and an
increased risk of potentially lethal metastasis.12
Another limitation of wide surgical excision is
the creation of a defect requiring local wound
care or intermediate coverage with skin au-
tograft or homograft until permanent histologic
evaluation is completed. This can result in a
desiccated, colonized, and/or contracted wound
bed, making optimal reconstruction more diffi-
cult. In addition, several surgical procedures
may be required, creating the need for serial
operative scheduling, which proves cumbersome
for both the patient and the surgeon.
For these reasons, a simple alternative method
of treatment, first introduced by Johnson et al. in
1997 and modified in 2001, has been used at the
University of Michigan Medical Center to pro-
vide staged, permanent section peripheral mar-
gin clearance before definitive resection of the
lesion and reconstruction.12,21 This technique,
known as the “square” procedure, uses perma-
nent histologic sectioning to provide circumfer-
ential clearance of the entire peripheral margin
before excision of the lesion itself. When the
technique of staged peripheral margin excision
was first described,12 margins were excised at
90-degree angles to one another; thus, the term
“square.” As the technique evolved, surgeons
learned to vary the angles of the margin excision
on a case-by-case basis to provide for maximal
tissue preservation and allow for adequate mar-
gins. Therefore, although the final peripheral
margin excision may not be a true square, it will
1250
be of some geometric design. We sought to re-
view our experience with excision and recon-
struction of facial lesions that had been cleared
by this technique and report on the utility and
benefits of this treatment modality, particularly
as it affects the reconstruction of such defects.
PATIENTS AND METHODS
Description of Technique
Incisional or excisional biopsy was performed
on suspicious lesions to obtain a tissue diagnosis
and to ascertain the Breslow depth for invasive
lesions. Candidates for sentinel lymph node bi-
opsy (Breslow depth for lentigo maligna mela-
noma, ⱖ1.00 mm) underwent standard wide local
excision with sentinel lymph node biopsy, and
were excluded from this analysis. Patients in whom
initial biopsy revealed lentigo maligna or thin len-
tigo maligna melanoma (Breslow depth, ⬍1.00
mm) were considered appropriate candidates for
the square procedure to obtain total peripheral
margin control in an office-based setting. If a pa-
tient had remaining lesion that was clinically or
pathologically suspicious for invasive melanoma
following the initial biopsy, the lesion was reex-
cised before the square procedure and sent for
histopathologic evaluation to ensure that the mi-
crostaging remained unchanged.
To perform the square procedure, the sur-
geon outlined the clinical margins of the lesion
and then added surgical margins of 0.5 to 1.0 cm.
The margins were converted into straight lines
with angled corners (Fig. 1). This created a geo-
metrically shaped outline surrounding the lesion,
to allow histologic processing of 100 percent of the
peripheral margin. Thin strips of tissue were ex-
cised along the marked margins using a two-
bladed knife spaced 2 mm apart (Robbins Instru-
ments, Chatham, N.J.), under local anesthesia.
The resulting linear, 2 mm-wide defects were
closed with fine, running, nonabsorbable sutures.
The resulting strips of excised tissue, which com-
prised the entire peripheral margin, were pinned
to Styrofoam, labeled, placed in formalin, and
processed for paraffin-embedded, permanent ver-
tical sectioning.
After the tissue was processed and sectioned,
an experienced dermatopathologist evaluated the
entire peripheral margin for evidence of persis-
tent lesion. Repeated peripheral margin excision
was performed as necessary on positive margins, at
a usual distance of 0.5 cm from the previously
excised positive margin, in the office. Once the
peripheral margins were determined to be free of
Volume 120, Number 5 • Facial Lentigo Maligna Melanoma
Fig. 1. Illustration of the square technique for peripheral margin
clearance. Patients with lentigo maligna/melanoma in situ or in-
vasive melanoma, lentigo maligna subtype undergo peripheral
margin control in an office-based setting. The surgeon outlines
the lesion margins and then adds margins of 0.5 to 1.0 cm. The
margins are converted into straight lines with angled corners to
allow orientation for vertical sectioning of the entire peripheral
margin, and are then removed as 2-mm strips of tissue using a
double-bladed knife. Because the entire peripheral margin is ex-
amined as permanent sections, regions of subclinical extension
of lentigo maligna/lentigo maligna melanoma, such as the right
superior margin, are detected. Additional strips of tissue can then
be serially excised at additional 5- to 10-mm margins around the
area of the positive margin until the entire trailing edge of the
lesion is cleared of residual melanocytic atypia. At this point, de-
finitive excision of the lesion and immediate reconstruction can
proceed.
residual melanocytic atypia, the patient could pro-
ceed with definitive resection of the central “is-
land” that incorporated the lesion and immediate
reconstruction.
Review of Patients
A multidisciplinary team consisting of derma-
tologists, dermatopathologists, and plastic sur-
geons performed the evaluation and treatment of
all patients in the study group, from November of
2001 through April of 2004. Forty-eight consecu-
tive patients with diagnoses of lentigo maligna or
thin (⬍1.00 mm) lentigo maligna melanoma were
identified. Before review of the medical records,
permission was obtained from the University of
Michigan Institutional Review Board and from the
University of Michigan Health System Privacy Board.
RESULTS
Forty-eight consecutive patients with 51 dis-
crete lesions underwent total peripheral margin
control of facial lentigo maligna/lentigo maligna
melanoma by means of the two-bladed square
technique following initial lesion biopsy. Mean
patient age was 63 ⫾ 14 years (range, 20 to 83
years; all results are reported as average ⫾SD).
Final pathology results showed lentigo maligna in
42 lesions (82 percent) and lentigo maligna mel-
anoma in nine (18 percent). For those patients
diagnosed with lentigo maligna melanoma, the
mean Breslow depth was 0.65 ⫾ 0.57 mm. The
mean number of staged square procedures re-
quired for margin clearance was 1.84 ⫾ 0.80
(range, one to five stages). Only 18 of the 51
lesions (35 percent) had completely clear patho-
logic margins after the first square excision with
0.5- to 1.0-cm surgical margins; 25 lesions (49 per-
cent) required two procedures, seven lesions (14
percent) required three procedures, and one (2
percent) required five procedures. For all pa-
tients, the mean peripheral margin size required
to obtain clear margins was 1.1 ⫾ 0.5 cm. For
patients with lentigo maligna, the average periph-
eral margin required to obtain clear margins was
1.0 ⫾ 0.5 cm, compared with 1.3 ⫾ 0.4 cm for
patients with lentigo maligna melanoma.
Lesions most often involved the cheek (57 per-
cent), followed by the nose (18 percent), the fore-
head (16 percent), the lips and ears (4 percent
each), and the scalp (2 percent). The average size
of excision for all lesions was 16 ⫾ 11 cm2 (range,
2 to 49 cm2). Procedures used for reconstruction
included 18 full-thickness skin grafts (36 percent),
11 cervicofacial flaps (22 percent), seven rhom-
boid flaps (14 percent), six nasolabial flaps (12
percent), five rotation-advancement flaps (10 per-
cent), two local tissue rearrangements (4 per-
cent), and two forehead flaps (4 percent). The
total complication rate was 9.8 percent, including
partial loss of one full-thickness skin graft, partial
loss of two flaps, and two cases of hypertrophic scar
formation. In addition, one patient required re-
excision because of pathologic evidence of mela-
noma in situ at the base of a hair follicle imme-
diately adjacent to the deep margin. Repeated
wide local excision did not reveal evidence of re-
sidual disease in this patient.
There were no functional complications, such
as ectropion, dry eye, or oral or nasal obstruction
in the group. No known cases of recurrence exist
in this group of patients, with an average derma-
tologic follow-up of 953 ⫾ 246 days (range, 473 to
1251
 Plastic and Reconstructive Surgery • October 2007

Fig. 2. A 59-year-old man with melanoma in situ of the right forehead. (Left) Clear margins were obtained after one square excision.
Margins of the square excision are enhanced with blue lines. Excision of the central island was performed, followed by immediate
reconstruction with bilateral advancement flaps, without the need for intermediate dressing changes or grafting. (Center) Photo-
graph of the patient obtained 3 weeks postoperatively, demonstrating immature scars. (Right) Photograph of the patient obtained
5 months postoperatively. Scars are virtually imperceptible at this point. Aesthetic and functional compromise were avoided with
immediate reconstruction.

1373 days) elapsed since surgical reconstruction.
Virtually all of the patients expressed their plea-
sure with the final reconstructive results at their
last clinic visit. Representative patients are high-
lighted in Figures 2 through 4.
DISCUSSION
Traditional staged surgical excision of lentigo
maligna and lentigo maligna melanoma, with de-
layed reconstruction pending histopathologic ex-
amination of the margins, necessitates leaving an
open wound or covering the wound with skin au-
tograft or allograft until the margins are deter-
mined to be clear. This algorithm promotes wound
contraction, fibrosis, and desiccation, which can
have deleterious effects on the outcome of the final
reconstruction. Dressing changes and/or the cre-
ation of donor-site morbidity can be painful and
burdensome. The effect of margin clearance on
operative planning is cumbersome. The square
procedure provides for excision of the central
lesion in combination with immediate recon-
struction, thereby facilitating an immediate opti-
mal functional and aesthetic reconstructive result.
Not only is the excision limited in size to that
which adequately clears the tumor, but the sur-
geon can proceed confidently with immediate re-
construction after excision of the lesion, knowing
that the peripheral margins have been confirmed
to be free of residual disease.
In addition to promoting improved functional
and aesthetic results, the square procedure allows
a more thorough evaluation of the entire periph-
eral margin compared with standard wide local
excision. Traditional histopathologic evaluation
consists of taking a series of vertical sections ori-
ented transversely across the surgical specimen,
generally at 2- to 3-mm intervals, known as the
bread loaf method of sectioning. This technique
results in examination of only a small percentage
of the entire peripheral margin.20 Thus, subclin-
ical extensions that are characteristic of lentigo
maligna and lentigo maligna melanoma can be
missed and tissue margins erroneously inter-
preted as clear.20 A much more thorough assess-
ment of the margins is accomplished with the
square technique, as thin, permanent vertical sec-
tions of the entire periphery are examined histo-
logically before definitive tumor extirpation. In
patients with lentigo maligna/lentigo maligna
melanoma, this meticulous investigation of the
entire peripheral margin for subclinical extension

1252
Volume 120, Number 5 • Facial Lentigo Maligna Melanoma

Fig. 3. Photographs of a 46-year-old woman with melanoma in situ of the medial left
cheek. (Left) Three square excisions were required to obtain clear peripheral margins of
residual melanocytic atypia (first excisions are outlined in blue, the second in red, and the
third in yellow). (Right) Photograph of the patient obtained 5 months after excision and
immediate reconstruction with left-sided cervicofacial rotation-advancement flap. Note
the lack of ectropion and use of optimal reconstructive technique afforded by immediate
reconstruction.

Fig. 4. A 61-year-old man with melanoma in situ of the nasal tip and dorsum. (Left) Two square excisions were required to obtain clear
margins (first excisions outlined in blue; the second, in red). (Center) Intraoperative appearance after excision of the lesion and the
remainder of the nasal tip subunit. A left-sided paramedian forehead flap was designed for coverage. (Right) Photograph of the
patient obtained 4 months after division and insetting of the forehead flap.

increases the cure rate and lessens the likelihood
of late recurrences of potentially lethal invasive
melanoma.14,22,23
In this study, the initial peripheral margin ex-
cision of 0.5 to 1.0 cm was adequate for complete
excision in only 35 percent of cases. Almost half of
the lesions required two square excisions, with an
average surgical margin of 10 mm in patients with
lentigo maligna and 13 mm in those with lentigo
maligna melanoma. This is consistent with the

1253
 Plastic and Reconstructive Surgery • October 2007
findings of other authors, who have specifically
investigated adequate surgical margins for lentigo
maligna and lentigo maligna melanoma. Agarwal-
Antal et al. examined adequate margins for exci-
sion of lentigo maligna and found that 5-mm mar-
gins were sufficient only 42 percent of the time,24
whereas Robinson found that 6-mm margins
cleared only 23 percent of lentigo maligna and
lentigo maligna melanoma tumors.10 Similarly,
Zitelli et al. reported that margins smaller than 6
mm achieved clearance in only half of their cases
of lentigo maligna/lentigo maligna melanoma,13
whereas Cohen et al. averaged 6 to 10 mm for clear
margins.11 Although the National Comprehensive
Cancer Network currently recommends 5- to
10-mm surgical margins for lentigo maligna/len-
tigo maligna melanoma,17 it is clear that these
margins often will be insufficient to clear the en-
tire periphery of residual disease.
The square method of excision, while en-
suring complete tumor removal with examina-
tion of the entire peripheral margin, also allows
for maximal tissue conservation. Lentigo ma-
ligna and lentigo maligna melanoma often have
irregular shapes. The use of geometric patterns
with straight lines and angled corners, as op-
posed to standard elliptical excision, allows the
pathologist to make sections along the entire
periphery and pinpoint the exact sites of sub-
clinical tumor involvement. With this informa-
tion and tissue orientation, the surgeon can per-
form the next margin excision knowing the
exact site of positive margins, thereby prevent-
ing the needless excision of uninvolved regions.
In this study, the most commonly involved sites
were the cheek and nose, anatomical regions
that can provide significant reconstructive chal-
lenges. Minimizing the removal of normal tissue
in these sites significantly aids the surgeon in
achieving the best functional and aesthetic re-
constructive result.
The objective of the square technique is to
clear the peripheral margins of residual lentigo
maligna/lentigo maligna melanoma before defin-
itive excision and reconstruction of the lesion.
The surgeon must be mindful to perform the ul-
timate extirpation at the level of the mid to deep
subcutaneous tissues, or deeper, thereby perform-
ing complete excision of hair follicles and glands
to ensure that any adnexal epithelial extension of
in situ melanoma is removed. Histopathologic ex-
amination of the deep surgical margin is accom-
plished when the central island is excised and
submitted for histologic evaluation.
1254
CONCLUSIONS
The square technique is a simple, office-based
method for peripheral margin clearance of len-
tigo maligna and thin invasive lentigo maligna
melanoma of the head and neck. By allowing a
complete examination of the tumor periphery be-
fore definitive excision, the square procedure al-
lows the surgeon to proceed with immediate and
optimal reconstruction. By avoiding delayed re-
construction and by promoting maximal tissue
conservation, improved functional and aesthetic
outcomes are achieved.
David L. Brown, M.D.
University of Michigan Medical Center
Section of Plastic Surgery
2130 Taubman Health Care Center
1500 East Medical Center Drive
Ann Arbor, Mich. 48109-0340
davbrown@umich.edu
DISCLOSURE
None of the authors has any financial interest or
commercial associations that might pose or create a con-
flict of interest with the information presented in this
article.
REFERENCES
1. Ries, L. A., Hankey, B. F., Miller, B. A., et al. Cancer statistics
review 1973–1988. NIH Publication 91-2789. Washington, D.C.:
National Cancer Institute, U.S. Government Printing Office,
1991.
2. Ahmed, I., and Stevenson, O. Lentigo maligna: Prognosis
and treatment options. Am. J. Clin. Dermatol. 6: 151, 2005.
3. Mohrle, M. Micrographic surgery (3D-histology) in cutane-
ous melanoma. J. Dtsch. Dermatol. Ges. 11: 869, 2003.
4. Robinson, J. K. Use of digital epiluminescence microscopy to
help define the edge of lentigo maligna. Arch. Dermatol. 140:
1095, 2004.
5. Cohen, L. M. Lentigo maligna and lentigo maligna mela-
noma. J. Am. Acad. Dermatol. 33: 923, 1995.
6. Kuflik, E. G., and Gage, A. A. Cryosurgery for lentigo ma-
ligna. J. Am. Acad. Dermatol. 31: 75, 1994.
7. Silvers, D. N. Focus on melanoma: The therapeutic dilemma
of lentigo maligna (Hutchinson’s freckle). J. Dermatol. Surg.
Oncol. 2: 301, 1976.
8. Litwin, M. S., Krementz, E. T., Mansell, P. W., et al. Topical
chemotherapy of lentigo maligna with 5-fluorouracil. Cancer
35: 721, 1975.
9. Naylor, M. F., Crawson, N., Kuwahara, R., et al. Treatment of
lentigo maligna with topical imiquimod. Br. J. Dermatol. 149:
66, 2003.
10. Robinson, J. K. Margin control for lentigo maligna. J. Am.
Acad. Dermatol. 31: 79, 1994.
11. Cohen, L. M., McCall, M. W., Hodge, S. J., et al. Successful
treatment of lentigo maligna and lentigo maligna melanoma
with Mohs’ micrographic surgery aided by rush permanent
sections. Cancer 73: 2964, 1994.
12. Johnson, T. M., Headington, J. T., Baker, S. R., and Lowe, L.
Usefulness of the staged excision for lentigo maligna and
lentigo maligna melanoma: The “square” procedure. J. Am.
Acad. Dermatol. 37: 758, 1997.
Volume 120, Number 5 • Facial Lentigo Maligna Melanoma

13. Zitelli, J. A., Brown, C., and Hanusa, B. H. Mohs’ micro-
graphic surgery for the treatment of primary cutaneous mel-
anoma. J. Am. Acad. Dermatol. 37: 236, 1997.
14. Johnson, T. M., Smith, J. W., Nelson, B. R., et al. Current therapy
for cutaneous melanoma. J. Am. Acad. Dermatol. 32: 689, 1995.
15. Balch, C. M., Urist, M. M., Karakousis, C. P., et al. Efficacy of
2-cm surgical margins for intermediate-thickness melanomas
(1– 4 mm): Results of a multi-institutional randomized sur-
gical trial. Ann. Surg. 218: 262, 1993.
16. National Institutes of Health Consensus Conference. Diagnosis
and treatment of early melanoma. J.A.M.A. 268: 1314, 1992.
17. NCCN Clinical Practice Guidelines in Oncology (Web site).
Available at: http://www.nccn.org/professionals/physician_gls/
PDF/melanoma.pdf. Accessed September 2, 2005.
18. O’Brien, C. J., Coates, A. S., Peterson-Schaefer, K., et al.
Experience with 998 cutaneous melanomas of the head and
neck over 30 years. Ann. J. Surg. 162: 310, 1991.
19. Anderson, A. P., Gottlieb, J., Drzewlecki, K. T., et al. Skin
melanoma of the head and neck. Cancer 69: 1153, 1992.
20. Rapini, R. P. Comparison of methods for checking surgical
margins. J. Am. Acad. Dermatol. 23: 288, 1990.
21. Anderson, K. W., Baker, S. R., Lowe, L., et al. Treatment of
head and neck melanoma, lentigo maligna subtype. Arch.
Facial Plast. Surg. 3: 202, 2001.
22. Hill, D. C., and Gramp, A. A. Surgical treatment of lentigo
maligna and lentigo maligna melanoma. Australas. J. Derma-
tol. 40: 25, 1999.
23. Mahoney, M. H., Joseph, M., and Temple, C. L. The perim-
eter technique for lentigo maligna: An alternative to Mohs
micrographic surgery. J. Surg. Oncol. 91: 120, 2005.
24. Agarwal-Antal, N., Bowen, G. M., and Gerwels, J. W. Histo-
logic evaluation of lentigo maligna with permanent sections:
Implications regarding current guidelines. J. Am. Acad. Der-
matol. 47: 743, 2002.

Instructions for Authors: Update

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More information on registering clinical trials can be found in the following article: Rohrich, R. J., and
Longaker, M. T. Registering clinical trials in Plastic and Reconstructive Surgery. Plast. Reconstr. Surg. 119: 1097,
2007.

1255

Romberg’s Disease Associated with Horner’s
Syndrome: Contour Restoration by a Free
Anterolateral Thigh Perforator Flap and
Ancillary Procedures
Dogan Tuncali, M.D.
Nesrin Tan Baser, M.D.
Ahmet Terzioglu, M.D.
Gurcan Aslan, M.D.
Cebeci, Ankara, Turkey
R
omberg’s disease (also known as Parry-
Romberg syndrome or progressive hemifa-
cial atrophy) is a rare pathologic process
involving progressive wasting of skin, subcutane-
ous fat, muscle, and occasionally bones of the
face. The condition was first described by Parry
in 1825 and later by Romberg in 1846 as “tro-
phoneurisis facialis,” though Eulenberg has
coined the term “progressive facial hemiatro-
phy.” The onset of the disease is slow and pro-
gressive and usually commences in the first or
second decade of life, more often between the
ages of 5 and 15 years.1 It is more common in the
female population, with a female-to-male ratio of
1.5 to 1. The atrophy is unilateral in 95 percent
of cases. The right and left sides of the face are
affected with equal frequency.
Pensler et al.,2 in an evaluation of 41 patients,
have noted that in all patients the atrophic
changes began in a localized area of the face and
progressed within the dermatome of one or
more branches of the trigeminal nerve. The av-
erage age of onset of the disease was 8.8 years,
and the mean period of progression was 8.9 ⫾ 6
years. In a group of patients with skeletal involve-
ment in their series, the mean age of onset was
5.4 years versus 15.4 years for patients without
skeletal involvement. No correlation could be
established between severity of soft-tissue defor-
mity and age of onset. When bony hypoplasia is
present, it affects predominantly the middle and
lower face.3
From the Department of Plastic and Reconstructive Surgery,
Ankara Education and Research Hospital.
Received for publication March 23, 2005; accepted July 28,
2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279325.32286.7a
www.PRSJournal.com
CASE REPORT
The timing of surgery should be based on
correction of the deformity after cessation of the
ongoing atrophic process, usually after a period
of at least 1 year.1 Soft-tissue reconstruction tech-
niques should address the augmentation of de-
ficient soft-tissue volume. There is a wide range
of methods described, from dermal fat grafts to
free tissue transfers. The myriad of methods re-
flects the lack of a single best method.
The cause of the disorder is unknown, al-
though many theories have been proposed.
Among these, the most popular are infection,4
trauma, immunologic abnormality, heredity, tri-
geminal neuritis, scleroderma, and cervical sym-
pathetic loss.5,6 Regardless of the cause, the re-
sultant deformity is usually characterized by a
stable “burned-out” appearance of the hemiface.
The proposed theory of alteration in periph-
eral sympathetic stimulation has gained a certain
popularity following studies reporting Romberg-
like changes observed in laboratory animals after
superior cervical sympathectomy.5,7–10 Only one
report of Romberg’s disease following thoraco-
scopic sympathectomy (performed for palmar
hyperhidrosis) was reported for humans in the
English literature. However, previously, Tebloev
and Kalashnikov11 and Tebloev et al.7 reported a
total of 28 patients in whom facial hemiatrophy
developed after the onset of ganglionitis of the
superior cervical sympathetic ganglion, brain-
stem encephalitis, trigeminal neuralgia, tumors
of the gasserian ganglion, and syringobulbia. In
contrast, if the sympathetic nervous system is
responsible, it remains unclear whether facial
atrophy results from postinflammatory hypo-
function or sympathetic hyperactivity in the pres-
ence of active inflammation.12
Horner’s syndrome (Claude-Bernard-Horner
syndrome) is characterized by an interruption of
67e
 Plastic and Reconstructive Surgery • October 2007
the oculosympathetic nerves anywhere on the
pathway between its origin in the hypothalamus
and the eye. The classic clinical findings associ-
ated with Horner’s syndrome are ptosis, pupil-
lary miosis, and facial anhidrosis. Other findings
may include apparent enophthalmos, increased
amplitude of accommodation, heterochromia of
the iris, paradoxical contralateral eyelid retrac-
tion, transient decrease in intraocular pressure,
and changes in tear viscosity.13 Iris pigmentation
is under sympathetic control during develop-
ment and is completed by the age of 2, making
heterochromia an uncommon finding in Hor-
ner’s syndrome acquired later in life.14
Despite these studies and reports, and al-
though one would expect it to be more com-
mon, the coexistence of Romberg’s disease with
a peripheral traumatic Horner’s syndrome in
the same patient has not been reported previ-
ously in the English literature. An extensive
search of the literature revealed only one case
following syringomyelia reported by Boudour-
esques and Naquet in 1951.15 In this article, we
report a severe case of Romberg’s disease asso-
ciated with an ipsilateral Horner’s syndrome,
treated with a combination approach consisting
of a free anterolateral thigh perforator flap and
ancillary procedures.
CASE REPORT
A 23-year-old-woman presented with Romberg’s disease af-
fecting the right side of her face. The problem had initiated at
Fig. 1. Romberg’s disease affecting all three branches of the trigeminal nerve with type III and
IV depressions. Note the anisocoria with right-sided miosis, slight ptosis, and enophthalmos.
(Left) Preoperative frontal view. (Right) Eighteen-month postoperative result.
68e
age 15 following a fall and trauma to the involved side of the
face and neck. The progressive atrophy had spontaneously re-
solved in approximately 5 years. Her main complaints were the
starved and aged facial appearance and the resultant severe
facial asymmetry (Figs. 1 and 2). Physical examination revealed
the disease to affect all three branches of the trigeminal nerve.
Preoperative three-dimensional computed tomography re-
vealed hypoplasia of the right zygoma and corpus of the man-
dible (Fig. 3). There were no temporomandibular joint dys-
function or occlusion problems. Located on the ipsilateral side
of the disease, miosis, slight ptosis, and enophthalmos were also
observed (Fig. 1). However, anhidrosis was not noted in either
the patient history or the physical examination, which sug-
gested a possible postganglionic lesion. Other possible associ-
ations such as heterochromia iridis, cranial nerve palsies,
Klumpke’s paralysis, or any other neurologic symptoms could
not be found. A topical cocaine (2%) test confirmed the diag-
nosis of Horner’s syndrome and a hydroxyamphetamine (1%)
test indicated a postganglionic location.
After discussion of the reconstruction options with the pa-
tient, a combination approach of a free anterolateral thigh flap
and porous polyethylene implants (Medpor; Porex Surgical,
Inc., Newnan, Ga.) was planned. The patient was informed
beforehand about the possibility of further minor revisions after
the initial operation.
In the first operation, a porous polyethylene malar implant
and a sheet of porous polyethylene implant, shaped in the form
of the mandibular margin, was introduced. An anterolateral 10
⫻ 8-cm thigh flap was harvested on a single musculocutaneous
perforator. The recipient pocket was prepared through a preau-
ricular incision at a standard face-lift level. The superficial tem-
poral artery and vein were used as recipient vessels and the flap
was secured by nonabsorbable sutures to the periosteum of the
zygoma and the infraorbital rim. The early postoperative period
was uneventful other than the perception by the patient of the
pulse rate at the anastomosis site.16
Volume 120, Number 5 • Romberg’s Disease
Fig. 2. (Left) Preoperative right oblique view. (Right) Eighteen-month postoperative result.
Fig. 3. Three-dimensional computed tomographic scan dem-
onstrating right-sided skeletal hypoplasia including the zygoma
and the mandible.
In the second operation, which was performed 4 weeks later,
a total of 40 cc of fat graft was injected into the right temporal,
alar, nasolabial, upper and lower lips, chin, upper and lower
orbital rim, and the lower eyelid areas. No overcorrection was
performed.
Six months later, debulking of the anterolateral thigh flap
was performed. The dissection was performed beneath the
dermis of the flap to avoid hindering the smooth contour
achieved on the cheek area. With the aim of extending the
reach area of the flap, turnover flaps17 obtained from the areas
of relative excess to adjacent deficient areas, such as the lateral
orbital and the angle of the mandible, were introduced. An ad-
ditional 20 cc of fat graft was injected into the right chin, upper
and lower lips, and temporal regions and a dermal-fat graft was
introduced into the right nasolabial fold (Figs. 1 and 2).
At the 18-month follow-up (approximately 2 years after the
first operation), a good aesthetic contour was obtained. How-
ever, the chin (the coup de sabre deformity) and the upper lip
vermilion border still need further interventions, and the pro-
jection of the malar eminence is insufficient despite the use of
the largest malar implant available (Fig. 1). This problem is a
constant observation even in the largest series in the literature
and can be attributed to the severity of the deformity.18,19 De-
spite the residual deformities, the patient states that she is very
satisfied with the result and does not want any further opera-
tions for now.
DISCUSSION
This case is very interesting for several reasons.
Horner’s syndrome after blunt trauma is a very
rare condition that may be present when the neck
or maxillofacial region is involved.20 –32 However, it
is not uncommon in thoracic surgical practice.33,34
Similarly, hemifacial atrophy following trauma is
also rare. We believe that the coexistence of hemi-
facial atrophy and Horner’s syndrome is yet ad-
ditional evidence for the theory that alteration of
sympathetic innervation may play a role in Rom-
berg’s disease as a possible cause.
Existence of bone hypoplasia, despite the
rather late onset of the symptoms in our patient,
is also of concern. Skeletal deformities were pre-
viously reported to be associated with early onset
of symptoms.2 This may indicate a possible poten-
tialization effect of blunt trauma or a direct effect
of the trauma, or it may represent the existence of
the disease before the trauma. Moore et al.3 be-
lieve that the restriction imposed by the abnormal
soft-tissue envelope compounds any primary skel-
69e
 Plastic and Reconstructive Surgery • October 2007
etal growth disturbance. They conclude that if the
disease involves bone, it would seem to exert an
effect on skeletal structure only during periods
of facial growth acceleration. They have pro-
posed that the treatment should provide a three-
dimensional reconstruction of all soft-tissue and
skeletal problems. Facial contour restoration in
Romberg’s disease is still a challenge for the re-
constructive surgeon. This is particularly evident
when severe cases with involvement of bone are
encountered.
Autologous fat injection is a long-accepted
technique for facial rejuvenation and certainly has
a place in the augmentation of soft-tissue defi-
ciency observed in Romberg’s disease.35 However,
the results are more successful when the tech-
nique is used for mild to moderate contour irreg-
ularities. For the latter, regional flaps can also be
used.35,36 Severe atrophy associated with skeletal
disturbances is much more difficult to correct
with fat injections alone, because a large volume
of fat is needed, which is apt to resorb. Thus,
when large-volume correction is necessary, free
tissue transfer is generally warranted. The greater
omentum,37–39 latissimus dorsi,40 radial forearm,41
groin,42– 44 scapular and parascapular,17,19 deep in-
ferior epigastric,45 transverse rectus abdominis
muscle,46 and recently anterolateral thigh47,48 free
flaps have been used for this purpose.
Free flaps even grow and gain weight along
with the patient.18 However, it is usually accepted
that in approximately one-third to two-thirds of
patients, minor contour adjustments such as de-
bulking, turnover flaps, flap resuspensions, or an-
cillary procedures are often necessary.17,18 Accord-
ing to Guerrerosantos,35 especially when treating
patients with type III and IV depressions, a com-
bination surgical approach using concomitant
procedures such as flaps, dermal-fat grafts, bone
grafts, and cartilage grafts is of primary impor-
tance. He has concluded that combining the tech-
niques with lipoinjection will provide a more nat-
ural appearance. Upton et al.19 have reported
their experience with the scapular and parascapu-
lar flaps in five patients and stated that deficiency
of the malar eminence could not always be cor-
rected with soft tissue alone and that this area
often needed bone grafting or alloplastic im-
plants. Longaker and Siebert18 have reported their
experience with 15 cases and presented their use
of deepithelialized extended parascapular flaps
with large fascial extensions. The fascia could be
folded into a variable thickness to correct subtle
contour defects. To correct skeletal deficiencies,
Rigotti et al.49 have proposed the use of free paras-
70e
capular flaps with the adjunct of porous polyeth-
ylene implants. Mordick et al.50 have compared
the results of dermal-fat grafting and free tissue
transfers. They have concluded that although the
former was a satisfactory technique for mild to
moderate defects, free flap transfers were re-
quired for moderate to severe cases, generally in
the form of dermal-fat or only adiposal compo-
nents. The use of muscle flaps have been primarily
abandoned because of their excessive bulk and
unpredictable risk of atrophy.45
We have used a combination approach includ-
ing a free anterolateral thigh perforator flap along
with porous polyethylene implants, autologous fat
injections, and dermal-fat grafts. Further fat in-
jections, debulking, and remodeling of the flap
along with transposition of turnover flaps were
subsequently needed. The value of the anterolat-
eral thigh flap in numerous designs and recon-
structive challenges present in almost every body
part are well described in the literature.51–59 It has
also been used for facial contour restorations.47,48,60
In recent years, the versatility of the anterolateral
thigh flap has even led some authors to interpret
the technique as the ideal soft-tissue flap.61,62 The
vascular anatomy and its variations have been
studied in detail,63– 65 and it has a low donor-site
morbidity.51,61,62,66 We believe that in the dimen-
sions of a major single-sided contour restoration,
most donor sites can be closed primarily. Patient
positioning on the operating table is easy, and a
simultaneous double-team procedure is always
possible.
To treat severe Romberg’s disease patients, a
combination approach is mandatory and should
be planned following accurate evaluation of the
deformity before any intervention is undertaken.
When alloplastic implants are introduced, the free
flap can be used for implant coverage and to re-
store the remaining major soft-tissue deficiency.
Although the techniques of dermal-fat grafting
and fat injections seem to be out of date, they are
very useful when subtle corrections are needed.
Thus, ancillary procedures are important and can
be regarded as an essential part of the entire re-
constructive approach to obtain a final result. The
possibility of such subsequent interventions for
fine tuning, following the “extended” initial op-
eration, should be discussed beforehand with the
patient to prevent superfluous discouragement.
CONCLUSIONS
A severe case of Romberg’s disease associated
with an ipsilateral Horner’s syndrome that was
treated with a free anterolateral thigh perforator
Volume 120, Number 5 • Romberg’s Disease
flap, porous polyethylene implants, autologous fat
injections, and dermal-fat grafts is presented. Co-
existence of these two clinical entities in the same
patient has not been reported previously in the
English literature. This case may be additional
evidence for the theory that alteration of sympa-
thetic innervation may play a role in Romberg’s
disease as a possible cause. Facial contour resto-
ration is still a challenge for the reconstructive
surgeon. This is particularly evident when severe
cases with involvement of bone are encountered.
With a combination approach, a good aesthetic
contour was obtained at the 18-month follow-up.
Ancillary procedures are important and an essen-
tial part of the entire reconstructive approach for
a final result. The possibility of such subsequent
interventions should be discussed beforehand
with the patient to prevent superfluous discour-
agement.
Dogan Tuncali, M.D.
Mahatma Gandi cad.
Mesa Ufuk 1 sitesi 51/28
Gaziosmanpasa 06700, Ankara, Turkey
dogan_tuncali@yahoo.com
DISCLOSURE
The authors have no financial interest or conflict of
interest to disclose.
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alies: Conditions of craniofacial atrophy/hypoplasia and
neoplasia. Plast. Reconstr. Surg. 111: 1497, 2003.
2. Pensler, J. M., Murphy, G. F., and Mulliken, J. B. Clinical and
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3. Moore, M. H., Wong, K. S., Proudman, T. W., et al. Progres-
sive hemifacial atrophy (Romberg’s disease): Skeletal in-
volvement and treatment. Br. J. Plast. Surg. 46: 39, 1993.
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5. Moss, M. L., and Crikelair, G. F. Progressive facial hemiat-
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6. Scope, A., Barzilai, A., Trau, H., et al. Parry-Romberg syn-
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7. Tebloev, I. K., Karlov, V. A., and Gemonov, V. V. Trophic
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8. Resende, L. A., Pai, D. V., and Alves, A. Experimental study
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9. Sherman, B. E., and Chole, R. A. In vivo effects of surgical
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J. Otol. 17: 343, 1996.
10. Pai-Silva, M. D., Ueda, A. K., Resende, L. A., et al. Morpho-
logical aspects of rabbit masseter muscle after cervical sym-
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11. Tebloev, I. K., and Kalashnikov, IuD. Pathogenesis of symp-
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Psikhiatr. Im. S. S. Korsakova. 79: 413, 1979.
12. Cory, R. C., Clayman, D. A., Faillace, W. J., et al. Clinical and
radiologic findings in progressive facial hemiatrophy (Parry-
Romberg syndrome). A.J.N.R. Am. J. Neuroradiol. 18: 751,
1997.
13. Nautiyal, A., Singh, S., DiSalle, M., et al. Painful Horner
syndrome as a harbinger of silent carotid dissection. PloS.
Med. 2: e19, 2005.
14. Diesenhouse, M. C., Palay, D. A., Newman, N. J., et al. Ac-
quired heterochromia with Horner syndrome in two adults.
Ophthalmology 99: 1815, 1992.
15. Boudouresques, J., and Naquet, R. Syringomyelia of uni-
lateral predominance with facial hemiatrophy and Claude-
Bernard-Horner syndrome of the same side. Rev. Otoneu-
roophtalmol. 23: 290, 1951.
16. Tuncali, D., Yilmaz, N., and Aslan, G. An unusual compli-
cation following free-tissue transfer: Pulse rate perception.
Plast. Reconstr. Surg. 114: 1010, 2004.
17. Siebert, J. W., Anson, G., and Longaker, M. T. Microsurgical
correction of facial asymmetry in 60 consecutive cases. Plast.
Reconstr. Surg. 97: 354, 1996.
18. Longaker, M. T., and Siebert, J. W. Microvascular free-flap
correction of severe hemifacial atrophy. Plast. Reconstr. Surg.
96: 800, 1995.
19. Upton, J., Albin, R. E., Mulliken, J. B., et al. The use of
scapular and parascapular flaps for cheek reconstruction.
Plast. Reconstr. Surg. 90: 959, 1992.
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21. Naf, E. Posttraumatic Horner’s syndrome. Klin. Monatsbl.
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22. Richardson, J. D., McElvein, R. B., and Trinkle, J. K. First rib
fracture: A hallmark of severe trauma. Ann. Surg. 181: 251,
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23. Starr, B. E., Shubert, R. A., and Baumann, B. A child with
isolated Horner’s syndrome after blunt neck trauma.
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24. Urakawa, M., Ueda, Y., Yasuda, H., et al. Vertebral artery
occlusion following neck trauma: Report of two cases. No To
Shinkei 55: 141, 2003.
25. Ozveren, M. F., Uchida, K., Erol, F. S., et al. Isolated abducens
nerve paresis associated with incomplete Horner’s syndrome
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26. Edwards, A., and Andrews, R. A case of Brown-Sequard syn-
drome with associated Horner’s syndrome after blunt injury
to the cervical spine. Emerg. Med. J. 18: 512, 2001.
27. Bell, R. L., Atweh, N., Ivy, M. E., et al. Traumatic and iatro-
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literature. J. Trauma 51: 400, 2001.
28. Jeffery, A. R., Ellis, F. J., Repka, M. X., et al. Pediatric Horner
syndrome. J. A.A.P.O.S. 2: 159, 1998.
29. Oono, S., Saito, I., Inukai, G., et al. Traumatic Horner syn-
drome without anhidrosis. J. Neuroophthalmol. 19: 148, 1999.
30. Liu, G. T., Deskin, R. W., and Bienfang, D. C. Horner’s
syndrome caused by intra-oral trauma. J. Clin. Neuroophthal-
mol. 12: 110, 1992.
31. White, P. R. Horner’s syndrome and its significance in the
management of head and neck trauma. Br. J. Oral Surg. 14:
165, 1976.
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 Plastic and Reconstructive Surgery • October 2007
32. Kammen, I. F., and Belinfante, L. S. Horner’s syndrome
associated with maxillofacial trauma: Report of case. J. Oral
Surg. 28: 910, 1970.
33. Kaya, S. O., Liman, S. T., Bir, L. S., et al. Horner’s syndrome
as a complication in thoracic surgical practice. Eur. J. Car-
diothorac. Surg. 24: 1025, 2003.
34. Chan, C. C., Paine, M., and O’Day, J. Carotid dissection: A
common cause of Horner’s syndrome. Clin. Exp. Ophthalmol.
29: 411, 2001.
35. Guerrerosantos, J. Long-term outcome of autologous fat
transplantation in aesthetic facial contouring: Sixteen years
of experience with 1936 cases. Clin. Plast. Surg. 27: 515, 2000.
36. Sabapathy, S. R., Venkatramani, H., and Bharathi, R. Rom-
berg’s disease: Modified Washio flap for facial contour re-
construction. Plast. Reconstr. Surg. 108: 705, 2001.
37. Jurkiewicz, M. J., and Nahai, F. The use of free revascularized
grafts in the amelioration of hemifacial atrophy. Plast. Re-
constr. Surg. 76: 44, 1985.
38. Losken, A., Carlson, G. W., Culbertson, J. H., et al. Omental
free flap reconstruction in complex head and neck defor-
mities. Head Neck 24: 326, 2002.
39. Wallace, J. G., Schneider, W. J., Brown, R. G., et al. Recon-
struction of hemifacial atrophy with a free flap of omentum.
Br. J. Plast. Surg. 32: 15, 1979.
40. Pisarek, W. Reconstruction of craniofacial microsomia and
hemifacial atrophy with free latissimus dorsi flap. Acta Chir.
Plast. 30: 194, 1988.
41. Koshy, C. E., and Evans, J. Facial contour reconstruction in
localised lipodystrophy using free radial forearm adipofascial
flaps. Br. J. Plast. Surg. 51: 499, 1998.
42. Inigo, F., Rojo, P., and Ysunza, A. Aesthetic treatment of
Romberg’s disease: Experience with 35 cases. Br. J. Plast. Surg.
46: 194, 1993.
43. Cooper, T. M., Lewis, N., and Baldwin, M. A. Free groin flap
revisited. Plast. Reconstr. Surg. 103: 918, 1999.
44. Harashina, T., and Fujino, T. Reconstruction in Romberg’s
disease with free groin flap. Ann. Plast. Surg. 7: 289, 1981.
45. Koshima, I., Inagawa, K., Urushibara, K., et al. Deep inferior
epigastric perforator dermal-fat or adiposal flap for correc-
tion of craniofacial contour deformities. Plast. Reconstr. Surg.
106: 10, 2000.
46. Coessens, B., and Van Geertruyden, J. P. Simultaneous bi-
lateral facial reconstruction of a Barraquer-Simon lipodys-
trophy with free TRAM flaps. Plast. Reconstr. Surg. 95: 911,
1995.
47. Guelinckx, P. J., and Sinsel, N. K. Facial contour restoration
in Barraquer-Simons syndrome using two free anterolateral
thigh flaps. Plast. Reconstr. Surg. 105: 1730, 2000.
48. Masaki, F. Correction of hemifacial atrophy using a free flap
placed on the periosteum. Plast. Reconstr. Surg. 111: 818,
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49. Rigotti, G., Cristofoli, C., Marchi, A., et al. Treatment of
Romberg’s disease with parascapular free flap and polyeth-
ylene porous implants. Facial Plast. Surg. 15: 317, 1999.
50. Mordick, T. G., II, Larossa, D., and Whitaker, L. Soft-tissue
reconstruction of the face: A comparison of dermal-fat
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29: 390, 1992.
72e
51. Huang, C. H., Chen, H. C., Huang, Y. L., et al. Comparison
of the radial forearm flap and the thinned anterolateral thigh
cutaneous flap for reconstruction of tongue defects: An eval-
uation of donor-site morbidity. Plast. Reconstr. Surg. 114:
1704, 2004.
52. Ozkan, O., Coskunfirat, O. K., and Ozgentas, H. E. The use
of free anterolateral thigh flap for reconstructing soft tissue
defects of the lower extremities. Ann. Plast. Surg. 53: 455,
2004.
53. Chana, J. S., and Wei, F. C. A review of the advantages of the
anterolateral thigh flap in head and neck reconstruction. Br.
J. Plast. Surg. 57: 603, 2004.
54. Rosenberg, J. J., Chandawarkar, R., Ross, M. I., et al. Bilateral
anterolateral thigh flaps for large-volume breast reconstruc-
tion. Microsurgery 24: 281, 2004.
55. Chen, H. C., Tang, Y. B., Mardini, S., et al. Reconstruction
of the hand and upper limb with free flaps based on mus-
culocutaneous perforators. Microsurgery 24: 270, 2004.
56. Kuo, Y. R., Kuo, M. H., Lutz, B. S., et al. One-stage recon-
struction of large midline abdominal wall defects using a
composite free anterolateral thigh flap with vascularized fas-
cia lata. Ann. Surg. 239: 352, 2004.
57. Kuo, Y. R., Kuo, M. H., Chou, W. C., et al. One-stage recon-
struction of soft tissue and Achilles tendon defects using a
composite free anterolateral thigh flap with vascularized fas-
cia lata: Clinical experience and functional assessment. Ann.
Plast. Surg. 50: 149, 2003.
58. Koshima, I., Yamamoto, H., Moriguchi, T., et al. Extended
anterior thigh flaps for repair of massive cervical defects
involving pharyngoesophagus and skin: An introduction to
the “mosaic” flap principle. Ann. Plast. Surg. 32: 321, 1994.
59. Koshima, I., Yamamoto, H., Hosoda, M., et al. Free combined
composite flaps using the lateral circumflex femoral system
for repair of massive defects of the head and neck regions:
An introduction to the chimeric flap principle. Plast. Reconstr.
Surg. 92: 411, 1993.
60. Ji, Y., Li, T., Shamburger, S., et al. Microsurgical anterolateral
thigh fasciocutaneous flap for facial contour correction in
patients with hemifacial microsomia. Microsurgery 22: 34,
2002.
61. Wei, F. C., Jain, V., Celik, N., et al. Have we found an ideal
soft-tissue flap? An experience with 672 anterolateral thigh
flaps. Plast. Reconstr. Surg. 109: 2219, 2002.
62. Chen, H. C., and Tang, Y. B. Anterolateral thigh flap: An
ideal soft tissue flap. Clin. Plast. Surg. 30: 383, 2003.
63. Kawai, K., Imanishi, N., Nakajima, H., et al. Vascular anatomy
of the anterolateral thigh flap. Plast. Reconstr. Surg. 114: 1108,
2004.
64. Valdatta, L., Tuinder, S., Buoro, M., et al. Lateral circumflex
femoral arterial system and perforators of the anterolateral
thigh flap: An anatomic study. Ann. Plast. Surg. 49: 145, 2002.
65. Kimata, Y., Uchiyama, K., Ebihara, S., et al. Anatomic vari-
ations and technical problems of the anterolateral thigh flap:
A report of 74 cases. Plast. Reconstr. Surg. 102: 1517, 1998.
66. Kimata, Y., Uchiyama, K., Ebihara, S., et al. Anterolateral
thigh flap donor-site complications and morbidity. Plast. Re-
constr. Surg. 106: 584, 2000.
 RECONSTRUCTIVE

New Continuous Negative-Pressure and

Irrigation Treatment for Infected Wounds and
Intractable Ulcers
Kensuke Kiyokawa, M.D.,
Ph.D.
Nagahiro Takahashi, M.D.
Hideaki Rikimaru, M.D.,
Ph.D.
Toshihiko Yamauchi, M.D.,
Ph.D.
Yojiro Inoue, M.D., Ph.D.
Kurume City, Japan
Background: Continuous irrigation and the vacuum-assisted closure system are
effective methods for the treatment of infected wounds and intractable ulcers.
The objective of this study was to simultaneously use both of the above methods
as a new approach for obtaining more satisfactory, accelerated wound healing.
Methods: After debridement of the wound, indwelling irrigation and aspiration
tubes are placed in the wounds that have been sutured closed. With open
wounds, a sponge with the same shape as the wound is placed directly onto the
wound surface, and after the two tubes are inserted in the sponge, the wound
is covered with film dressing to make the wound completely airtight. A bottle
of physiologic saline solution is then attached to the irrigation tube, and a
continuous aspirator (Mera Sacume) is attached to the aspiration tube. The
bottle of physiologic saline solution is placed at the same height as the wound,
and with a pressure gradient between the two of 0, continuous aspiration is
applied.
Results: All nine cases treated as closed air cavity wounds with this method
healed after 2 to 3 weeks. In eight cases of open wound, recurrence of infection
was observed in only one case.
Conclusions: The two treatments of continuous irrigation and negative pres-
sure were observed to have an additive and synergistic effect for earlier wound
healing. Furthermore, the present method can dramatically reduce the number
of dressing changes required, patient pain, psychological stress, and treatment
cost. (Plast. Reconstr. Surg. 120: 1257, 2007.)

F
requent irrigation with physiologic saline
and other solutions is the most important
step in the management of infected wounds.
A continuous irrigation method is extremely effec-
tive, particularly for intractable wound infections
such as osteomyelitis, and is widely used by ortho-
pedic surgeons.1– 4 If the wound is also subjected to
continuous negative pressure, blood flow to the
wound increases and the surface of the wound is
activated, accelerating wound healing. This system
of treatment using a vacuum-assisted closure sys-
tem is already used for wounds and precordial
open wounds following cardiac surgery and has
been reported to be a satisfactory treatment
method.5–11 However, there have been no reports
concerning the use of these two methods simulta-
From the Department of Plastic and Reconstructive Surgery,
Kurume University School of Medicine.
Received for publication November 23, 2005; accepted
March 24, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279332.27374.69
neously and continuously for 24 hours. Although
both methods impede patient mobility, we devel-
oped a system that enables simultaneous, continu-
ous treatment using the two methods while provid-
ing the patient with freedom of movement.
Clinically, it is exceptionally effective and has been
used to heal in a comparatively short time wounds
that were considered impossible to heal and
wounds that were thought to require an extremely
long time to heal. This is a report of the clinical
results and the usefulness of this system.
PATIENTS AND METHODS
There are open and closed wounds, but it is
assumed that for both types thorough debride-
ment is conducted and negative-pressure condi-
tions in the wound are maintained to ensure that
the wound is completely sealed and airtight. For
closed wounds, two fairly thick tubes are passed
through holes and located inside the wound, and
then the edges of the wound are sutured, avoiding
tension, to make it airtight (Fig. 1, left). For open
wounds, a piece of sponge is trimmed to match the

www.PRSJournal.com 1257
 Plastic and Reconstructive Surgery • October 2007

Fig. 1. (Above) Schematic representation of continuous negative-pressure and irrigation wound treatment. (Below, left) Closed
wound. (Below, right) Open wound. Polyurethane film over the sponge makes the wound completely airtight.

shape of the wound and applied closely to the wound

surface. A comparatively hard, rough sponge is used.
Some cuts in the sponge are made, and the two tubes
(one set) are placed through the holes and placed
inside the sponge. Then, the wound is covered with
polyethylene film to make the inside of the wound
completely airtight (Fig. 1, right). With both open
and closed wounds, if the wound is particularly wide,
the use of four tubes (two sets) may be required.
After these procedures, one tube is con-
nected to a bottle of physiologic saline solution,
and the other is connected to a continuous as-
pirator [Mera Sacume MS-008; Izumi Kokako-
gyo Co., Ltd. (hereafter referred to as Mera)].
The bottle of physiologic saline solution should
be placed at the same height as the wound to
maintain a pressure gradient between the bottle
and the wound of 0. Then, continuous aspira-
tion through the other tube is started. This main-
tains a fixed state of negative pressure at all times,
which ensures that the physiologic saline solution
continuously irrigates the wound (Fig. 2). One thou-
sand to 7000 ml/day of irrigation solution should be
used, depending on the degree of wound contam- Fig. 2. Actual application of continuous negative-pressure and
ination. Installing the entire system on a drip stand irrigation wound treatment in the supine position. The wound (A)
with a trolley base enables the patient to move and bottle of physiologic saline solution (B) for irrigation are po-
around freely (Fig. 3). The Mera can recharge in sitioned at the same height to maintain a pressure gradient of 0,
approximately 1 hour. However, during the re- and a continuous aspirator (C) is connected.

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Volume 120, Number 5 • Treatment of Intractable Ulcers
Fig. 3. Actual application of continuous negative-pressure
and irrigation wound treatment in the standing position. The
wound (A) and bottle of irrigation solution (B) are maintained
at the same height and installed with the continuous aspirator
(C) on a drip stand (D) with a trolley base enabling the patient
to move freely.
Fig. 4. Actual application of continuous negative-pressure and
irrigation wound treatment in the sitting position. When sitting
from a standing position, a large difference occurring in the
heights of the wound (A) and bottle of irrigation solution (B) can
create positive pressure, preventing negative pressure from be-
gin maintained in the wound. The bottle (B) must be lowered to
the same height as the wound (A) as soon as possible (arrows).
charge, the height of the bottle of physiologic saline
solution and the wound must always remain the
same, and a pressure gradient of 0 must be main-
tained. The bottle can become higher, resulting in
the physiologic saline solution subjecting the wound
to positive pressure, particularly when a patient
moves from a standing position to a sitting or supine
position, so sufficient care should be taken to ensure
that a condition of negative pressure is maintained
in the wound (Fig. 4).
With a closed wound, this method of treatment
is continued for 3 to 7 days until the irrigation so-
lution stops flowing even when aspiration is applied.
After that, aspiration is applied by means of both
tubes for 1 to 2 weeks to maintain negative pressure
and to obtain complete adhesion and healing. With
an open wound, after treatment with this method for
2 to 3 weeks, when granulation tissue condition has
improved, a skin or muscle flap graft is performed if
required to heal the wound.
RESULTS
This method was used for nine closed wound
cases (six cases of epidural abscess and two cases
of cranial subcutaneous abscess following brain
surgery, and one case of infection following frac-
ture of the mandible) and eight open wound ca-
ses(six cases of mediastinitis, one case of pressure
ulcer on sacrum, and one case of abdominal wall
cicatricial hernia following cardiac surgery), for a
total of 17 cases. The age of the patients was be-
tween 22 and 71 years (mean, 47.6 years), with 12
men and five women. In the nine closed wound
cases treated with this method, all the wounds
healed and there was no recurrence of infection.
In the eight open wound cases, recurrence of in-
fection was observed in one case only, with the
remaining seven cases healing. Among the six
cases of mediastinitis following cardiovascular sur-
gery, four cases (including two cases of artificial
blood vessel exposure), this method was applied
for 2 to 3 weeks after debridement. As a result,
granulation of the wound surface improved dra-
matically and the infection was almost eliminated.
After this, the wound was healed by filling it with
a pectoralis major muscle flap and mesh split-
thickness skin graft. In one case of mediastinitis
only, this method was applied for 4 weeks and the
wound was later healed with conservative treat-
ment. In one remaining case of mediastinitis, by
strong request from the cardiac surgeon, this
method was applied for just 1 week before surgery
was performed to fill the wound. Because of this,
there was partial recurrence of infection, but this
was healed with additional debridement and a
1259
 Plastic and Reconstructive Surgery • October 2007

mesh split-thickness skin graft. For the one case of
pressure ulcer on the sacrum, this method was
applied for 3 weeks followed by a mesh split-thick-
ness skin graft and the wound healed, whereas in
the one case of postoperative infection after cic-
atricial abdominal wall hernia surgery the wound
was healed with conservative treatment. It is cur-
rently between 2 months and 1 year 10 months
since the cases underwent surgery, and no recur-
rence of infection has been observed in any of the
cases (Table 1). The following are some represen-
tative cases.
CASE REPORTS
Case 1: Subdural and Cerebral Abscess
A 64-year-old man was admitted to this hospital’s emergency
center following subarachnoidal bleeding after trauma. After
emergency craniotomy to eliminate hematoma, the patient suf-
fered cerebral infarction and developed subdural and cerebral
abscesses, which is when he was introduced to our department
(Fig. 5, left). When the wound was opened, necrosis and infec-
tion were observed over a large area of the dura mater and
brain, debridement was performed as far as possible, and this
method of treatment was applied. Because the infection was
over an extensive area, approximately 7000 ml of physiologic
saline solution was used for irrigation during the first 3 days,
with the volume after that being gradually reduced. On a com-
puted tomographic scan 3 weeks after surgery, virtually no
findings of infection were observed, and the wound healed
without problems. The patient was able to be transferred from
the emergency center after removal of the tubes (Fig. 5, right).
Case 2: Epidural and Subdural Abscess
The patient in case 2 was a 53-year-old man in whom, ap-
proximately 2 weeks after extirpation of a brain abscess at
another hospital, pus was observed emanating from the wound.
Several operations were performed, but no trend toward im-
provement was observed, at which point the patient was intro-
duced to our department. At the first examination, pus ema-
nating from the wound and exposed bone were observed (Fig.
6, above, left). First, infected bone fragments were extirpated
together with the tissue along the line of the incision from the
previous operation, and a large quantity of pus and unhealthy

Table 1. Details of the Cases Treated with the New Method

No. of Recurrence
Wound Type Case Details Cases Additional Treatment of Infection
Closed Epidural abscess 6 None 0
Cranial subcutaneous abscess 2 None 0
Infection following fracture of the 1 None 0
mandible
Open Mediastinitis 6 Five muscle flap grafts (two cases 1
of artificial blood vessel exposure)
One none 0
Pressure sore on sacrum 1 Reticular split-thickness skin graft 0
Abdominal wall cicatricial hernia 1 None 0

Fig. 5. The patient in case 1, a 64-year-old man with subdural and cerebral abscess. (Left) Computed
tomographic findings at the time of crisis. Findings of inflammation and abscess over a wide area can be
observed. (Right) Computed tomographic findings after 3 weeks of treatment with this method. The in-
flammation and abscess have healed.

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Volume 120, Number 5 • Treatment of Intractable Ulcers

Fig. 6. The patient in case 2, a 53-year-old man with epidural and subdural abscess. (Above, left) Findings in
the right temporal area at the initial examination. Discharge of pus and exposed cranium can be observed.
(Above, right) Large amounts of pus and unhealthy granulation tissue observed under, above, and around
artificial dura mater when the wound was opened. (Center, left) Irrigation and aspiration tubes are placed in
the wound. (Center, right) Postoperative findings. The wound is closed with a bipedicled scalp skin flap from
the occipital region. (Below) Findings 3 weeks after surgery. The wound is completely healed and the patient
has been transferred from the emergency room.

1261
 Plastic and Reconstructive Surgery • October 2007
granulation tissue seen on the artificial dura mater was re-
moved. The artificial dura mater was excised, as it was in a
condition that could have caused infection. Pus and unhealthy
granulation tissue were also observed under the artificial dura
mater (Fig. 6, above, right). Debridement was performed (in-
cluding the brain surface), an irrigation tube and aspirator tube
were located in the wound (Fig. 6, center, left), and a bipedicled
scalp skin flap was created and moved to close the wound; then,
this treatment method was applied (Fig. 6, center, right). At first,
the wound was irrigated with approximately 3000 ml/day of
physiologic saline solution. After 1 week of treatment, when it
was confirmed that there was no outflow of irrigation solution,
both tubes were used to create negative pressure. After approx-
imately 2 weeks of maintaining the wound in a state of negative
pressure by aspiration, the tubes were removed. The wound had
healed 3 weeks after the procedure, and the patient was dis-
charged from the hospital in the fourth week (Fig. 6, below). No
recurrence of infection has been observed in the last 1 year 6
months.
Case 3: Mediastinitis after Cardiac Surgery
The patient in case 3 was a 67-year-old woman in whom, after
diagnosis of myocardial infarction, a heart surgeon at this hos-
pital performed a bypass operation. Two weeks after the oper-
ation, dehiscence of the central sutures along the sternum was
observed with emanation of pus, severe mediastinitis was diag-
nosed, and the patient was introduced to this department. First,
debridement of the sternum, costal cartilage, and surrounding
infected tissue, including unhealthy granulation tissue, was con-
ducted before proceeding with this treatment method. There
was an artificial object providing support for the blood vessel
that was bypassed and, because this could have been a cause of
infection, also debrided (Fig. 7, above, left and center). The pa-
tient also suffered from renal failure for which dialysis was
performed, and her general physical condition deteriorated.
Irrigation with approximately 5000 ml/day of physiologic saline
solution was conducted, and the sponge was changed every 3 to
4 days. After approximately 1 week, there was attached necrotic
tissue (Fig. 7, above, right); however, after additional debride-
ment and 3 weeks of treatment, necrotic tissue disappeared and
healthy granulation tissue regeneration was observed. As a re-
sult, muscle flaps were then moved onto the wound (Fig. 7,
below, left). The operation involved a bilateral pectoralis major
muscle flap procedure to fill the wound, after which split-thick-
ness skin grafts were used to cover the muscle (Fig. 7, below,
center). The postoperative course was satisfactory, the muscle
flap took completely, and the wound healed despite the bad
conditions of serious infection and general physical deteriora-
tion. No recurrence of infection was observed in the 3 months
after treatment, and the patient is currently undergoing reha-
bilitation. (Fig. 7, below, right).
DISCUSSION
Rather than just increasing blood flow to ac-
tivate the wound surface, applying continuous neg-
ative pressure to the wound surface also shrinks the
entire wound. With this method, the negative pres-
sure also enables ejection of accumulated pus inside
the wound.10 The vacuum-assisted closure system has
already been used widely to treat intractable ulcers
and infected wounds, and satisfactory treatment re-
sults have been reported.5– 8,11–13 We also used this
vacuum-assisted closure system (manufactured by
Kinetic Concepts, Inc., San Antonio, Tex.) for four
1262
cases of infected wound (two cases of pressure ulcer,
one case of mediastinitis, one case of open fracture
of the lower leg). A problem at the time was that,
after 1 to 2 days, the sponge placed on the wound
became extremely contaminated, making control of
infection impossible.
Frequent washing away of pus (necrotic tissue
and emanating fluids) from the wound with liq-
uids such as physiologic saline solution cleans the
wound and decreases the number of bacteria. For
this reason, it is the most important step taken for
infected wounds. Ichioka et al.14 reported quan-
tifying the number of bacterial colonies before
irrigation and then 6, 12, and 24 hours after irri-
gation to evaluate the antibacterial effect. Accord-
ing to the report, the results suggested a 45 to 71
percent washout effect from shower irrigation
conducted 6 hours after the initial irrigation, but
the level of bacteria after 12 hours was nearly the
same as that before irrigation.12 This suggests that
increasing the frequency of irrigations would pro-
vide more effective cleaning, and that if continu-
ous 24-hour irrigation were possible, it would be
still more effective. In the field of orthopedic sur-
gery, a continuous irrigation method is already
used to treat osteomyelitis, an extremely intracta-
ble disease, and it has proved to be effective at
decreasing the number of bacteria.1– 4 We used this
system for eight cases of open wound, changing
the sponge once after 3 to 4 days. Compared with
the four cases treated using the vacuum-assisted
closure system, the degree of contamination of the
sponge was extremely low, clearly indicating that
infection was controlled. It is also probable that
this effectiveness is behind the healing without
recurrence of infection in 16 of our 17 cases. Par-
ticularly for the two cases of mediastinitis, where
healing was achieved despite exposure of artificial
blood vessels, the virtual elimination of bacteria
surrounding the artificial objects is thought to
have made it possible.
Maintaining a wound in a state of continuous
24-hour negative pressure has another important
significance, namely, that it enables healing of
touching and adhering tissue. Negative pressure
on a wound can easily be maintained for 2 to 3
weeks, enabling adhering tissue to completely
heal without the need for troublesome anchor
sutures and/or external pressure. This is a partic-
ularly important point for the treatment of closed
wounds, which easily develop dead spaces. It is
even more important if it is taken into consider-
ation that even among closed wounds, there are
cases of epidural abscess developing after use of
artificial dura mater (cases 1 and 2). The reason
Volume 120, Number 5 • Treatment of Intractable Ulcers

Fig. 7. The patient in case 3, a 67-year-old woman, with mediastinitis after cardiac surgery. (Above, left) Findings directly after
debridement include severe infection and partial sequestration of the sternum. (Above, center) Condition when continuous negative-
pressure and irrigation wound treatment was applied. The entire wound is covered with polyurethane film to make the wound
completely airtight. (Above, right) After 1 week, active infection and unhealthy granulation tissue and necrotic tissue are observed
in places. (Below, left) After 3 weeks, necrotic tissue has disappeared and granulation tissue regeneration is observed. (Below, center)
Condition after wound was filled with bilateral pectoralis major muscle flap and mesh split-thickness skin graft. (Below, right) After
3 months, no recurrence of infection is observed.

is that, in cases like these, after debridement, loss
of dura mater leads to cerebrospinal leaks that
create positive pressure, making healing of the
wound (scalp and remaining dura mater) diffi-
cult. This is why this type of wound is particularly
intractable. With this system, aspiration stronger
than cerebrospinal fluid pressure can be applied
to maintain negative pressure in the wound, thereby
enabling healing to occur. However, there is the
danger that applying continuous aspiration to the
cerebrospinal fluid can reduce intracranial pressure.
To thoroughly overcome this problem, the differ-
ence between the incoming and outgoing volumes
of irrigation solution (in other words, the amount of
aspirated cerebrospinal fluid) can be measured pre-
cisely and then continuous negative pressure can be
adjusted so that the amount is maintained at 150 to
200 ml or less. In the six cases we treated, not one
suffered from a drop in intracranial pressure, and
healing occurred in all cases without any problems.
As can be seen from the above, both contin-
uous irrigation and continuous negative pressure
are useful treatments, but there have been no
reports of them being used together simulta-

1263
 Plastic and Reconstructive Surgery • October 2007
neously. The first advantage of this system is that
using these two treatments simultaneously and
continuously could have both an additive and a
synergistic effect on wound healing. When the
combined treatment is used to treat cases of in-
tractable open wounds, there is a dramatic in-
crease in wound-healing speed. When changing
the sponge placed in the wound every 3 to 4 days,
only proliferation of soft unhealthy granulation
tissue was observed during the initial stage of treat-
ment, and contamination of the sponge decreased
rapidly. As the condition of the wound improved,
healthy granulation tissue invaded the sponge
and, after approximately 2 to 3 weeks, peeling it off
the wound was difficult. At this stage, it was pos-
sible to use a muscle flap with exceptional wound-
healing capabilities to fill the wound, which even-
tually healed it completely. In other words, the
condition of a wound that would have been thought
to require several months to heal was improved rap-
idly with just 2 to 3 weeks of treatment. With a case
of serious mediastinitis, at the strong request of a
heart surgeon, a muscle flap was moved to the
wound at an early stage (1 week after starting this
treatment), but partial recurrence of infection was
seen. Looking at these results, it is thought that
for severe infections of open wounds, a muscle
flap or skin graft should be used when a wound
has improved sufficiently after 2 to 3 weeks of
this treatment.
The second advantage of the system is that it
enables suturing of an infected wound that is then
managed as a closed wound. Because this pro-
motes the proliferation of bacteria and the devel-
opment of dead spaces, it is generally considered
to be contradictory to wound recovery. However,
particularly for cases in which the brain surface is
exposed after brain surgery (case 1) (Fig. 5) and
cases in which bone is exposed (case 2) (Fig. 7),
treating the wound as an open wound is difficult,
and despite the danger of recurrent infection,
many such cases are treated as closed wounds with
drains inserted. With this method, it becomes pos-
sible to conduct this safely. The reason is that using
the system continuously irrigates the closed wound
to strongly decrease the number of bacteria while
continuous negative pressure enables complete heal-
ing of the wound (scalp and remaining dura ma-
ter). The effectiveness of the system is most con-
spicuous in case 1, the first case it was used for. In
this case, in addition to an epidural abscess de-
veloping after brain surgery, there was also the
complication of cerebral infarction, with cerebral
necrosis and infection occurring in the area of
infarction. As a result, debridement was conduced
1264
over a wide area, including sequestra, artificial
dura mater, and brain tissue, but it was consid-
ered that rather than the wound healing, it was
highly likely that the patient would die. Because
the patient’s general physical condition was
poor, instead of invasive surgery requiring a
long time, such as moving a free flap, just four
tubes (two sets) were located in the wound and
this method was applied. As a result, the wound
healed completely in just 3 weeks and the pa-
tient was able to be transferred to another hos-
pital. With the experience gained from this case,
the system was used to treat numerous other
cases of wound infection, further confirming
that it is extremely effective.
The third advantage of this system is that the
number of dressing changes is reduced dramati-
cally. In addition to reducing patient pain, this
also greatly reduces the labor of those providing
the treatment and the amount of material re-
quired for treatment, making it an extremely ef-
fective method. Furthermore, the patient can move
around freely, which greatly reduces patient stress.
The view is that, while promoting the patient’s psy-
chological recovery, this also helps to boost the pa-
tient’s physical strength and immunity, to further
promote healing of the wound. It is thought that in
the future the use of this method will be possible in
the home.
Although the patient can move around freely,
the danger with this system is positive pressure
occurring in the wound. Particularly when the
patient sits down or adopts a supine position from
a standing position, the bottle of physiologic saline
solution becomes higher than the wound, thereby
exerting strong positive pressure in the wound. In
addition to causing outside leakage of the physi-
ologic saline solution, positive pressure once again
separates tissue involved in wound healing under
negative pressure. Consequently, the wound and
the solution bottle must always be kept at the same
height so that the pressure gradient between the
two remains at 0. This procedure is currently per-
formed manually, but a device that automatically
detects pressure gradient changes and makes ad-
justments to maintain a value of 0 is under devel-
opment. At present, a Mera Sacume aspirator is
used to create negative pressure, but the develop-
ment of a device that will enable monitoring of
negative pressure in a wound and adjustment as
required is scheduled.
CONCLUSIONS
In this article, we report a new method for
treating infected wounds and intractable ulcers
Volume 120, Number 5 • Treatment of Intractable Ulcers

with a continuous negative-pressure and irrigation
system. In addition to being efficient and effective,
this treatment method reduces patient pain and
psychological stress and is also economical, mak-
ing it an extremely useful method.
Kensuke Kiyokawa, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Kurume University School of Medicine
67 Asahi-Machi, Kurume City
Fukuoka Prefecture, 830-0011, Japan
prsmf@med.kurume-u.ac.jp
DISCLOSURE
There are no commercial associations that might pose
or create a conflict of interest with information presented
in this article.
REFERENCES
1. Clawson, D. K., Davis, F. J., and Hansen, S. T. Treatment of
chronic osteomyelitis with emphasis on closed suction irri-
gation technic. Clin. Orthop. 96: 88, 1973.
2. Goldman, M., et al. A new approach to chronic osteomyelitis.
Am. J. Orthop. 2: 63, 1960.
3. Compere, E. L., Metzger, W. I., and Mitra, R. N. The treat-
ment of pyogenic bone and joint infections by closed irri-
gation (circulation) with a non-toxic detergent and one or
more antibiotics. J. Bone Joint Surg. (Am.) 49: 614, 1967.
4. Compere, E. L. Treatment of osteomyelitis and infected
wounds by closed irrigation with a detergent-antibiotic so-
lution. Acta Orthop. Scand. 32: 324, 1962.
5. Argenta, L. C., and Morykwas, M. J. Vacuum-assisted closure:
A new method for wound control and treatment. Clinical
experience. Ann. Plast. Surg. 38: 563, 1997.
6. DeFranzo, A. J., Argenta, L. C., Marks, M. W., et al. The use
of vacuum-assisted closure therapy for the treatment of low-
er-extremity wounds with exposed bone. Plast. Reconstr. Surg.
108: 1184, 2001.
7. Fleischmann, W., Becker, U., Bischoff, M., et al. Vacuum
sealing: Indication, technique, and result. Eur. J. Orthop. Surg.
Traumatol. 5: 37, 1995.
8. Harlan, J. W. Treatment of open sternal wounds with the
vacuum-assisted closure system: A safe, reliable method.
Plast. Reconstr. Surg. 109: 710, 2002.
9. Morykwas, M. J., Argenta, L. C., Shelton-Brown, E. I., et al.
Vacuum-assisted closure: A new method for wound control
and treatment. Animal studies and basic foundation. Ann.
Plast. Surg. 38: 553, 1997.
10. Isago, T., Shimoda, K., Morita, N., Takahashi, Y., and
Tomoyasu, Y. Treatment effects of the vacuum-assisted
closure of skin ulcers. Jpn. Pharmacol. Ther. 30: 311, 2002.
11. Ohura, N., Ichioka, S., Shibata, M., Tsuji, S., Sekiya, N., and
Nakatsuka, T. Evaluation of hydrocellular adhesive dressing
for pressure ulcers. Jpn. J. PU. 6: 14, 2004.
12. Hersh, R. E., Jack, J. M., D’Ahman, M. I., Morgan, R. F., and
Drake, D. B. The vacuum-assisted closure device as a bridge
to sternal wound closure. Ann. Plast. Surg. 46: 250, 2001.
13. Tachi, M., Hirabayashi, S., Yonehara, Y., Uchida, G., Toh-
yama, T., and Ishii, H. Topical negative pressure using a
drainage pouch without foam dressing for the treatment of
undermined pressure ulcers. Ann. Plast. Surg. 53: 338, 2004.
14. Ichioka, S., Ohura, N., Nakatsuka, T., and Harii, K. A con-
venient local shower system for wound irrigation. Jpn. J. PU
3: 32, 2001.

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1265
SPECIAL TOPIC

Mechanisms Governing the Effects of

Vacuum-Assisted Closure in Cardiac Surgery
Malin Malmsjö, M.D., Ph.D.
Richard Ingemansson, M.D.,
Ph.D.
Johan Sjögren, M.D., Ph.D.
Lund, Sweden
Summary: Vacuum-assisted closure has been adopted as the first-line treatment
for poststernotomy mediastinitis as a result of the excellent clinical outcome
achieved with its use. Scientific evidence regarding the mechanisms by which
vacuum-assisted closure promotes wound healing has started to emerge, al-
though knowledge regarding the effects on heart and lung function is still
limited. The organs in the mediastinum are hemodynamically crucial, and in
patients with poststernotomy mediastinitis, vulnerable bypass grafts and reduced
cardiac function must be taken into consideration during vacuum-assisted clo-
sure therapy. This article provides an overview of the effects of vacuum-assisted
closure on heart and lung function and summarizes the current knowledge on
the mechanisms by which vacuum-assisted closure therapy promotes wound
healing. (Plast. Reconstr. Surg. 120: 1266, 2007.)

C
ardiac surgery is complicated in 1 to 5
percent of all procedures by poststerno-
tomy mediastinitis,1 and is a potentially life-
threatening complication.2 The reported early
mortality rate in poststernotomy mediastinitis
following coronary bypass surgery grafting is be-
tween 8 and 25 percent.3,4 Established treatment
of poststernotomy mediastinitis includes de-
bridement with frequent postoperative irriga-
tion, change of wound dressings, and direct sec-
ondary closure or secondary closure by use of
vascularized muscle flaps. In 1999, Obdeijn and
colleagues described a new mode of treatment
for poststernotomy mediastinitis using a vacuum-
assisted closure technique5 based on the princi-
ple of applying subatmospheric pressure by con-
trolled suction through a porous dressing. This
technique, also known as vacuum therapy, vac-
uum sealing, or topical negative pressure ther-
apy, has emerged as a simple and effective form
of treatment for a wide spectrum of wounds and
is at present the therapy of choice for treatment
of poststernotomy mediastinitis.6 It was recently
shown that patients who are treated with vacuum-
assisted closure have a similar long-term survival
as patients without mediastinitis after coronary
artery bypass graft surgery.7 Despite the exten-
From the Departments of Medicine and Cardiothoracic Sur-
gery, Lund University Hospital.
Received for publication February 17, 2006; accepted April
25, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279326.84535.2d
sive clinical use and excellent outcome of vac-
uum-assisted closure therapy for the treatment
of mediastinitis, the fundamental scientific is-
sues regarding the effects on heart and lung
function are, to a large extent, unknown. The
organs in the mediastinum are hemodynami-
cally crucial and, unlike vacuum-assisted clo-
sure therapy of peripheral wounds, vulnerable
bypass grafts and reduced cardiac function
must be taken into consideration when treat-
ing mediastinitis. Nearly all the recommenda-
tions made for the vacuum-assisted closure tech-
nique are based on expert opinions rather than
scientific evidence. This article provides an over-
view of the effects of vacuum-assisted closure on
heart and lung function and summarizes the cur-
rent knowledge on the mechanisms of action.
VACUUM-ASSISTED CLOSURE
TECHNIQUE IN STERNOTOMY
WOUNDS
The vacuum-assisted closure technique was de-
scribed for the first time by Argenta and Morykwas
in 1997 and entails applying a subatmospheric
pressure to a wound in a controlled manner.8 Sev-
eral technical aspects must be considered before
applying high negative pressure to an open ster-
notomy wound. An important issue is how the
foam interacts with the underlying vital structures.
In a study of 40 patients with vacuum-assisted clo-
sure–treated deep sternal wound infections at our
department, the surgical technique and a man-
agement protocol for vacuum-assisted closure ap-
plication were described.9 Paraffin gauze dressing

1266 www.PRSJournal.com
Volume 120, Number 5 • Vacuum-Assisted Closure

is placed at the bottom of the wound to protect the

right ventricle, lung tissue, and bypass grafts from
the sternal edges. Sterile polyurethane foam dress-
ing is placed between the sternal edges, but not
below the level of the sternum, so that hemody-
namic and respiratory function are not affected. A
second layer of foam is placed subcutaneously and
secured with a running suture to the surrounding
skin. This facilitates the application of the adhe-
sive drape and reduces the risk of accidental move-
ment of the device. Drainage tubes are inserted
into the foam. The wound is then sealed with a
transparent adhesive drape. The drainage tubes
are connected to a purpose-built vacuum pump and
a canister for collection of effluents. Initially, a low
pressure (e.g., ⫺50 mmHg) is applied to allow
adjustment of the foam as the air is evacuated. If
the wound geometry and foam contraction are
considered satisfactory, a pressure of ⫺125 mmHg is
applied. Air leakage is known to dry out the wound
and can be prevented by additional draping. It is
generally recommended that a stabilizing sternum
harness be used during the entire period of treat-
ment. Most of the patients can be extubated and
mobilized immediately after vacuum-assisted clo-
sure application. The choice of antibiotics is made
on the basis of tissue cultures. Revisions and
dressing changes should be performed at least
three times per week under aseptic conditions
and general anesthesia. The sternal wound can
be closed and rewired when the C-reactive pro- Fig. 1. (Above) Illustration of a cross-section of the thoracic cav-
tein level has declined to 30 to 70 mg/liter and ity with an open sternotomy wound before the negative pressure
when visual inspection shows a well-vascularized is applied. A polyurethane foam dressing is placed between the
wound covered with granulation tissue.10 In cases when sternal edges and noncollapsible drainage tubes are inserted
confounding factors affect the C-reactive protein into the foam. The open wound is sealed with transparent adhe-
levels, wound cultures can guide closure. The sive drape and drainage tubes are connected to a purpose-built
method is simple and effective and is believed to vacuum source. (Below) Illustration of the effects when the neg-
combine the benefits of closed and open wound ative pressure is applied. Fluid and debris are drained from the
treatment to create an environment that promotes wound (green arrowheads). Vacuum-assisted closure affects local
wound healing (Figs. 1 and 2). blood flow, reduces wound edge edema, and stimulates angio-
genesis and granulation tissue formation (for details, see Fig. 2).
EFFECTS OF VACUUM-ASSISTED The foam is inhabited by granulocytes that may promote bacte-
CLOSURE rial clearance, although this is currently debated. The sternal wound
is stabilized and ventilation is facilitated. The effect of vacuum-as-
Sternal Wound Stabilization
sisted closure on hemodynamics is a matter of controversy.
The previous standard treatment for deep
sternal wound infections involved surgical de-
bridement, drainage, irrigation, and reconstruc-
tion using a pectoral muscle flap or omentum pressure that provides adequate sternum stability
transposition, which is known to lead to an un- has not yet been determined and current treat-
stable sternum. In vacuum-assisted closure ther- ment is based on expert opinion only. At a neg-
apy, the sternal bone is preserved, which enables ative pressure of 125 mmHg, the foam is firm and
a high degree of sternal refixation by rewiring. the sternum is stabilized, which enables early mo-
This provides a stable sternum and complete res- bilization, with no more pain than after a rewired
toration of the thoracic cage. The exact negative sternotomy.9,11 Some patients experience pain,

1267
 Plastic and Reconstructive Surgery • October 2007
Fig. 2. Detailed drawings of a cross-section of the sternal wall.
(Above) Illustration of the wound edge before the vacuum has
been turned on. (Center) Illustration of the immediate effects of
vacuum application. Note how the pressure against the wound
edge compresses the tissue and presumably results in edema
removal. Local blood flow is reduced in immediate proximity to
the foam (blue), whereas at 1 to 2 cm from the wound edge, blood
flow is increased (red). The distance from the wound edge to the
point where the blood flow is increased is shorter in muscular
tissue than in subcutaneous tissue. (Below) Illustration of how the
granulation tissue is formed over the wound edge.
and the pressure has to be reduced.5,11 It has been
speculated that less negative pressure leads to
insufficient sternum stability and thereby pro-
motes shear and stretching between the sternal
edges and the right ventricle, with an increased
risk of right ventricular rupture.12 In contrast, too
great a negative pressure may impair the right
ventricular function or compromise the function
of the coronary artery bypass grafts. The maxi-
mum positive or negative pressure that can be
induced in the thorax by, for example, breathing
or coughing, is approximately ⫾75 mmHg. It is
likely that ⫺75 mmHg is the negative pressure
threshold value that admits sternal wound stabil-
ity, depending on the patient’s size and strength.
1268
A negative pressure of 125 mmHg is the most
commonly used pressure in clinical practice and is
theoretically a safe choice.
The wound stability that is produced by vac-
uum-assisted closure therapy may depend not en-
tirely on the level of negative pressure applied but
also on the efficiency of the vacuum source. In this
respect, a vacuum source that has the capacity to
shift large volumes of air in a short period of time
will produce a reliable and stable pressure level
despite mechanical stress and unstable conditions,
irrespective of the level of negative pressure that
is applied.
Hemodynamic Effects
The effect of subatmospheric pressure on cen-
tral hemodynamics is of major concern in cardiac
surgery, especially because many patients with
poststernotomy mediastinitis have reduced car-
diac function. Theoretically, high negative pres-
sures might impair right ventricular function, re-
sulting in decreased cardiac output. Conquest and
colleagues showed that negative pressures of 50
and 125 mmHg immediately decreased left ven-
tricular volume, stroke volume, cardiac output,
and systolic blood pressure in pigs, using a sono-
metric technique.13 Application of a rectus muscle
flap to the sternal wound before vacuum-assisted
closure therapy significantly reduced the negative
hemodynamic effects. Conversely, in one of our
previous studies, using thermodilution, cardiac
output was found not to be impaired by negative
pressures between 50 and 175 mmHg.14
Both sonometry and thermodilution have
known limitations. We recently quantified cardiac
output and ventricular chamber volumes using
magnetic resonance imaging (unpublished re-
sults), which is known to be one of the most ac-
curate methods for quantifying these measures.15
Vacuum-assisted closure resulted in an immediate
decrease in cardiac output. Interestingly, the ef-
fects were of a much lesser magnitude (approxi-
mately 10 percent decrease in cardiac output)
than in the previous study using sonometry (ap-
proximately 30 percent decrease).6
Careful monitoring of the hemodynamic func-
tion in patients undergoing sternal vacuum-as-
sisted closure therapy has been suggested, espe-
cially when cardiac function is reduced.13 In the
studies conducted so far, only acute hemodynamic
evaluation has been performed, and the effects
might be temporal, with the patient eventually
acclimatizing to the device.13,14 Studies of the
chronic nature of the hemodynamic effects must
Volume 120, Number 5 • Vacuum-Assisted Closure
be performed before recommendations about in-
vasive monitoring can be made. Furthermore, no
comparison has yet been made of the hemody-
namic effects of vacuum-assisted closure between
patients with normal and impaired left ventricular
function.
Right ventricle rupture has been reported
when using vacuum-assisted closure therapy in
poststernotomy mediastinitis.12 The surgical tech-
nique used to minimize the risk of right ventricle
rupture has been described by Gustafsson et al.9
Adherences below the sternal edges must be re-
leased, and three or four layers of paraffin gauze
should be placed at the bottom of the wound to
cover and protect visible parts of the right ventri-
cle from the sternal edges. The paraffin gauze
reduces the formation of adherences between the
sternum and the right ventricle, and the paraffin
content facilitates movement. This procedure en-
ables the force of the vacuum to be distributed
horizontally, thereby acting on the sternum and
not on the underlying vital structures.
Concerns have been raised regarding the po-
tential negative effects of vacuum-assisted closure
on large blood vessels, including coronary bypass
grafts. The vascular effect of subatmospheric
pressure has been investigated by application to
a porcine femoral artery.16 No spontaneous
bleeding, perforation, or dissection was ob-
served. The endothelium-dependent vasodilatory
responses were increased, and no endothelium
dysfunction developed. Furthermore, vasocon-
striction induced by endothelin was enhanced.
These vascular effects may act counterregulatory
to maintain blood flow through vessels that are
exposed to vacuum-assisted closure therapy. The
cause of these changes in blood vessel reactivity is
not known, although pressure against the vessel
wall and shearing forces at the foam/wound in-
terface may contribute.
Respiratory Effects
A major advantage of vacuum-assisted closure
therapy in poststernotomy mediastinitis is the ster-
num-stabilizing effect and the reduced need for
mechanical ventilation. Improved ventilation and
more effective physiotherapy have been reported
with vacuum-assisted closure therapy when com-
pared with conventional open-chest care.17 Vacuum-
assisted closure also improves lung function in
patients with severe poststernotomy mediastinitis
and sternal bone necrosis.18 As a bridging therapy
to reconstructive surgery, it provides adequate
temporary stabilization of the thorax, which en-
hances lung function. The effect of different
subatmospheric pressures on ventilation and ox-
ygenation has been investigated in a porcine ster-
notomy wound model.19 The respiratory function
did not differ at the different pressures applied
(⫺50, ⫺125, and ⫺175 mmHg), although a ten-
dency toward increased airway resistance was
noted at ⫺175 mmHg.
Granulation Tissue Formation
Positive effects of vacuum-assisted closure
therapy on granulation tissue formation were first
reported by Morykwas et al. using a porcine back
wound model, and their findings were confirmed
by Fabian et al. using a rabbit ischemic wound
model.20,21 A pressure of ⫺125 mmHg was used in
these studies. It was later shown that lower (⫺25
mmHg) or higher (⫺500 mmHg) negative pres-
sures were not as effective.22 Also, the presence of
an unregulated air leak in the sealing drape re-
sulted in progression of the wound, secondary to
dehydration and progressive necrosis.22
Subsequent studies on humans confirmed
these positive effects of vacuum-assisted closure on
granulation tissue formation. Skin graft donor
sites reepithelialize faster when treated with sub-
atmospheric pressure.23 Vacuum-assisted closure
therapy induces increased granulation tissue for-
mation and decreased wound volume.24 Moues et
al. have performed one of the largest quantitative
studies on the effects of vacuum-assisted closure
on wound healing in patients.25 Fifty-four patients
requiring open-wound management before surgi-
cal closure were randomized to either vacuum-
assisted closure therapy or conventional moist
gauze therapy. The reduction in wound surface
area was greater in the vacuum-assisted closure–
treated wounds. No scientific quantitative study on
granulation tissue formation has yet been per-
formed on sternotomy wounds.
A detailed study of the effects of negative pres-
sure on granulation tissue formation has been
performed by Chen et al. in wounds created by the
removal of full-thickness skin from the backs of
rabbits’ ears.26 In the vacuum-assisted closure–
treated group, granulation tissue began to form 3
days after the wound was created. The epithelium
on the wound edge began to transmigrate, and
abundant neogenetic vessels were found. The
surface area of the wound was reduced by day 6.
Fibroblasts had proliferated markedly and there
were abundant extracellular matrixes. On the
ninth day, the wound had basically healed.
These effects were not as pronounced in the
control group.
1269
 Plastic and Reconstructive Surgery • October 2007
The mechanism by which granulation tissue
formation is increased by vacuum-assisted closure
therapy is not known, but could be attributable to
the beneficial effects of shearing forces at the foam/
wound interface. Mechanical stress is known to pro-
mote the expression of growth factors (e.g., vas-
cular endothelial growth factor and fibroblast
growth factor-2) and to stimulate granulation tis-
sue formation and angiogenesis.27–29 In a comput-
erized model of vacuum-induced wound deforma-
tion, most elements were stretched 5 to 20 percent
by vacuum-assisted closure,30 which is similar to in
vitro strain levels shown to promote cellular pro-
liferation.
In the wound-healing process, apoptosis is re-
sponsible for the removal of inflammatory cells
and the evolution of granulation tissue formation
into scar tissue.31 The application of vacuum-as-
sisted closure has been shown to alter the expres-
sion of apoptosis-related proteins and genes, in-
cluding Bcl-2, NGF/NGFmRNA, c-myc, and c-jun,
to promote healing.32,33 Matrix metalloproteinases
degrade the proteins of the extracellular matrix
and are involved in all stages of wound repair.
Vacuum-assisted closure therapy was found to de-
crease the expression of metalloproteinase 1, 2,
and 13 in chronic wounds,34 which may reduce the
degradation of collagen and facilitate healing.
Other beneficial effects of vacuum-assisted closure
therapy on granulation tissue formation include
stimulation of blood flow, elevation of wound fluid
pO2 and lactate levels, removal of edema, drainage
of excess wound fluid, and stimulation of the cell-
mediated immune response, as is discussed later.
Microvascular Blood Flow
A common practice in thoracic surgery is uni-
lateral or bilateral harvesting of the internal mam-
mary arteries. Postoperative mediastinitis is more
common when bilateral harvesting has been per-
formed, especially in patients with diabetes and
obesity.35–37 The reason for the high risk of infec-
tion in these groups of patients may be that the soft
tissue is poorly perfused postoperatively. The
blood flow and the subsequent nutrition of the
wound edge may then not be sufficient for heal-
ing. Enhancing blood flow to the soft tissue of the
peristernal wound may be one of the mechanisms
by which vacuum-assisted closure therapy facili-
tates sternal wound healing.
Laser Doppler measurements have shown that
the microvascular blood flow to wounds on the
backs of pigs increased four times above the base-
line value when a negative pressure of 125 mmHg
1270
was applied, whereas it was inhibited at ⫺400
mmHg and greater negative pressures.20 In a re-
cent study, the cutaneous blood flow in healthy
intact forearm skin was found to increase by ap-
plication of negative pressure.38 The microvascu-
lar blood flow has been examined in detail using
laser Doppler techniques in a porcine sternotomy
wound model, using different negative pressures
(⫺50 to ⫺200 mmHg).39 Subcutaneous and mus-
cular tissues were studied separately and the blood
flow was measured at different distances from the
sternal wound edge. The distance from the wound
edge to the point where the blood flow increased
was shorter in muscular tissue than in subcutane-
ous tissue.39 It was speculated that the pressure is
transduced differently in soft and dense tissue,
and the optimal level of negative pressure for vac-
uum-assisted closure therapy may depend on the
wound tissue composition.
The changes in the peristernal wound blood
flow resulting from vacuum-assisted closure ther-
apy was found to vary with the distance from the
wound edge.39 A few centimeters away from the
wound edge, the blood flow increased when sub-
atmospheric pressure was applied. Conversely, in
the most superficial layers of the wound wall, the
negative-pressure blood perfusion was reduced.39
Pressure against the wound wall may be beneficial
during surgical procedures because it has been
shown to tamponade superficial bleeding40 and
may reduce wound edge edema. Also, factors re-
leased in response to hypoperfusion are strong
stimulators of angiogenesis and granulation tissue
formation, which may be one of the mechanisms
governing the positive effects of vacuum-assisted
closure. In contrast, long-standing hypoperfusion
may cause ischemia. To balance these effects, a
negative pressure that does not cause a large isch-
emic zone but still eliminates interstitial fluid ac-
cumulation and bleeding may be preferable. The
hypoperfused zone is smaller in muscular tissue
than in subcutaneous tissue, which may be attrib-
utable to the easier collapse of soft tissue under
pressure.39,41 The size of the hypoperfused zone
depends on the subatmospheric pressure applied,
and increases with increasing pressure.39,41 In a
porcine sternotomy wound, the maximal net in-
crease in blood flow was observed at ⫺75 and ⫺100
mmHg, and these may be, from this point of view,
suitable negative pressures for vacuum-assisted
closure treatment of sternotomy wounds.39
The possible mechanisms by which subatmo-
spheric pressure alters blood flow has been stud-
ied in detail by Chen et al.26 Wounds were created
by the removal of full-thickness skin on the backs
Volume 120, Number 5 • Vacuum-Assisted Closure
of rabbit ears and the effect of different pressures
(⫺40 to ⫺150 mmHg) on wound microcircula-
tion was studied. Vacuum-assisted closure induced
an immediate increase in capillary blood flow
velocity at negative pressures greater than 75 mmHg,
and at ⫺112.5 and ⫺150 mmHg the capillary diam-
eter increased.26 Negative pressure has also been
found to stimulate endothelial cell proliferation and
angiogenesis.26 Vacuum-assisted closure induces me-
chanical stress, and a pressure gradient between the
wound and the surrounding tissue may force blood
to the wound, increase blood flow velocity, dilate
capillaries and open up the capillary beds.29,42 Me-
chanical forces and increased blood flow are known
to affect the cytoskeleton in vascular cells and stim-
ulate endothelial proliferation, capillary budding,
and angiogenesis.43
Oxygenation and Nutrition
To evaluate the metabolic effects of vacuum-
assisted closure therapy on a sternotomy wound,
Wackenfors et al. analyzed pH, pO2, pCO2, HCO3⫺,
and lactate were analyzed in the wound fluid
during 60 minutes of vacuum-assisted closure
therapy.39 Wound fluid pO2 was seen to increase
and pCO2 decreased, which may be the result of
the changes in wound edge microvascular blood
flow.39 Wound fluid lactate also increased during
vacuum-assisted closure therapy. Lactate is pro-
duced through oxygen-dependent glycolysis by
neutrophils, macrophages, fibroblasts, and other
proliferating cells that are present in the granu-
lation tissue of wounds.44,45 Elevated lactate levels
are often accompanied by increased oxygen ten-
sion and are known to promote wound healing.46
Lactate stimulates wound granulation tissue for-
mation by inducing collagen transcription and
vascular endothelial growth factor production,
and oxygen is an essential cofactor in collagen
synthesis and promotes cell proliferation and
angiogenesis.45,47,48 Oxygen is also important in
the defense against infections.49
Wound Edema
The inflammatory response to wounding is
accompanied by soft-tissue edema and decreased
peripheral perfusion because of increased inter-
stitial pressure. As a result, nutrition and oxygen-
ation of the wound edge are compromised, which
decreases the resistance to secondary infections
and delays healing. To ensure proper healing, it is
important to manage wound edema. Vacuum-as-
sisted closure transmits a pressure that reduces
blood perfusion in the most superficial layers of
the wound edge tissue.39,41 The pressure is strong
enough to tamponade superficial bleeding during
the surgical procedure.40 In a quantitative, exper-
imental study, it was shown that the permeability
of blood vessels and wound edema were decreased
markedly after vacuum-assisted closure treatment.50
Wounding destroys the integrity of the capillary
basement membrane and the endothelial space
becomes enlarged. After vacuum-assisted closure
treatment, the integrity of the basement mem-
brane was restored and the endothelial spaces
were narrowed,26 which probably reduced the per-
meability of blood vessels and the degree of wound
edema.
Bacterial Clearance
Extensive debridement and open-wound man-
agement have been widely advocated to prevent
infection. Currently, vacuum-assisted closure is
used for the treatment of mediastinitis until sec-
ondary wound closure is possible, although the
effect of vacuum-assisted closure on bacterial load
is the subject of debate. A reduction in the number
of bacterial species and colonies during vacuum-
assisted closure therapy has been found in small
clinical and animal studies.20,51–53 In contrast, in a
relatively large randomized prospective trial, the
positive effects of vacuum-assisted closure on
wound healing could not be explained by changes
in the bacterial load.25 Similar results have been
presented by Weed et al., suggesting that negative
pressure does not affect bacterial clearance.54
In the study by Moues et al.,25 the amount of
nonfermentative, gram-negative bacilli decreased,
whereas the amount of Staphylococcus aureus in-
creased in vacuum-assisted closure–treated wounds.
It was speculated that the shift in bacterial spe-
cies may be attributable to the creation of an
external hypoxic environment. A case of an an-
aerobic infection leading to sepsis in a vacuum-
assisted closure–treated, immune-deficient pa-
tient has been reported.55 The infection was
reversed by discontinuing vacuum-assisted clo-
sure therapy. Furthermore, a case of staphylo-
coccal toxic syndrome has been associated with
vacuum-assisted closure therapy.56 Close surveil-
lance of bacterial flora while using vacuum-
assisted closure therapy has been recom-
mended, particularly in susceptible patients.
Most of the patients with postoperative me-
diastinitis are infected with coagulase-negative
staphylococci,10 which is a growing problem among
postoperative cardiac patients.57,58 An advantage
of vacuum-assisted closure, being a closed and
1271
 Plastic and Reconstructive Surgery • October 2007
controlled system, is the decreased risk of con-
tamination of the environment.10
Inflammatory Response
The most common signs of postoperative me-
diastinitis are chest pain and unstable sternum,
with purulent discharge, fever, leukocytosis, and
high plasma C-reactive protein levels,10 all of
which indicate activation of the immune system.
The immune system plays a key role in resolving
infections and promoting granulation tissue for-
mation and wound healing.
The immune cell populations that infiltrate
the polyurethane foam, and their potential role in
resolving the infection and promoting granula-
tion tissue formation, have been studied by Gout-
tefangeas et al.59 These authors found that the
foam was inhabited by immune cells, mainly gran-
ulocytes, but also macrophages and T lympho-
cytes. Neutrophilic granulocytes form the first line
of defense against wound infection, whereas mac-
rophages and T lymphocytes play a critical role for
granulation tissue formation and wound healing.
They suggested that the vacuum-assisted closure
polyurethane foam could be redesigned to im-
prove T-cell infiltration and activation by coating
the foam with co-stimulatory substances and
T-cell–attracting chemokines.59 It has previously
been shown that T-cell infiltration of sponge ma-
trices can be manipulated by prior injection of
antigens or various cytokines.60 – 64
C-reactive protein is secreted by the liver in
response to inflammatory cytokines.65 Levels of
C-reactive protein increase rapidly in response to
trauma, inflammation, and infection, and de-
crease just as rapidly with resolution of the con-
dition. Thus, the measurement of C-reactive
protein is widely used to monitor various inflam-
matory states. Plasma C-reactive protein levels re-
vealed a typical pattern during the process of ster-
nal wound healing.10 Granulation tissue could be
observed in all parts of the sternotomy wound
when the plasma C-reactive protein level had de-
cline to 30 to 70 mg/liter, and it was suggested that
surgical closure could be guided by C-reactive pro-
tein levels. The method was considered safe be-
cause the risk of reinfection was low. After sec-
ondary closure, the C-reactive protein level again
rose and reached a peak within 72 hours before
declining to preclosure levels. This elevation was
attributable to the surgical trauma, and was not con-
sidered a sign of reinfection. C-reactive protein levels
may remain high as a result of confounding factors,
such as tissue injuries or concomitant infections. It
1272
was suggested that quantitative sternal tissue cul-
tures could be used to monitor wound infection
and to guide sternal closure in these cases. This
can be debated because others have observed no
significant effect on bacterial load attributable to
vacuum-assisted closure therapy.25,54
Wound Drainage
For many years, surgeons have used negative
pressure suction to drain surgical wounds. Topical
negative pressure uses this concept but in a more
controlled manner. Putrid secretions and toxic
products are cleared by the continuous suction,
preventing fluid retention in the deeper parts of
the wound. Active drainage may remove inhibitory
components (e.g., proteolytic enzymes and met-
alloproteinases), which have been observed at
high levels in chronic wounds and are known to
degrade extracellular matrix and delay wound
healing.66,67 Also, the removal of proinflammatory
cytokines, which have been implicated in immu-
nosuppression in wounds, may have a positive
effect.68,69 Vacuum-assisted closure drainage prob-
ably improves the wound environment, although
no quantitative study has yet been performed to
evaluate this hypothesis.
FUTURE VACUUM-ASSISTED CLOSURE
TREATMENT MODALITIES
Negative-Pressure Level
The optimal negative pressure for vacuum-as-
sisted closure treatment of sternotomy wounds has
not yet been scientifically determined. On the ba-
sis of clinical experience, it has been suggested
that the level of subatmospheric pressure be tai-
lored to the individual wound. Low negative pres-
sures (e.g., 50 to 75 mmHg) are used for chronic
ulcers and split-skin grafts, whereas greater pres-
sures (e.g., ⫺125 mmHg) are used for larger cav-
ities and traumatic wounds.8 Positive effects on
blood flow to the peristernal thoracic wall39 and
biochemical pathways involved in granulation tis-
sue formation32 have been observed at lower neg-
ative pressures (⫺75 to ⫺100 mmHg). Theoretically,
it is likely that ⫺75 or ⫺100 mmHg is sufficient to
stabilize the sternum because the maximum pres-
sure that can be produced in the thoracic cavity by
deep breathing or coughing is approximately 75
mmHg, depending on the patient’s size and
strength. Lowering the pressure to ⫺75 mmHg for
the treatment of sternal wounds has been re-
ported, especially when patients experience dis-
comfort with higher levels of vacuum.5,11 Further
research is required to identify the exact pressure
Volume 120, Number 5 • Vacuum-Assisted Closure
that both stimulates sternal wound healing and
stabilizes the sternum for safe mobilization, while
not compromising the function of the right ven-
tricle or the coronary artery bypass grafts.
Soft tissue (e.g., subcutaneous fat) collapses
easily, and only small negative pressures are needed
to stabilize the wound and to stimulate blood
flow.8,41 In more dense tissue, such as the peri-
sternal thoracic wall, higher pressures are re-
quired for sternal wound stabilization and the
stimulation of blood flow.8,39 Currently, vacuum-
assisted closure therapy is guided by the pressure
in the drainage tubes. Because the biological ef-
fect exerted by a vacuum-assisted closure pressure
depends on the tissue composition, it may be more
accurate if the vacuum source is guided by a pres-
sure transducer in tissue (e.g., 1 to 2 cm from the
edge). This statement is substantiated by the find-
ings by Jones et al. that interposition of dressings
at the wound/foam interface significantly affects
the pressure transmission.70
Intermittent Negative Pressure
Intermittent pressures in vacuum-assisted clo-
sure have been reported to improve healing rates
and blood flow in animal studies.20,41 Intermittent
vacuum-assisted closure therapy has also proven to
be successful in clinical settings.8 Changing the
external forces may be a more efficient way to
stimulate angiogenesis and granulation tissue
formation.71 Because the organs in the mediasti-
num are hemodynamically crucial and stabiliza-
tion of the sternum is one of the major advantages
of vacuum-assisted closure therapy in poststerno-
tomy mediastinitis, it is unlikely that an intermit-
tent regimen would be suitable for the treatment
of sternal wounds.
Therapy Monitoring by Analysis of
Wound Effluents
Monitoring and wound management can
be guided by serial plasma C-reactive protein
measurements.10 C-reactive protein is secreted by
the liver in response to inflammatory cytokines,
including interleukin-1, interleukin-6, and tumor
necrosis factor-␣.65 These cytokines are released
into the wound with different kinetics and de-
crease to normal levels once the healing process
has been established.72,73 It would be of interest to
identify the different cytokines produced in ster-
notomy wounds during vacuum-assisted closure
therapy and to characterize the course of events.
Analyzing these cytokines in the wound effluents
collected in the vacuum-assisted closure canister
may offer a more precise way of monitoring the
inflammatory status and may guide the secondary
closure of sternotomy wounds.
CONCLUSIONS
Vacuum-assisted closure has been adopted as
the standard treatment for deep sternal wound
infections as a result of the excellent clinical out-
come with which it is associated. Scientific evi-
dence regarding the mechanisms by which vacuum-
assisted closure promotes wound healing has started
to emerge, although knowledge regarding its effects
on heart and lung function is still limited. Vacuum-
assisted closure therapy was initially developed for
peripheral wounds. The organs in the mediastinum
are hemodynamically crucial and, in patients with
poststernotomy mediastinitis, vulnerable bypass
grafts and reduced cardiac function must be taken
into consideration during vacuum-assisted closure
therapy. By using current knowledge of the mech-
anisms by which vacuum-assisted closure acts, there
are, in our opinion, considerable opportunities to
develop and optimize the technique in cardiac
surgery.
Malin Malmsjö, M.D., Ph.D.
Vascular Research, BMC A13
Lund University Hospital
SE-221 84 Lund, Sweden
malin.malmsjo@med.lu.se
DISCLOSURE
None of the authors has a financial interest in any
of the products, devices, or drugs mentioned in this
article.
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70. Jones, S. M., Banwell, P. E., and Shakespeare, P. G. Interface
dressings influence the delivery of topical negative-pressure
therapy. Plast. Reconstr. Surg. 116: 1023, 2005.
71. Ilizarov, G. A. The tension-stress effect on the genesis and
growth of tissues: Part I. The influence of stability of fixation
and soft-tissue preservation. Clin. Orthop. Relat. Res. 238: 249,
1989.
72. Ford, H. R., Hoffman, R. A., Wing, E. J., et al. Characteriza-
tion of wound cytokines in the sponge matrix model. Arch.
Surg. 124: 1422, 1989.
73. Holzheimer, R. G., and Steinmetz, W. Local and systemic
concentrations of pro- and anti-inflammatory cytokines in
human wounds. Eur. J. Med. Res. 5: 347, 2000.
1275
IDEAS AND INNOVATIONS
Does AlloDerm Stretch?
Maurice Y. Nahabedian,
M.D.
Washington, D.C.
T
here are numerous applications for Allo-
Derm (LifeCell Corp., Branchburg, N.J.) in
surgical practice. It has been used exten-
sively for abdominal wall reconstruction,1–7 for
gynecologic and urologic reconstruction,8 –10 and
most recently for breast reconstruction.11,12 Its
utility as a biological tissue substitute is now well
appreciated and acknowledged. In addition to
the clinical studies, there have been experimen-
tal studies validating its safety and efficacy.13,14
However, one of the ongoing debates is focused
on the elastic properties of AlloDerm and whether
or not it will stretch. This case report illustrates
the elastic properties of AlloDerm when used to
repair an abdominal bulge following breast re-
construction with a deep inferior epigastric per-
forator (DIEP) flap.
CASE REPORT
A 54-year-old woman underwent a left mastectomy and had
immediate breast reconstruction with a DIEP flap. A single
dominant perforator was identified along the left medial row of
perforators. The anterior rectus sheath was incised and a my-
otomy was performed. No portion of the anterior rectus sheath
or the rectus abdominis muscle was removed. The laterally
based intercostal innervation to the muscle was left intact. After
harvest of the DIEP flap, the anterior rectus sheath was closed,
incorporating all layers.
Postoperatively, the patient complained of a left lower ab-
dominal bulge that was confirmed on physical examination
(Fig. 1). The cutaneous dimensions of the bulge were approx-
imately 20 ⫻ 10 cm. The bulge was repaired 10 months after the
initial reconstruction. Intraoperative findings included atten-
uation of the anterior rectus sheath. The bulge was delineated
and then plicated with nonabsorbable suture (Fig. 2). After
plication, the anterior rectus sheath was reinforced with a 4 ⫻
16-cm sheet of thick AlloDerm (Fig. 3, above). The AlloDerm was
applied to the surface of the anterior rectus sheath; moderately
stretched, dermal side down; and sutured (Fig. 3, below). The
dimensions of the AlloDerm after application were 17 ⫻ 4.5 cm.
A single drain was inserted.
After the repair, abdominal contour was initially improved;
however, there was a gradual recurrence of the abdominal
bulge (Fig. 4). The dimensions of the bulge were again ap-
From the Department of Plastic Surgery, Georgetown Uni-
versity, and Johns Hopkins University.
Received for publication February 26, 2006; accepted March
21, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279342.48795.9a
1276 www.PRSJournal.com
proximately 20 ⫻ 10 cm. The recurrent bulge was repaired 8
months later. The intraoperative findings were noteworthy.
There was a nonadherent layer of tissue overlying the AlloDerm
(Fig. 5, above). No seroma was identified. The anterior surface
of the AlloDerm was smooth and capsular in texture and the
posterior surface was adherent to the anterior rectus sheath
(Fig. 5, below). The AlloDerm was visibly revascularized (Fig. 6).
The smooth capsular layer on the anterior surface of the
AlloDerm was very adherent and when detached demonstrated
bleeding from the AlloDerm surface (Fig. 7, above). The borders
of the AlloDerm were well defined and measured. The sutures
that were placed at the initial operation were intact. The di-
mensions of the AlloDerm were 7 cm in width and 17 cm in
length. The bulge was repaired by plication of the anterior
rectus sheath and the overlying AlloDerm followed by rein-
forcement of the anterior abdominal wall using a polypropylene
mesh that extended from the pubis to the costal margin and the
anterior axillary line laterally (Fig. 7, below).
DISCUSSION
The impact of AlloDerm in surgical practice
has been significant. It has facilitated our ability to
repair complex defects and deformities with min-
imal morbidity. As an acellular dermal allograft, its
ability to incorporate into host tissue and to re-
vascularize has made it an ideal tissue substitute.15
Comparative studies have demonstrated that the
tensile strength or maximal load to failure of
AlloDerm was superior to synthetic and autolo-
gous tissue.10 However, questions about its elastic
potential remain. AlloDerm has been used exten-
sively to reinforce or support tissues in situations
of native tissue laxity. General, gynecologic, uro-
logic, and plastic surgeons have used AlloDerm for
the repair of complex abdominal hernias and
bladder and vaginal suspension procedures. In-
terestingly, the outcomes have been mixed. When
used to repair complex abdominal hernias, its abil-
ity to support and reinforce the integrity of the
abdominal wall has been achieved over 96 percent
of the time. When used for bladder and vaginal
suspension, support of these structures has been
achieved only 50 percent of the time. A meta-
analysis of seven studies and 107 patients (Table 1)
who underwent repair of complex abdominal wall
hernias using AlloDerm has demonstrated a re-
current bulge in only four patients, or 3.7 percent.
However, the use of AlloDerm to repair anterior
vaginal wall prolapse has been demonstrated to
have a 50 percent failure rate based on objective
Volume 120, Number 5 • Elasticity of AlloDerm

Fig. 1. Preoperative view of a left lower abdominal bulge follow-

ing a DIEP flap breast reconstruction.

Fig. 3. (Above) The 4 ⫻ 16-cm sheet of thick AlloDerm used for

the repair. (Below) The AlloDerm is sutured to the anterior rectus
sheath over the fascial repair. It was placed under moderate ten-
sion and sutured using nonabsorbable suture.

Fig. 2. (Above) Intraoperative view of the lower abdominal

bulge. The area to be plicated is delineated and orientated ver-
tically. (Below) The anterior rectus sheath is plicated using a non- Fig. 4. Postoperative view of a recurrent bulge following repair
absorbable suture in an interrupted fashion. by plication and reinforcement with AlloDerm.

1277
 Plastic and Reconstructive Surgery • October 2007
Fig. 5. (Above) Intraoperative view of the nonadherence of the
superficial tissue overlying the AlloDerm. (Below) The sheet of
AlloDerm is shown in its entirety. The lateral dimension has in-
creased by 43 percent. Note that the sutures are intact.
Fig. 6. A close-up view of the AlloDerm demonstrating revascu-
larization.
1278
Fig. 7. (Above) The thin capsular layer adheres to the surface of
the AlloDerm. (Below) A sheet of synthetic mesh was applied to
the surface of the anterior rectus sheath and secured under ten-
sion using a nonabsorbable suture.
evidence of stage II prolapse.8 On the basis of
these analyses, it appears that AlloDerm is effective
in resisting the expansible properties of the ante-
rior abdominal wall but is less effective in resisting
the pressure of vaginal or bladder prolapse. What
is the explanation for this difference in outcomes?
When evaluating the efficacy of AlloDerm as
a tissue substitute, it is important to appreciate
it basic composition. In its native state, AlloDerm
is composed of collagen, elastin, hyaluronan, pro-
teoglycans, fibronectin, and a vascular framework.16
Review of the company literature confirms that
AlloDerm is capable of stretching up to 50 percent
in its hydrated state16; however, there are essen-
tially no data available on its elastic potential fol-
lowing revascularization. After revascularization,
it is histologically indistinguishable from host tis-
sue. Given that living dermis is elastic and that
AlloDerm is essentially dermal in its tissue char-
acteristics, it can be reasonably assumed that Allo-
Volume 120, Number 5 • Elasticity of AlloDerm
Table 1. Review of the Published Literature Highlighting Seven Clinical and Two Experimental Studies in
Which AlloDerm Was Used to Repair Complex Abnormalities of the Abdominal Wall
Authors Year Subjects
Guy et al.1 2003 Human
Hirsh2 2004 Human
Silverman et al.3 2004 Human
Singh et al.4 2004 Human
Buinewicz and Rosen5 2004 Human
Butler et al.6 2005 Human
Kolker et al.7 2005 Human
Menon et al.13 2003 Rabbits
Silverman14 2004 Swine
Derm-reinforced structures will maintain some de-
gree of elasticity.
The effectiveness of AlloDerm is dependent
on a variety of factors. These include application
as an inlay or onlay graft, application in a stretched
or nonstretched fashion, and application with
the dermal side up or down. These variables
have been experimentally and clinically studied.
Butler et al. have demonstrated that when Allo-
Derm is applied with little or no tension, the
tendency to stretch is increased.6 Butler et al.
have demonstrated that AlloDerm is most effec-
tive when applied as an inlay graft6; however,
Buinewicz and Rosen have demonstrated that it
is equally effective when applied as an onlay
graft.5 In an experimental model, Butler and
Prieto have demonstrated histologic revascular-
ization of AlloDerm that is independent of the
orientation of the basement membrane.17
The amount that AlloDerm should be stretched
before application when in the hydrated state is
uncertain. Review of the manufacturer’s informa-
tion suggests that it can be stretched by 50 percent
in the hydrated state.16 When AlloDerm is used as
an inlay graft and sutured to fascial edges, the
forces applied to the hydrated AlloDerm sheet
may cause additional stretch because it is sutured
under some degree of tension because of the op-
posing vectors of the defect. However, when used
as an onlay graft, the tension or stretch is depen-
dent solely on the suturing technique. Maximal
stretch may not be achieved until the AlloDerm is
revascularized. Buinewicz and Rosen have used
AlloDerm in both manners, applying it both as an
inlay graft and as an onlay graft in the repair of
abdominal hernias, and reported a recurrence
rate of 4.5 percent.5 The amount that the Allo-
Derm was stretched before application was not
reported.
To understand the rationale for using Allo-
Derm in this setting, it is first necessary to under-
Postoperative Follow-Up
No. Bulge/Hernia (mo)
9 1 18
1 0 6
13 0 3–12
10 0 3–12
44 3 8–32
14 0 2–13
16 0 9–23
10 0 1
12 2 3–9
stand the pathophysiology of an abdominal bulge
following DIEP flap reconstruction. To date, there
has been only one study that has examined this
phenomenon in detail.18 In all cases of a lower
abdominal bulge, the intraoperative findings con-
firmed attenuation of the anterior rectus sheath.
A true hernia was never observed. The forces re-
sponsible for this are unclear but appear to be
related to increased intraabdominal pressure caus-
ing the sheath to stretch at the site of repair.
Predicting the occurrence of a bulge has not been
possible. Repair has consisted of fascial plication
and reinforcement of the anterior rectus sheath
with a polypropylene mesh. The use of AlloDerm
was considered based on reports of success fol-
lowing its use for complex hernia repairs.1–5
It is evident, based on this study, that revascu-
larized AlloDerm has the potential to stretch when
subjected to an appropriate force. There was a 75
percent increase in the surface area based on an
initial area of 68 cm2 and a subsequent area of 119
cm2. However, previous studies using AlloDerm on
the abdominal wall have made the indirect con-
clusion that the elastic potential was negligible
based on the fact that a recurrent bulge or hernia
was rarely reported. The cumulative recurrence
rate of 3.7 percent is noteworthy because previous
studies evaluating traditional methods of repair
have demonstrated long-term recurrence rates
that range from 15 to 67 percent.19 –21 Two ques-
tions arise from these findings. What is the expla-
nation for this difference, and why was AlloDerm
so effective in preventing recurrence? One possi-
ble explanation for the difference was the length
of follow-up for the two groups. The range of
follow-up for the patients who underwent repair
with AlloDerm ranged from 3 to 32 months,
whereas the range of follow-up for patients who
had traditional repairs ranged from 1 to 25
years.1–7,19 –21 As with all studies, long-term fol-
1279
 Plastic and Reconstructive Surgery • October 2007
low-up is an absolute requirement to assess safety
and efficacy.
CONCLUSIONS
AlloDerm is an excellent tissue substitute, but
it will stretch when subjected to certain forces.
Based on the published literature, its use as an
inlay or onlay graft appears justified. Randomized,
controlled, prospective studies are necessary to
evaluate the effectiveness of AlloDerm in these set-
tings and to critically assess its long-term benefit.
Maurice Y. Nahabedian, M.D.
Department of Plastic Surgery
Georgetown University Hospital
3800 Reservoir Road, N.W.
Washington, D.C. 20007
drnahabedian@aol.com
DISCLOSURES
Dr. Nahabedian serves on the speaker’s bureau for
LifeCell Corporation and has presented his experience
with nipple and breast reconstruction. He is not a con-
sultant for LifeCell.
REFERENCES
1. Guy, J. S., Miller, R., Morris, J. A., Diaz, J., and May, A. Early
one-stage closure in patients with abdominal compartment
syndrome: Fascial replacement with human acellular dermis
and bipedicle flaps. Am. Surg. 69: 1025, 2003.
2. Hirsch, E. Repair of an abdominal wall defect after a salvage
laparotomy for sepsis. J. Am. Coll. Surg. 198: 324, 2004.
3. Silverman, R. P., Singh, N. K., Li, E., et al. Restoring abdom-
inal wall integrity in contaminated tissue-deficient wounds
using autologous fascia grafts. Plast. Reconstr. Surg. 113: 673,
2004.
4. Singh, N., Silverman, R. P., Rodriguez, E., and Goldberg, N.
A pilot report: Use of AlloDerm in recalcitrant abdominal
wall hernias. Proceedings of the American Society of Reconstructive
Microsurgery. Palm Springs, Calif., 2004.
5. Buinewicz, B., and Rosen, B. Acellular cadaveric dermis
(AlloDerm): A new alternative for abdominal hernia
repair. Ann. Plast. Surg. 52: 188, 2004.
6. Butler, C. E., Langstein, H. N., and Kronowitz, S. J. Pelvic,
abdominal, and chest wall reconstruction with AlloDerm in
patients at increased risk for mesh-related complications.
Plast. Reconstr. Surg. 116: 1263, 2005.
1280
7. Kolker, A. R., Brown, D. J., Redstone, J. S., Scarpinato, V. M.,
and Wallack, M. K. Multilayer reconstruction of abdominal
wall defects with acellular dermal allograft (AlloDerm) and
component separation. Ann. Plast. Surg. 55: 36, 2005.
8. Clemons, J. L., Myers, D. L., Aguilar, V. C., and Arya, L. A.
Vaginal paravaginal repair with an AlloDerm graft. Am. J.
Obstet. Gynecol. 189: 1612, 2003.
9. Lemer, M. L., Chalkin, D. C., and Blaivas, J. G. Tissue strength
analysis of autologous and cadaveric allografts for the pubo-
vaginal sling. Neurourol. Urodyn. 18: 497, 1999.
10. Choe, J. M., Kothandapani, R., James, L., and Bowling, D.
Autologous, cadaveric, and synthetic materials in sling sur-
gery: Composite biomechanical analysis. Urology 58: 482,
2001.
11. Breuing, K. H., and Warren, S. M. Immediate bilateral breast
reconstruction with implants and inferolateral AlloDerm
slings. Ann. Plast. Surg. 55: 232, 2005.
12. Baxter, R. A. Intracapsular allogenic dermal grafts for breast
implant related problems. Plast. Reconstr. Surg. 112: 1692,
2003.
13. Menon, N. G., Rodriguez, E. D., Byrnes, C. K., Girotto, J. A.,
Goldberg, N. H., and Silverman, R. P. Revascularization of
human acellular dermis in full thickness abdominal wall
reconstruction in the rabbit model. Ann. Plast. Surg. 50: 523,
2003.
14. Silverman, R. P. Ventral hernia repair using allogenic acel-
lular dermal matrix in swine. Proceeding from the American
Hernia Society, Orlando, Fla., 2004.
15. Eppley, B. L. Revascularization of acellular human dermis
(AlloDerm) in subcutaneous implantation. Aesthetic Surg. J.
20: 291, 2000.
16. LifeCell Corp. AlloDerm: Regenerative Tissue Matrix. LifeCell
Product Information. Branchburg, N.J.: LifeCell Corp., 2004.
17. Butler, C. E., and Prieto, V. G. Reduction of adhesions with
composite AlloDerm/polypropylene mesh implants for ab-
dominal wall reconstruction. Plast. Reconstr. Surg. 114: 464,
2004.
18. Nahabedian, M. Y., and Momen, B. Lower abdominal bulge
after DIEP flap breast reconstruction. Ann. Plast. Surg. 54:
124, 2005.
19. Girotto, J. A., Chiaramonte, M., Menon, G., et al. Recalcitrant
abdominal wall hernias: Long-term superiority of autologous
tissue repair. Plast. Reconstr. Surg. 112: 106, 2003.
20. Burger, J. W., Liujendijk, R. W., Hop, W. C., Halm, J. A.,
Verdaasdonk, E. G., and Jeekel, J. Long-term follow-up of a
randomized controlled trial of suture versus mesh repair of
incisional hernia. Ann. Surg. 240: 578, 2004.
21. Langer, C., Liersch, T., Kley, C., et al. Twenty-five years of
experience in incisional hernia surgery: A comparative ret-
rospective study of 432 incisional hernia repairs. Chirurg 74:
638, 2003.
 RECONSTRUCTIVE

Prevention of Microsurgical Anastomotic

Thrombosis Using Aspirin, Heparin, and the
Glycoprotein IIb/IIIa Inhibitor Tirofiban
Thomas L. Chung, D.O.
David W. Pumplin, Ph.D.
Luther H. Holton, III, M.D.
Jesse A. Taylor, M.D.
Eduardo D. Rodriguez,
D.D.S., M.D.
Ronald P. Silverman, M.D.
Baltimore, Md.
Background: Recent clinical trials involving patients with acute coronary syn-
dromes have demonstrated significant reduction in the progression of coronary
artery thrombosis using a regimen of aspirin, heparin, and the glycoprotein
IIb/IIIa inhibitor tirofiban. Acute coronary syndromes and free tissue transfer
are similar pathophysiologically in that they both involve endothelial injury,
thrombosis, and ischemia. In this study, the authors investigate tirofiban, com-
bined with aspirin and heparin, for the prevention of microsurgical anastomotic
thrombosis in a thrombogenic rat model.
Methods: Using a randomized, controlled, double-blind experimental design,
80 thrombogenic anastomoses were performed on rat femoral arteries (n ⫽ 40)
and veins (n ⫽ 40). Preoperatively, each rat received one of four treatment
regimens: aspirin and heparin (regimen 1), aspirin and heparin plus tirofiban
(regimen 2), tirofiban alone (regimen 3), or isotonic saline (control) (regimen
4). Vessels were assessed for patency at 5, 15, 30, and 120 minutes after reper-
fusion and then harvested for microscopic analysis.
Results: At 120 minutes after reperfusion, regimen 1 had an arterial and venous
patency rate of 80 percent and 70 percent, respectively, whereas the vessel
patency rate for regimen 2 was 100 percent. The difference between regimens
1 and 2 was not statistically significant. Regimens 3 and 4 had vessel patency rates
of 40 percent or less. The aspirin/heparin and aspirin/heparin/tirofiban
groups both demonstrated significantly improved vessel patency and signifi-
cantly less thrombotic occlusion compared with controls.
Conclusions: Combination therapy with aspirin, heparin, and tirofiban signif-
icantly increases arterial and venous patency and decreases anastomotic throm-
bus formation in thrombogenic anastomoses in rats. The role of glycoprotein
IIb/IIIa inhibitors in microsurgery warrants further investigation. (Plast. Re-
constr. Surg. 120: 1281, 2007.)

D
espite meticulous technique and anti-
thrombotic drug therapy, microsurgical
procedures still carry a significant risk of
thrombosis. Failure is reported to occur in 4
percent of free flaps1 and in 10 to 30 percent of
digital replantations.2– 4 Although there are in-
From the Division of Plastic and Reconstructive Surgery,
University of Maryland Medical Center, and Department of
Anatomy and Neurobiology, University of Maryland School
of Medicine.
Received for publication February 17, 2006; accepted May
3, 2006.
Presented at the 22nd Annual Meeting of the American
Society of Reconstructive Microsurgery, in Tucson, Arizona,
January 15, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279327.75083.ae
trinsic and extrinsic causes of free flap and re-
plantation failure, the main cause is thrombotic
occlusion at or near the anastomosis.5 Studies have
shown that thrombosis may occur in “perfect” mi-
crosurgical anastomoses as a result of endothelial
trauma from the incision and placement of
sutures.6,7 Numerous studies have been conducted
to evaluate the cause, pathogenesis, therapy, con-
sequences, and prevention of anastomotic throm-
bosis. Nonetheless, there remains no standard pro-
phylactic antithrombotic regimen used by
surgeons performing microsurgical procedures.
The purpose of this study was to investigate
the effects of combined anticoagulant and anti-
platelet drug therapy using aspirin, heparin, and
the glycoprotein IIb/IIIa inhibitor tirofiban for
the prevention of microsurgical anastomotic

www.PRSJournal.com 1281
 Plastic and Reconstructive Surgery • October 2007

thrombosis in a well-described thrombogenic

model in rats. Although single-drug regimens
have resulted in a lower incidence of anasto-
motic thrombosis in this model, we hypothesize
that the addition of the glycoprotein IIb/IIIa
inhibitor tirofiban to a regimen consisting of
aspirin and heparin may optimize arterial and
venous patency rates and reduce the incidence
of thrombosis. We selected tirofiban for our
study because of its proven consistency, low in-
cidence of thrombocytopenia and bleeding com-
plications, and relatively short half-life.8 –11

MATERIALS AND METHODS

This was a randomized, controlled, double-
blinded animal study. All procedures were per-
formed according to protocols approved by the
Institutional Animal Care and Use Committee at
the University of Maryland, Baltimore. Eighty
male Sprague-Dawley rats (approximately 300 g)
were divided randomly and equally into three
treatment groups and one control group, and fur-
ther divided into either an arterial or a venous
group (n ⫽ 10 arteries and n ⫽ 10 veins for each
treatment regimen). Rats were maintained on
standard laboratory rodent chow and tap water ad
libitum until the time of the procedure. Each an-
imal underwent a thrombogenic femoral vessel
anastomosis of either the artery (n ⫽ 40) or the
vein (n ⫽ 40). Total vessel clamp time was 20
minutes in all operations. The same surgeon per-
formed all of the anastomoses.
Fig. 1. Intravenous access of the right femoral vein with a 24-
gauge cannula.
subsequent complete occlusion at the anastomosis
within 30 minutes. In the artery, a transverse in-
cision was made through one-half of its circum-
ference (Fig. 2, above) and then repaired with four
interrupted sutures of 10-0 nylon on a 75-␮m nee-
dle (Ethilon; Ethicon, Inc., Somerville, N.J.). The
two central sutures were placed in a manner that
inverted a considerable portion of the arterial wall
intraluminally, causing significant obstruction of
blood flow but maintaining vessel patency (Fig. 2,
below). This is in contrast to the original model

Surgical Procedure
General anesthesia was induced and main-
tained using isoflurane. The animals were posi-
tioned on their dorsum on a warm-water heating
pad. A transverse incision was extended from one
iliac crest to the other. Under a Leica Wild M3Z
microscope (Heerbrugg, Switzerland), intrave-
nous access was obtained by cannulating the right
femoral vein with a 24-gauge cannula (Fig. 1). On
the left side, approximately 1.5 cm of the femoral
artery or vein was dissected free.
To augment a more thrombogenic anastomo-
sis, minor modifications were made to the throm-
bogenic arterial model described by Barker et al.12
and the thrombogenic venous model described by
Peter et al.13 A pilot study was first performed on
four rats using each femoral artery (n ⫽ 8) and
vein (n ⫽ 8). These rats did not receive any treat-
ments or saline infusion. With the following mod- Fig. 2. (Above) Femoral arteriotomy. (Below) Thrombogenic ar-
ifications, both the arterial and venous anastomo- terial anastomosis. Two central sutures were used to invert a full-
ses produced consistent thrombus formation and thickness flap of the vessel wall intraluminally.

1282
Volume 120, Number 5 • Microsurgical Thrombosis
Fig. 3. (Above) Femoral venotomy. (Below) The thrombogenic
venous anastomosis consisted of primary repair with four simple
interrupted sutures (no vessel inversion).
description by Barker et al.,12 which consisted of a
smaller intraluminal flap intending to produce
thrombus formation and distal emboli, not occlu-
sion. The two outermost sutures were placed in a
standard fashion. For the vein, an incision was
made transversely through one-half of its circum-
ference (Fig. 3, above) and then repaired with four
simple interrupted sutures of 10-0 nylon (Fig. 3,
below). This is modified from the original model
described by Peter et al.,13 in which a venotomy is
made one-third of the vessel circumference and sub-
sequently repaired using two interrupted sutures.
Immediately before vessel clamping, each rat
received one of four treatment regimens intrave-
nously. By using coded samples, the surgeon per-
forming all operations was blinded to treatments
given. Regimen 1 consisted of aspirin (10 mg/kg)
plus heparin (120 units/kg); regimen 2 consisted
of aspirin and heparin plus tirofiban (1 mg/kg)
(Aggrastat HCl; Guilford Pharmaceuticals, Ben
Venue Laboratories, Bedford, Ohio); regimen 3
consisted of tirofiban only; and regimen 4 consisted
Fig. 4. Nonpatent femoral vein control at 120 minutes after
reperfusion.
of isotonic saline only (control). Drug concentra-
tions were adjusted so that for each treatment reg-
imen, the volume given to a rat was 1.5 ml.
Patency Assessment
After removing the vessel clamp, reestablish-
ing blood flow, and ensuring patency, vessels were
reassessed for patency using the milk test at 5, 15,
30, and 120 minutes after reperfusion. On release
of the upstream forceps, vessels were deemed
patent or nonpatent. Thrombus formation was
often visible in the nonpatent vessels (Fig. 4). After
each patency check, the wounds were inspected
for ongoing bleeding or hematoma formation.
Harvest
After the final patency assessment at 2 hours,
a 1-cm segment of the vessel including the anas-
tomosis was then resected and immediately fixed
for microscopic analysis. One end of a fixed vessel
segment was resected to within 1 mm of the anas-
tomosis. The vessel segments were then fixed in
4% formaldehyde and 1% glutaraldehyde in 0.1 M
cacodylate buffer (pH 7.2) containing 0.2 M su-
crose and stored at 4°C until further processing.
Animals were killed by a lethal injection of sodium
pentobarbital (100 mg/kg), followed by unilateral
thoracotomy.
Microscopic Analysis
Samples were postfixed in 1% osmium tetrox-
ide, stained en bloc with 1% uranyl acetate, de-
hydrated in graded ethanol solutions, and infil-
trated with 1:1 propylene oxide (Epon 812; Shell
Chemical, New York, N.Y.). Vessel segments were
flat embedded in a thin layer of Epon 812 and sec-
1283
 Plastic and Reconstructive Surgery • October 2007

tioned perpendicular to their long axis through the
region of the anastomosis; this was identified as hav-
ing cross-sectioned portions of sutures within the
vessel wall. Sections (0.5 ␮m in thickness) were cut
with glass knives on a Sorvall MT-5000 ultramic-
rotome (RMC Products, Boeckeler Instruments,
Inc., Tucson, Ariz.), stained with toluidine blue, and
photographed through 10⫻ to 40⫻ objectives on
a Leitz DMRX microscope (Leica Microsystems,
Inc., Allendale, N.J.) equipped with a scanning
digital camera (PhaseOne, Inc., Melville, N.Y.).
For analysis, the images were printed to fit on
letter-size paper. The boundaries of the vessel and
its occluding material were traced by hand. Trac-
ings were scanned digitally, and the areas of clots
and the total cross-sectional area of the vessel were
determined using NIH Image 1.63 software (Na-
tional Institutes of Health, Bethesda, Md.).
The rats treated with tirofiban only (regimen
3) had an arterial patency rate of 80 percent at 5
minutes, which then decreased stepwise to 40 per-
cent by 120 minutes. Venous patency rates simi-
larly decreased from 90 percent at 5 minutes to 30
percent by 120 minutes. This was consistent with
the control groups (saline only, regimen 4), which
had an arterial patency rate of 60 percent at 5
minutes and 40 percent thereafter, and a venous
patency rate of 80 percent at 5 minutes decreasing
to 20 percent by 120 minutes. Vessel patency rates
are summarized in Figure 5.

Statistical Analysis
Arterial and venous patency rates for each treat-
ment regimen were compared using the Fisher’s
exact test. A statistical analysis of anastomotic
thrombus formation and vessel occlusion in each
treatment regimen (using combined microscopy
data from both the arterial and venous groups)
was performed using the independent t test.

RESULTS
One rat that had received treatment regimen
2 (triple therapy) died intraoperatively as a result
of complications of anesthesia. Necropsy of the
animal was performed to rule out hemorrhagic
shock as a potential cause of death; however, there
was no evidence of any internal bleeding or he-
matoma formation. Two of the remaining 19 rats
that received regimen 2 developed a hematoma
(10 percent). No hematomas or other complica-
tions were noted in any other treatment group.

Vessel Patency
Rats treated with aspirin and heparin alone
(regimen 1) had an arterial patency rate of 100
percent at 5 minutes and 70 percent at 15 minutes,
which then increased to 80 percent at 30 and 120
minutes. One rat in this group demonstrated a non-
patent arterial anastomosis at 15 minutes that was
later found to be patent at 30 minutes after reper-
fusion. Venous patency rates for regimen 1 were 90
percent at 5 and 10 minutes and 70 percent there-
after. The rats treated with the combined regimen of
aspirin, heparin, and tirofiban (regimen 2) had a
patency rate of 100 percent in both arteries (n ⫽ 10) Fig. 5. (Above) Arterial patency rates and (below) venous pa-
and veins (n ⫽ 9) at every time interval. tency rates at 5, 10, 15, and 120 minutes after reperfusion.

1284
Volume 120, Number 5 • Microsurgical Thrombosis

Fig. 6. Cross-sections (0.5 ␮m thick) of arteries (above) and veins (below) at sites of anastomosis. Suture material is
relatively unstained (asterisks). A layer of intensely stained endothelial cells (arrowheads) forms the boundary of the
vessel lumen. Lumens ranged from nearly completely open (left) to completely occluded by fibrous clot material (F)
(right), and aggregated erythrocytes (E) (above, right). Vessels shown were obtained from animals treated with aspirin,
heparin, and tirofiban (above, left), aspirin and heparin (below, left), or saline alone (right). Scale bars are 100 ␮m
(left and above, right) and 50 ␮m (below, right).

The only statistical difference between reg-
imen 1 and the controls was for venous patency
at 120 minutes (p ⬍ 0.04, Fisher’s exact test).
Regimen 2 significantly increased arterial and
venous patency rates compared with controls at
120 minutes (p ⬍ 0.01, Fisher’s exact test).
There was no statistical difference between reg-
imens 1 and 2.
Microscopic Analysis
The endothelial layer of each vessel lumen was
stained intensely and readily recognized in light
micrographs of sections (Fig. 6). The anasto-
mosed segment had varied amounts of thrombus
formation, containing both fibrin and aggregated
platelets (Fig. 6, above, right). Light and electron
microscopy (data not shown) both demonstrated
that the structure of these clots was similar to
previous descriptions.14,15 Additional portions of
the lumen were occluded by aggregated erythro-
cytes (Fig. 6, above, right). These erythrocyte ag-
gregations were not seen in vessels lacking sig-
nificant thrombus formation, so the areas they
occupied were considered to be part of the total
occluded area. This was observed in both arter-
ies (Fig. 6, above, right) and veins (Fig. 6, below,
right).
The results of microscopic analyses of vessel
thrombosis after the various treatment regimens
were consistent with gross assessments of vessel
patency. Vessels that were patent 2 hours after

1285
 Plastic and Reconstructive Surgery • October 2007
Fig. 7. Percentage area of the lumen occluded by thrombus for-
mation at anastomotic sites in vessels from animals treated with
aspirin and heparin (regimen 1); aspirin, heparin, and tirofiban
(regimen 2); tirofiban alone (regimen 3); or saline only (regimen
4). Areas were obtained from light micrographs of 0.5-␮m-thick
cross-sections of the vessels. Each column represents all vessels
per treatment regimen: 10 arteries and 10 veins (regimen 1); 10
arteries and nine veins (regimen 2); 10 arteries and 10 veins (reg-
imen 3); and 10 arteries and 10 veins (regimen 4). Main bars in-
dicate means and the error bars indicate standard deviations.
anastomosis were 28.6 ⫾ 26.6 percent occluded
(n ⫽ 47), whereas vessels that were grossly non-
patent at 2 hours were 94.1 ⫾ 15.4 percent oc-
cluded (n ⫽ 30); the difference was highly signif-
icant (p ⬍ 0.0001, independent t test).
In every treatment regimen, there were vessels
whose lumens contained thrombus formation to
different extents (Fig. 7). The amount of throm-
bus observed was significantly less in the animals
treated with aspirin and heparin (regimen 1; p ⫽
0.002, independent t test) or with aspirin, heparin,
and tirofiban (regimen 2; p ⬍ 0.0001) compared
with animals treated with tirofiban or saline alone
(regimens 3 and 4, respectively). The addition of
tirofiban to aspirin and heparin did not signifi-
cantly reduce the degree of thrombus formation
compared with aspirin and heparin alone (p ⫽
0.66, independent t test). Interestingly, tirofiban,
when given alone (regimen 3), did not inhibit
thrombus formation, and the degree of occlusion
was similar to that of controls (p ⫽ 0.99).
1286
DISCUSSION
Anastomotic thrombosis is a devastating
complication in microsurgery that may cause
significant morbidity to patients. Many pharma-
cologic agents used either as single agents or in
a combined drug regimen have been investi-
gated for their ability to prevent thrombus for-
mation. These agents include aspirin,13,16,17 hepa-
rin,16,18 –22 dextran,16,22,23 various thrombolytics,24 –26
and glycoprotein IIb/IIIa inhibitors.27,28 Despite the
reported success rates of these agents, there remains
no current consensus regarding antithrombotic
pharmacologic prophylaxis for microsurgical proce-
dures. Furthermore, most microsurgeons institute
their own prophylactic antithrombotic drug regi-
men based solely on anecdotal evidence or personal
experience.29
Khouri et al., in a multicenter, multinational,
prospective study of free flap practice and out-
come, observed that of all the perioperative anti-
thrombotic regimens reported in their study, only
subcutaneous heparin given postoperatively dem-
onstrated a trend toward lowering the risk of flap
thrombosis.1 The authors concluded that most
current antithrombotic regimens are potentially
ineffective, and anastomotic thrombosis resulting
in flap failure is likely directly related to tech-
nique. However, because flap failure has been
known to occur despite “perfect” anastomoses,
thrombosis is likely multifactorial and varies ac-
cording to individual physiology.
The pathophysiologic mechanisms of throm-
bus formation in arteries and veins are not iden-
tical. Arterial thrombi usually form in areas of
disturbed flow and are primarily composed of
platelets bound to fibrin,30,31 whereas venous
thrombi are typically formed in areas of stasis and
are more influenced by coagulation factors.32
Therefore, because both platelets and the coagu-
lation cascade play a role in thrombus formation,
each should be an important pharmacologic tar-
get for the prevention of thrombosis.
The glycoprotein IIb/IIIa receptor is the most
abundant receptor on platelets and represents a
significant component of platelet-fibrin attach-
ments.31,33,34 Ching et al. studied the effect of the
glycoprotein IIb/IIIa antagonist SR121566A on
the prevention of arterial anastomotic thrombosis
in a rabbit model.27 The study found that both the
glycoprotein IIb/IIIa antagonist and heparin,
given separately, significantly improved patency
rates compared with saline controls, but were not
statistically different. However, the authors sug-
gested that the thrombogenic stimulus in their
Volume 120, Number 5 • Microsurgical Thrombosis
model may have been too potent and likely could
not have been completely suppressed by pharma-
cologic means.
Yates et al. similarly evaluated the effect of the
glycoprotein IIb/IIIa inhibitor tirofiban in pre-
venting thrombosis in an arterial anastomotic crush
model in rats.28 The study found significant improve-
ment in patency rates using tirofiban as a local irri-
gant versus irrigation with lactated Ringer’s (con-
trol). Furthermore, the study demonstrated even
more effective results when tirofiban was combined
with heparin, as compared with heparin or lactated
Ringer’s alone. Although there was no statistical dif-
ference between the tirofiban and tirofiban plus
heparin groups, the study demonstrated a signifi-
cant local effect using the combined regimen of
tirofiban and heparin topically.
Aspirin, when given in low doses (81 mg),
inhibits thromboxane A2, which is a potent vaso-
constrictor and stimulator of platelet aggregation.
Peter et al. studied the effect of low-dose aspirin on
preventing thrombosis using a thrombogenic
anastomotic model in rat femoral arteries and
veins.13 Their study found that low-dose aspirin
given preoperatively significantly decreases venous
anastomotic thrombosis and increases arterial mi-
crocirculatory perfusion distal to the anastomosis.
However, single-agent pharmacologic therapy may
not yield the highest patency rates in vessels that are
at risk of developing thrombotic occlusion.
Several large clinical trials involving patients
with acute coronary syndromes have shown a sig-
nificant reduction in the progression of coronary
artery thrombosis and a reduction in the rate of
death or myocardial infarction within 48 hours
using a combined pharmacologic regimen con-
sisting of low-dose aspirin, heparin, and the gly-
coprotein IIb/IIIa inhibitor tirofiban, as com-
pared with treatment with aspirin and heparin
alone.35–38 Pathophysiologically, acute coronary
syndromes and free tissue transfer are similar in
that both processes involve endothelial injury,
thrombosis, and ischemia. Thus, our group sought
to parallel the success of these clinical trials by
testing the same combined systemic drug regimen
in well-known thrombogenic microsurgical anas-
tomotic models in rats.
The results of our study reinforce the effec-
tiveness of combined pharmacotherapy with an-
ticoagulant and antiplatelet agents in preventing
microsurgical anastomotic thrombosis. Although
there was no significant difference in patency rates
between the animal groups treated with aspirin
and heparin (with or without tirofiban), both
groups demonstrated a significant decrease in the
incidence of thrombosis compared with controls.
Of interest, the combination of aspirin, heparin,
and tirofiban (regimen 2) resulted in 100 percent
arterial and venous patency rates; however, this
was the only regimen in which hematomas had
developed (10 percent). We surmise that admin-
istering two antiplatelet agents in conjunction
with heparin may be associated with a higher risk
of surgical bleeding.
The authors recognize that the doses of aspi-
rin and heparin used in this study may have been
too potent, thereby precluding us from observing
any significant difference with the addition of an-
other agent. However, despite the doses given, the
animal groups treated with aspirin and heparin
alone did not achieve a 100 percent vessel patency
rate at 120 minutes after reperfusion, whereas the
groups treated with tirofiban in addition to aspirin
and heparin did.
Given the consistency of the thrombogenic
arterial and venous models used in this study, fur-
ther investigations of other pharmacologic regi-
mens are certainly warranted using the same study
design. Such additional trial arms could include
dextran or heparin infusion administered intra-
operatively or postoperatively, given alone or in
combination with other agents.
CONCLUSIONS
Using combination antiplatelet and anticoag-
ulant drug therapy significantly increases patency
and decreases thrombus formation in thrombo-
genic microsurgical anastomoses in rats. The ad-
dition of the glycoprotein IIb/IIIa inhibitor tiro-
fiban to a regimen of aspirin and heparin achieves
a high patency rate in thrombogenic arterial and
venous anastomoses. However, the benefit of us-
ing triple anticoagulant and antiplatelet drug
therapy during microsurgical procedures may not
outweigh the risk of potential bleeding. Neverthe-
less, glycoprotein IIb/IIIa inhibitors in combina-
tion with heparin used systemically or topically
warrant further investigation in microsurgery,
given their proven effectiveness in other disci-
plines of medicine.
Ronald P. Silverman, M.D.
Division of Plastic and Reconstructive Surgery
University of Maryland Medical Center
22 South Greene Street, S8D12
Baltimore, Md. 21201
rsilverman@smail.umaryland.edu
DISCLOSURE
The authors have no conflict of interest, commer-
cial associations, or intent of financial gain regarding
1287
 Plastic and Reconstructive Surgery • October 2007
any of the products, equipment, or drugs used in this
study.
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effects of venous stasis and arterial insufficiency on tissue
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of coagulation and glycoprotein IIb/IIIa receptor inhibition.
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35. Cohen, M., Ferguson, J. J., III, and Harrington, R. A. Trials
of glycoprotein IIb–IIIa inhibitors in non-ST-segment eleva-
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36. The Platelet Receptor Inhibition in Ischemic Syndrome
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37. Cannon, C. P., Weintraub, W. S., Demopoulos, L. A., et al.
Comparison of early invasive and conservative strategies in
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38. The Platelet Receptor Inhibition in Ischemic Syndrome
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The Effects of Systemic Phenylephrine and
Epinephrine on Pedicle Artery and
Microvascular Perfusion in a Pig Model of
Myoadipocutaneous Rotational Flaps
Marga F. Massey, M.D.
Dhanesh K. Gupta, M.D.
Salt Lake City, Utah
RECONSTRUCTIVE
Background: Anesthesiologists and reconstructive surgeons have differing views
regarding the control of rotational flap perfusion. Anesthesiologists view the
entire body as having flow that is dependent on systemic perfusion pressure,
whereas plastic surgeons conjure that systemic administration of vasoactive
agents causes vasoconstriction of the pedicle artery and the microvasculature.
The aim of this study was to investigate the effects of systemically administered
phenylephrine and epinephrine on rotational myocutaneous flap perfusion.
Methods: After institutional animal care and use committee approval, seven
vertical rectus abdominal myocutaneous (VRAM) flaps were created in six pigs.
Under 1.0 minimum alveolar concentration isoflurane anesthesia, pedicle artery
blood flow (transit time flow probe) and microvascular perfusion (laser Doppler
flow probe) were recorded at baseline and after achieving steady hemodynamics
with the systemic intravenous administration of phenylephrine (20, 40, and 80
␮g/minute) and epinephrine (0.5, 1, and 2 ␮g/kg/minute).
Results: Under stable physiologic conditions, phenylephrine consistently de-
creased the pedicle artery blood flow and the microvascular perfusion of porcine
VRAM rotational flaps, whereas epinephrine consistently increased both flows
across the entire dose range studied. Furthermore, epinephrine-induced in-
creases in cardiac output correlated well with the observed increases in pedicle
artery blood flow and microvascular perfusion.
Conclusions: With the systemic delivery of phenylephrine, rotational myocu-
taneous flaps react in a manner described by the surgeon. In contrast, the
anesthesiologist’s model of the hemodynamics is correct for low to moderate
doses of epinephrine. Therefore, epinephrine may be the vasoactive agent of
choice for treating perioperative hypotension without harming the rotational
flap blood flow. (Plast. Reconstr. Surg. 120: 1289, 2007.)

R
econstructive surgery using rotational and
free tissue transfers is the mainstay of on-
cologic reconstruction. Although tech-
niques in microvascular reconstruction have im-
proved dramatically over the past 10 years, there
From the Division of Plastic Surgery and Department of
Anesthesiology, University of Utah.
Received for publication January 31, 2006; accepted July 7, 2006.
Portions of this work were presented at the 49th Annual
Meeting of the Plastic Surgery Research Council, in Ann
Arbor, Michigan, June 9 through 12, 2004; the 77th Clin-
ical and Scientific Congress of the International Anesthesia
Research Society, in San Francisco, California, March 21
through 25, 2003; the 78th Annual Clinical and Scientific
Congress of the International Anesthesia Research Society, in
Tampa, Florida, March 27 through 31, 2004; and the 2004
Annual Meeting of the American Society of Anesthesiologists,
in Las Vegas, Nevada, October 23 through 27, 2004.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279371.63439.8d
continues to be a real risk of perioperative par-
tial or total flap loss of both free and rotational
tissue transfers, especially in high-risk patients.1,2
Hypotension under general anesthesia occurs in
40 to 60 percent of hypertensive patients under-
going general anesthesia.3 In addition to causing
flap hypoperfusion, systemic hypotension can
lead to hypoperfusion of critical organs, thereby
causing strokes, heart attacks, renal failure, and
even death.4,5 Perioperative hypotension can be
treated by decreasing the amount of anesthetic
administered. However, if too little anesthetic is
administered, there is a chance that the patient
will either move or have awareness of the intra-
operative events.6 Therefore, the minimum
amount of anesthetic that can be administered
without the patient “waking up” may force the
anesthesiologist to administer systemic vasoactive
agents to increase systemic mean arterial pressure
and avoid end-organ ischemia.7

www.PRSJournal.com 1289
 Plastic and Reconstructive Surgery • October 2007
Because perioperative hypotension is often mul-
tifactorial and differentiation of the physiologic
causes often requires invasive hemodynamic mon-
itoring, the treatment algorithm is complex. In
addition to correcting hypovolemia and decreas-
ing the amount of anesthetic being administered,
anesthesiologists most commonly use the systemic
adrenergic agonists (e.g., phenylephrine, epineph-
rine) to increase systemic mean arterial pressure
and maintain vital organ perfusion. Because anes-
thetic agents decrease systemic vascular resistance,
phenylephrine (an ␣1- and ␣2-agonist) is often the
first-line therapy for anesthetic-related hypoten-
sion. From an anesthesiologist’s viewpoint, preser-
vation of systemic mean arterial pressure should
maintain pedicle artery perfusion in the flap that
has had a partial sympathectomy. However, from
the viewpoint of the microvascular reconstructive
surgeon, systemic vasoconstrictors should decrease
muscle blood flow and skin island microvascular
perfusion in a manner similar to the local infiltra-
tion of epinephrine or norepinephrine.8
Although increasing systemic mean arterial pres-
sure 30 percent with systemically administered
phenylephrine has no detrimental effect on the
total flap blood flow and the skin island microvas-
cular perfusion of porcine free flaps,9 systemic
phenylephrine clearly inhibits skin blood flow in
porcine island musculocutaneous flaps10 and hu-
man forearm skin.11 Furthermore, local subcutane-
ous infiltration of phenylephrine or epinephrine
decreases skin blood flow.8 In contrast, systemic
administration of dobutamine (a ␤1-agonist) or
dopamine (an ␣- and ␤-agonist) results in an in-
crease in the blood flow in the thoracodorsal and
inferior epigastric arteries of free transverse rectus
abdominis myocutaneous (TRAM) flaps that par-
allels the observed increase in cardiac output.12
However, dobutamine and dopamine often cause
more of a decrease in the systemic vascular resis-
tance than an increase in cardiac output, thereby
potentiating anesthetic-related hypotension.12
The complex relationship between systemic
hemodynamic parameters, pedicle artery blood
flow, skin island microvascular perfusion, and
flap type complicates the selection of vasoactive
drugs used to treat perioperative hypotension
and not harm the rotational and free tissue
transfers. The addition of the opposing dogmas
of the microvascular surgeon and the anesthe-
siologist (who is not accustomed to thinking
about the skin as a vital organ) to this mix only
fuels the controversy. It is clear that further
understanding of the physiologic covariates that
influence and the pharmacologic responses that
1290
modulate the pedicle artery blood flow and micro-
vascular perfusion is necessary.
The aim of this study was to determine the
dose-dependent changes in the pedicle artery
blood flow and the microvascular perfusion of a
porcine vertical rectus abdominis myocutaneous
rotational flap with the systemic administration
of phenylephrine and epinephrine. Our hypoth-
esis was that increasing the mean arterial pres-
sure with the systemic administration of a pe-
ripheral nonselective ␣-agonist (phenylephrine)
would decrease pedicle artery blood flow and
flap microvascular perfusion, whereas systemic
administration of a mixed peripheral ␤1-, ␤2-,
and ␣-agonist (epinephrine) would result in an
increase in flap blood flows at low to moderate
doses followed by a decrease in flap blood flows
at high drug doses.
MATERIALS AND METHODS
Animal Anesthetic and Instrumentation
After institutional animal care and use com-
mittee approval, six female pigs weighing 29.4 ⫾
2.6 kg were fasted overnight before being anes-
thetized by administration of a single intramus-
cular injection of ketamine, xylazine, tiletamine,
and zolazepam. Isoflurane-maintained anesthesia
(1.0% atm) and intravenous pancuronium facili-
tated mechanical ventilation and surgical dissec-
tion. Continuous systemic hemodynamic param-
eters were measured by means of a femoral artery
catheter and a continuous cardiac output pulmo-
nary artery catheter. Euvolemia was maintained by
replacing the urine output and the minimal
amounts of blood loss that occurred during flap
dissection.
Surgical Dissection of Rotational Flaps
A right vertical rectus abdominis myocutane-
ous (VRAM) rotational flap was designed for each
of the six pigs. In addition, a left VRAM rotational
flap was performed in the initial animal (pilot
animal). All of the subsequent pigs (pigs 2
through 6) had a left VRAM free flap elevated with
a planned arterial and venous anastomosis time of
1 hour before any hemodynamic measurements
were obtained and any vasoactive agents admin-
istered. Although the design of a parallel rota-
tional flap and free flap could allow possible head-
to-head comparisons between flap types, because
of the anticipated complexity of the data sets (two
flap types and three doses of each of three drugs),
Volume 120, Number 5 • Vasoconstrictors

it was planned a priori to analyze and report the

data from the rotational flaps and the data from
the free flaps in separate articles.
The VRAM flap was created by designing a
15 ⫻ 5-cm rectangular skin island just lateral to the
midline, parallel to the long axis, and on the ven-
tral surface of the pig overlying the choke zone
vessels (Fig. 1, above). The rectus muscle was de-
livered from the constraints of the rectus fascia,
the muscle was divided at its distal insertion, and
the deep inferior epigastric artery and veins were
ligated. The flap was elevated from a distal to
proximal location, with ligation of all segmental
vessels, leaving only the superior epigastric vascu-
lar pedicle as the sole blood supply to the com-
posite flap. The superior epigastric vascular pedi-
cle was identified at the superior dorsal surface of
the elevated myocutaneous flap. The rib cartilage
overlying the vascular pedicle was carefully re-
sected to provide full access to the proximal pedi-
cle (internal thoracic artery and veins) of the
VRAM rotational flap from its emergence from the
thoracic cavity to where it entered the muscular
portion of the flap (Fig. 1, center).

Blood Flow Measurements

To measure the microvascular perfusion to the
skin of the flap, an integrating laser Doppler flow
probe (Perimed Probe 413; Perimed AB, Järfalla,
Sweden) was placed in the midportion of the skin
island of the VRAM flap in a position estimated to
be over the choke vessels of the muscular portion
of the flap (Fig. 1, above). An additional integrat-
ing laser Doppler flow probe was placed over the
skin of the left thigh to provide concomitant
control (skin) microvascular perfusion measure-
ments. The blood flow through the pedicle artery
was measured by placing the superior epigastric
artery (proximal to the skin island) into a 2-mm
ultrasonic transit time flow probe (2 PSB; Tran-
sonic, Inc., Ithaca, N.Y.) taking care not to strip the
adherent adventitia (Fig. 1, below). Fig. 1. (Above) The VRAM flap. The arrow points caudal. The filled
circles are the probe holders that remained in the same fixed lo-
Vasoactive Agent Protocol cation throughout the experiment. (Center) The muscular side of
After surgical dissection of the VRAM and the VRAM flap with the superior epigastric artery apparent from
placement of the flow meters, 30 minutes was al- its emergence from the thoracic cavity to its distal perpendicular
lowed for baseline stabilization, after which base- segmental muscular branches. (Below) The muscular side of the
line hemodynamic parameters and flows were VRAM flap with the transit time probe placed on the superior
recorded. Phenylephrine was infused at a rate of epigastric artery proximal to the skin island.
20 ␮g/minute until stable hemodynamics was
achieved and hemodynamic parameters and flows
were recorded. Phenylephrine was subsequently fashion for each dose. The phenylephrine was
infused at a rate of 40 ␮g/minute and then 80 then discontinued and a washout period was ob-
␮g/minute and data were recorded in a similar served until the animal achieved a new, stable

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 Plastic and Reconstructive Surgery • October 2007
baseline hemodynamic state. In a similar fashion,
epinephrine (0.5, 1, and 2 ␮g/kg/minute) and
then sodium nitroprusside (1, 2, and 15 ␮g/kg/
minute) were administered and the responses
were recorded. After each animal was killed with
potassium chloride–induced cardiac arrest, each
VRAM was removed and weighed.
Statistical Analysis and Sample
Size Determination
Because of the anticipated complexity of the
data sets and to prevent the loss of statistical
power,13 it was planned a priori to analyze and
report the data acquired from the administration
of phenylephrine and epinephrine (vasopressors)
in a separate article from the sodium nitroprusside
data. Sodium nitroprusside was administered to
allow exploration of how agents to provide delib-
erate hypotension affect flap blood flow. Further-
more, it was planned a priori to analyze and report
the data acquired from the rotational flaps in a
separate article from the free flap data.
Literature reports of blood flow to pig rectus
abdominis muscle and the SD of the blood flow
measured in pig skeletal muscle (␴) have not
been previously reported. An a priori sample
size determination was calculated using PASS
2002 (Number Cruncher Statistical Systems, Inc.,
Kaysville, Utah), with ␣ ⫽ 0.05 and ␤ ⱕ 0.20, and
a baseline mean value of the microvascular per-
fusion of the flap of 50 perfusion units, with a
within-subject SD of 20 perfusion units (as esti-
mated from data derived from porcine latissimus
dorsi myocutaneous free flaps).9 A repeated mea-
sures design with a single group of five subjects,
where each subject is measured at four time points,
achieves 72 percent power. Using six subjects and
seven subjects achieves 87 percent and 95 percent
power, respectively.
Statistical analysis was performed using NCSS
2004 (Number Cruncher Statistical Systems). All
of the data were tested for normality using the
Shapiro-Wilk W test. Normally distributed data are
presented as mean ⫾ SD, whereas nonnormally
distributed data are presented as median (25th
and 75th percentiles). Because of the known vari-
ability of the baseline blood flow data within and
between flaps, all pedicle artery blood flows and
microvascular perfusion of the flap and the con-
trol skin are reported as percentage change rela-
tive to baseline values.
Normally distributed data (hemodynamic pa-
rameters) were analyzed for changes among a sin-
gle drug’s three doses with repeated measures
1292
analysis of variance using a value of p ⬍ 0.05 as
significant followed by Dunnett’s two-sided test
compared with control, with p ⬍ 0.0167 consid-
ered significant. Nonnormally distributed data
(blood flows) were analyzed for changes within a
single drug’s three doses with Friedman’s test us-
ing a value of p ⬍ 0.05 as significant followed by
a nonparametric Dunnett’s two-sided test com-
pared with control, with p ⬍ 0.0167 considered
significant. To isolate any differences between the
effects of phenylephrine and epinephrine on
pedicle artery blood flow or microvascular perfu-
sion of the flap or the control skin, the maximum
change for any of the three drug doses were com-
pared using a Wilcoxon signed rank test with val-
ues of p ⬍ 0.05 considered significant.14 To de-
termine whether there was a relationship between
systemic hemodynamics (mean arterial pressure
or cardiac output) and blood flows (pedicle artery
blood flow, flap microvascular perfusion, or con-
trol skin microvascular perfusion), repeated mea-
sures regression was calculated, with R2 ⱖ0.85 con-
sidered a significant correlation.15,16
RESULTS
Only the systemic physiologic parameters (Ta-
ble 1) were found to be normally distributed.
Phenylephrine and epinephrine both increased
systemic mean arterial pressures, whereas only epi-
nephrine increased cardiac output.
Phenylephrine produced a dose-dependent
decrease in pedicle artery blood flow (compared
with baseline values) in the majority of flaps (Fig.
2, left). Because of the variability of the magnitude
of pedicle artery blood flow change, only the high-
est dose of phenylephrine produced a statistically
significant decrease (Fig. 2, right). The microvas-
cular perfusion of the flap decreased in a majority
of flaps in a dose-dependent fashion (Fig. 3, left),
with the highest phenylephrine dose producing
the only statistically significant difference (Fig. 3,
right). In contrast, there was a statistically signifi-
cant increase in the microvascular perfusion of all
of the control skin measurements with all doses of
phenylephrine (Fig. 4).
Increasing doses of epinephrine increased
pedicle artery blood flow in all flaps (Fig. 5). In all
but one flap, the flap microvascular perfusion in-
creased with increasing doses of epinephrine (Fig.
6, left). However, only the initial two doses of epi-
nephrine resulted in a statistically significant in-
crease in flap microvascular perfusion (Fig. 6,
right). As with phenylephrine, there was a statisti-
cally significant increase in the microvascular per-
Volume 120, Number 5 • Vasoconstrictors

Table 1. Systemic Physiologic Values during the Phenylephrine and Epinephrine Protocols*
Parameter PRE-PHE PHE 20 PHE 40 PHE 80 PRE-EPI EPI 0.5 EPI 1 EPI 2
HR, beats/min 112 ⫾ 24 108 ⫾ 25 107 ⫾ 25 112 ⫾ 17 128 ⫾ 15 209 ⫾ 18† 204 ⫾ 21† 212 ⫾ 36†
MAP, mmHg 82 ⫾ 6 96 ⫾ 9† 110 ⫾ 14† 134 ⫾ 16† 76 ⫾ 10 89 ⫾ 11 103 ⫾ 15† 122 ⫾ 22†
PAP, mmHg 20 ⫾ 2 22 ⫾ 2 23 ⫾ 2† 26 ⫾ 2† 21 ⫾ 2 24 ⫾ 2† 26 ⫾ 2† 30 ⫾ 2†
CO, liter/min 4.3 ⫾ 0.4 4.3 ⫾ 0.4 4.3 ⫾ 0.8 4.3 ⫾ 0.9 4.4 ⫾ 0.7 5.7 ⫾ 0.9 5.9 ⫾ 1.0† 5.8 ⫾ 1.1
TEMP, °C 37.0 ⫾ 1.2 37.1 ⫾ 1.2† 37.1 ⫾ 1.2† 37.2 ⫾ 1.1† 37.3 ⫾ 1.1 37.3 ⫾ 1.1 37.3 ⫾ 1.1 37.4 ⫾ 1.1
ETCO2, mmHg 36 ⫾ 2 37 ⫾ 2 38 ⫾ 2 38 ⫾ 2† 37 ⫾ 2 44 ⫾ 1† 46 ⫾ 3† 45 ⫾ 4†
ETISO, % atm 1.2 ⫾ 0.3 1.2 ⫾ 0.3 1.2 ⫾ 0.3 1.2 ⫾ 0.3 1.1 ⫾ 0.3 1.1 ⫾ 0.3 1.1 ⫾ 0.3 1.0 ⫾ 0.3†
PHE, phenylephrine; EPI, epinephrine; HR, heart rate; MAP, systemic (femoral artery) mean arterial pressure; PAP, mean pulmonary artery
pressure; CO, cardiac output from thermodilution continuous cardiac output; TEMP, pulmonary artery blood temperature; ETCO2, end-tidal
carbon dioxide concentration; ETISO, end-tidal isoflurane concentration.
*Systemic physiologic parameter values during the phenylephrine and epinephrine infusion protocols. Values are the mean ⫾ SD from six
pigs. PRE-PHE and PRE-EPI are the respective baseline measurements prior to systemic administration of study drug. PHE 20, 40, or 80 ⫽
20, 40, or 80 ␮g/min phenylephrine systemic infusion, EPI 0.5, 1, or 2 ⫽ 0.5, 1, or 2 ␮g/kg/min epinephrine systemic infusion.
†p ⬍ 0.0167 versus corresponding baseline values (Dunnett’s two-sided test).

Fig. 2. (Left) The dose-dependent effects of phenylephrine on the pedicle artery blood flow of each of the seven rotational flaps.
Pedicle artery blood flow is reported as the percentage change from the measured baseline value. (Right) Box plot summarizing the
effects of phenylephrine on the blood flow through the pedicle artery. Each box depicts the median (solid line within the box) and the
25th and 75th percentile values (as depicted by the bounds of the rectangle). Only the highest dose of phenylephrine resulted in a
statistically significant decrease in pedicle artery blood flow, although there was a trend for all doses to decrease pedicle artery blood
flow (Friedman’s test with ␣ ⫽ 0.05 followed by a nonparametric Dunnett’s two-sided test compared with control, with values of p
⬍ 0.0167 considered significant, as denoted by the asterisk).

fusion of the control skin with all doses of epi- DISCUSSION

nephrine (Fig. 7).
Phenylephrine and epinephrine had statisti-
cally different effects on flap blood flow—phen-
ylephrine decreased pedicle artery blood flow and
flap microvascular perfusion as opposed to the
increases in both flows observed with epinephrine
administration (Fig. 8). However, both phenyl-
ephrine and epinephrine increased control skin
microvascular perfusion in a similar manner (Fig.
8, below). The epinephrine-induced changes in sys-
temic mean arterial pressure and cardiac output
correlated well with pedicle artery blood flow, flap
microvascular perfusion, and control skin micro-
vascular perfusion. In contrast, only systemic
mean arterial pressure changes induced by phen-
ylephrine correlated with the three blood flows.
The main finding of this study is that the entire
dose range of phenylephrine consistently decreased
the pedicle artery blood flow and the microvascular
perfusion of porcine VRAM rotational flaps, whereas
epinephrine consistently increased both flows across
the entire dose range studied. Furthermore, epi-
nephrine-induced increases in cardiac output cor-
related well with the observed increases in pedicle
artery blood flow and microvascular perfusion.
Therefore, epinephrine may be the vasoactive agent
of choice for treatment of perioperative hypotension
without harming the flap blood flow.
Phenylephrine
Both free and rotational VRAM flaps are de-
pendent on a single pedicle artery for perfusion.

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 Plastic and Reconstructive Surgery • October 2007

Fig. 3. (Left) The dose-dependent effects of phenylephrine on the microvascular perfusion of each of the seven rotational flaps.
Microvascular perfusion is reported as the percentage change from the measured baseline value. (Right) A box plot summa-
rizing the effects of phenylephrine on the flap’s microvascular perfusion. Each box depicts the median (solid line within the box)
and the 25th and 75th percentile values (as depicted by the bounds of the rectangle). Only the highest dose of phenylephrine
resulted in a statistically significant consistent decrease in the flap’s microvascular perfusion, although there was a trend for
the low and moderate doses of phenylephrine to decrease flap microvascular perfusion (Friedman’s test with ␣ ⫽ 0.05 followed
by a nonparametric Dunnett’s two-sided test compared with control, with values of p ⬍ 0.0167 considered significant, as
denoted by the asterisk).

Fig. 4. (Left) The dose-dependent effects of phenylephrine on the microvascular perfusion of the control skin (ipsilateral thigh) of
each of the six animals. Compared with ipsilateral rotation flap, microvascular perfusion is increased in all animals with all doses of
phenylephrine. Microvascular perfusion is reported as the percentage change from the measured baseline value. (Right) A box plot
summarizing the effects of phenylephrine on the microvascular perfusion of the control skin (ipsilateral thigh). Each box depicts the
median (solid line within the box) and the 25th and 75th percentile values (as depicted by the bounds of the rectangle). As opposed to
the microvascular perfusion of the rotational flap, all of the doses of phenylephrine resulted in a statistically significant consistent
increase in the control skin’s microvascular perfusion (Friedman’s test with ␣ ⫽ 0.05 followed by a nonparametric Dunnett’s two-
sided test compared with control, with values of p ⬍ 0.0167 considered significant, as denoted by the asterisks).

However, the combination of ischemia-reperfu-
sion injury to the free flap endothelium and
vascular smooth muscle17 and the total sympa-
thectomy result in a macrocirculation and a micro-
circulation that have different vascular tones and
different responses to systemic and local vasoactive
stimuli. Therefore, it is not surprising that the free
tissue transfers studied by Banic et al. did not vaso-
constrict in response to systemically administered
phenylephrine.9 In contrast, our rotational flaps,
with the intact sympathetic innervation of the pedi-
cle artery and the microcirculation that was not di-

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Fig. 5. (Left) The dose-dependent effects of epinephrine on the pedicle artery blood flow of each of the seven rotational flaps. As
opposed to phenylephrine, epinephrine results in an increase in pedicle artery blood flow for all doses among all flaps. Pedicle artery
blood flow is reported as the percentage change from the measured baseline value. (Right) A box plot summarizing the effects of
epinephrine on the blood flow through the pedicle artery. Each box depicts the median (solid line within the box) and the 25th and
75th percentile values (as depicted by the bounds of the rectangle). In contrast to phenylephrine, all doses of epinephrine resulted in
a statistically significant increase in pedicle artery blood flow (Friedman’s test with ␣ ⫽ 0.05 followed by a nonparametric Dunnett’s
two-sided test compared with control, with values of p ⬍ 0.0167 considered significant, as denoted by the asterisks).

Fig. 6. (Left) The dose-dependent effects of epinephrine on the microvascular perfusion of each of the seven rotational flaps. As
opposed to phenylephrine, epinephrine generally increased microvascular perfusion, even at the highest doses. Microvascular
perfusion is reported as the percentage change from the measured baseline value. (Right) A box plot summarizing the effects of
epinephrine on the microvascular perfusion of the rotational flaps. Each box depicts the median (solid line within the box) and the 25th
and 75th percentile values (as depicted by the bounds of the rectangle). In contrast to phenylephrine, the initial two doses of epi-
nephrine resulted in a statistically significant increase in flap microvascular perfusion (Friedman’s test with ␣ ⫽ 0.05 followed by a
nonparametric Dunnett’s two-sided test compared with control, with values of p ⬍ 0.0167 considered significant, as denoted by the
asterisks).

rectly exposed to an ischemia-reperfusion insult had
a sharp decrease in macrocirculation blood flow
(pedicle artery) and in microcirculation perfusion
(skin). The response of the pedicle artery is similar
to that observed in a porcine rectus musculocuta-
neous flap10 and in the intramuscular blood flow of
ponies.18 Therefore, the pedicle artery of rotational
tissue transfers appears to react to ␣-adrenergic stim-
ulation, similar to the intact myocutaneous unit.
There have been no previous reports of the
effect of phenylephrine on myocutaneous flap
microvascular perfusion. The decrease in skin

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 Plastic and Reconstructive Surgery • October 2007

Fig. 7. (Left) The dose-dependent effects of epinephrine on the microvascular perfusion of the control skin (ipsilateral thigh) in each
of the six animals. Like phenylephrine, epinephrine generally increased microvascular perfusion, even at the highest doses. Micro-
vascular perfusion is reported as the percentage change from the measured baseline value. (Right) A box plot summarizing the effects
of epinephrine on the microvascular perfusion of the control skin (ipsilateral thigh). Each box depicts the median (solid line within the
box) and the 25th and 75th percentile values (as depicted by the bounds of the rectangle). Similar to its effects on the microvascular
perfusion of the rotational flaps, all of the doses of epinephrine resulted in a statistically significant consistent increase in the control
skin’s microvascular perfusion (Friedman’s test with ␣ ⫽ 0.05 followed by a nonparametric Dunnett’s two-sided test compared with
control, with values of p ⬍ 0.0167 considered significant, as denoted by the asterisks).

perfusion that we observed is similar to the ef-
fects of phenylephrine on intact human skin11
and mouse tail cutaneous flow19 and consistent
with the effects of infiltration of random skin flaps
with norepinephrine and epinephrine on skin
perfusion.8,20 In contrast, our control skin micro-
vascular perfusion consistently demonstrated an
increase in blood flow with all doses of phenyl-
ephrine. This is similar to the observations of
Moore et al.21 for the effects of norepinephrine
infusions on the microvascular perfusion of rota-
tional myocutaneous porcine flap and its con-
tralateral control skin.
Epinephrine
Previous investigations of the response of myo-
cutaneous rotational and free flaps to ␤-adrener-
gic agonists have been limited to dobutamine and
dopamine. Free TRAM flap pedicle artery flow12
and porcine VRAM flap pedicle artery flow10 both
increased in parallel with the increase in cardiac
output produced by dobutamine. Intravenous am-
rinone, an inhibitor of phosphodiesterase (the
downstream effector of the ␤-adrenergic recep-
tor) also increased the microvascular perfusion of
a variety of free flaps, whereas its topical applica-
tion relieved pedicle artery vasospasm.22 This is
consistent with our observations of the mixed ad-
renergic agonist epinephrine.
No previous investigations have looked at the
effects of systemically administered low- to mod-
erate-dose epinephrine on microvascular perfu-
sion of rotational or free tissue transfers. Our ob-
servation that microvascular perfusion increases
in parallel with increases in cardiac output and
mean arterial pressure is consistent with a pre-
dominately ␤-agonist action of epinephrine.23,24
However, we were not able to observe the postu-
lated decrease in pedicle artery blood flow or mi-
crovascular perfusion with the highest doses of
epinephrine. It is possible that we did not achieve
high enough plasma concentrations of epineph-
rine to produce a predominately ␣-agonist action.
Alternatively, it is possible that a redistribution of
systemic cardiac output caused by the vasocon-
striction of skeletal muscle vaculature25 may act in
a manner similar to norepinephrine: increased
flow through muscle arteriovenous anastomoses26
and decreased flow through skin arteriovenous
anatomoses.27 Redirection of this nondistributive
flow of the distal hind limb to the proximal hind
limb, which contains a large mass of muscle, may
explain these observations.27 A third possibility is
that epinephrine, acting as a type A vasoconstric-
tor, increased the muscle metabolism,28 and when
␣-adrenergic doses of epinephrine were adminis-
tered, the metabolic demands of the muscle in the
flap and the hind limb counteracted the drug-
induced vasoconstriction.24

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Volume 120, Number 5 • Vasoconstrictors
Fig. 8. (Above) A box plot comparing the largest effects of phen-
ylephrine (PHE) and epinephrine (EPI) on the pedicle artery blood
flow. Each box depicts the median (solid line within the box) and
the 25th and 75th percentile values (as depicted by the bounds of
the rectangle). There is a clear, statistically significant difference
between the largest effects of phenylephrine and epinephrine
on the blood flow through the flap’s pedicle artery (Wilcoxon
signed rank test, with ␣ ⫽ 0.05 considered significant). (Center) A
comparison of the largest effects of phenylephrine and epineph-
rine on the rotational flap’s microvascular perfusion. There is a
clear, statistically significant difference between the largest
effects of phenylephrine and epinephrine on the flap’s micro-
vascular perfusion (Wilcoxon signed rank test, with ␣ ⫽ 0.05
considered significant). (Below) A comparison of the largest
Porcine Model Considerations
In this investigation, we attempted to create a
model of rotational and free myocutaneous flaps
that closely represented the conditions that are
found in the operating room. The selection of a
fixed skin animal model for investigating myocu-
taneous flap perfusion is well supported by the
literature.8,10,20,29 We chose a rectus myocutaneous
flap because it is a myocutaneous flap with a large
adipose compartment and it most closely mimics
the human TRAM flap. Unlike the latissimus dorsi
flap, a type V muscle flap that has one large dom-
inant vascular pedicle and musculocutaneous per-
forator supply, the VRAM, a type II muscle flap,
has two dominant vascular pedicles, either one of
which can support the entire myocutaneous flap
because of the presence of choke vessels.30 The
possible advantage of developing a porcine flap
model of a myocutaneous flap that contains a
large adipose compartment is that the contri-
bution of the adipocutaneous perforators to
controlling flap microvascular perfusion can be
investigated. Furthermore, the contribution of
hemodynamic and ischemia-reperfusion pertur-
bations to the development of fat necrosis can
be investigated. Therefore, this animal model
could assist in studying biological questions im-
portant in breast reconstruction.
Several methodologic choices were made that
may limit the generalizability of our results. First,
we chose an anesthetic regimen that would min-
imally affect our vascular studies—previous stud-
ies have demonstrated that administering 1.0 min-
imum alveolar concentration (the concentration
of anesthetic that prevents immobility to surgical
stimulation in 50 percent of subjects) of isoflurane
to euvolemic pigs did not effect the pedicle blood
flow or microvascular perfusion of rotational myo-
cutaneous flaps and contralateral control muscle
and skin.31,32 With the careful attention that we
gave to ensuring euvolemia in our animals, this
anesthetic should have a constant effect of the
volatile anesthetic on vascular tone. Because there
are no studies regarding the effects of other an-
esthetic agents (e.g., propofol, opioids) on myo-
cutaneous flap perfusion, we chose to avoid the
addition of possibly confounding agents. How-
effects of phenylephrine and epinephrine on the microvascular
perfusion of the control skin (ipsilateral thigh). There is clearly no
statistically significant difference between the largest effects of
phenylephrine and epinephrine on the microvascular perfusion
of the control skin (Wilcoxon signed rank test, with ␣ ⫽ 0.05 con-
sidered significant).
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 Plastic and Reconstructive Surgery • October 2007
ever, this makes comparisons to porcine free flap
studies more complex, because of the addition of
fentanyl to their anesthetic regimen.9 Second, we
specifically did not control the temperature of the
isolated flap, because this is not routinely done in
our operating rooms. This may have augmented
the effects of phenylephrine on inhibiting micro-
vascular perfusion of the flap.19 Furthermore, this
may have accounted for some of the variability in
the microvascular perfusion measurements, espe-
cially as the increased metabolism secondary to
epinephrine administration may have a tempera-
ture carryover effect between doses. However, this
is unlikely given that we observed a flattening out
of the trajectory of increase of the microvascular
perfusion of both the flap and the control skin of
individual pigs (Figs. 6, left, and 7, left).
It is possible that the remote effects of the
ischemia-reperfusion produced by creating a free
flap on the contralateral side may have had an effect
on the vascular reactivity of our rotational flap.33
However, considering the fact that the simple act of
inflating a blood pressure cuff for three 5-minute
periods can produce protection from ischemia-
reperfusion injury in the contralateral arm,34 our
model may actually represent the events associated
with simply taking a noninvasive blood pressure. The
true impact of this effort to conserve animal re-
sources on the results of our study remains to be
elucidated.
Microvascular perfusion was measured by laser
Doppler flow probes. Although there are many
potential limitations of this technique, the laser
Doppler flow probe remains a standard method
with which to assess the microcirculation in a con-
tinuous and noninvasive fashion. Although micro-
sphere methods may have delineated the role of
arterial venous anastomoses in the pharmacologic
response of the flap and tracer washout tech-
niques may have given an absolute measurement
of blood flow that contained less variability, the
laser Doppler flow probe has been advocated as a
potential tool for real-time use in humans.35,36
Therefore, the results of investigations from this
model can be readily compared with human vol-
unteers and patients.
A final limitation of this model is that although
we are able to investigate the effects of systemically
administered vasoactive agents on flap perfusion
at two different parts of a composite myoadipocu-
taneous tissue transfer, we cannot readily answer
what happens during hypotension and whether
either of the two agents is better able to perfuse a
hypotensive flap. The quandary is that any method
of producing hypotension will change the vascular
1298
tone of the animal and inhibit some of the possible
systems that are present (i.e., not inhibited) dur-
ing intraoperative hypotension. Therefore, any at-
tempts to make the animal hypotensive before
performing our pharmacologic interventions would
confound and possibly obscure the “true actions” of
the drugs under investigation.37
CONCLUSIONS
Returning to the two hemodynamic models
described earlier, it is clear that with the systemic
delivery of phenylephrine, rotational myocutane-
ous tissue transfers react in a manner described by
the microsurgeon—the ␣-adrenergic agonist in-
hibits the blood flow to the total flap (pedicle
artery) and the skin (microvascular). In contrast,
epinephrine resulted in a steady increase in blood
flow to the pedicle artery and the skin. Further-
more, the increases in both flows paralleled in-
creases in systemic mean arterial pressure and car-
diac output. The anesthesiologist’s model of the
hemodynamics of the body (even if they often
ignore the skin in their everyday thinking) is cor-
rect when it comes to the low to moderate doses
of epinephrine. These results suggest that vasoac-
tive agents that vasodilate the skeletal muscle ar-
terioles are able to increase the total blood flow
and preserve or increase the microvascular per-
fusion of rotational myoadipocutaneous tissue
transfers. Although the administration of systemic
vasoactive agents is not without potential delete-
rious effects (e.g., tachyarrhythmia, myocardial
ischemia), if the chosen agent can increase sys-
temic perfusion pressure while maintaining or in-
creasing flap perfusion, both parties are content.
Marga F. Massey, M.D.
The Center for Microsurgical Breast Reconstruction
125 Doughty Street, Suite 590
Charleston, S.C. 29403
margamassey@diepflap.com
ACKNOWLEDGMENTS
Portions of this work (M.F.M.) were funded by Na-
tional Institute of Child Health and Human Develop-
ment grant 5K12HD043449-04 (The Utah Building
Interdisciplinary Research Careers in Women’s Health
Career Development Program in Women’s Health; prin-
cipal investigator, D. J. Bjorkman). The authors thank
Scott W. McJames, M.S., and Mark Cluff, R.N., for
assistance with performing the animal experiments, and
Julie I. Clark, M.D., for assistance with performing the
animal experiments and data entry.
Volume 120, Number 5 • Vasoconstrictors
DISCLOSURE
Neither of the authors has any commercial associa-
tions that might pose or create a conflict of interest with
information presented in this article.
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2. Boruk, M., Chernobilsky, B., Rosenfeld, R. M., and Har-El, G.
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4. Monk, T. G., Saini, V., Weldon, B. C., and Sigl, J. C. Anes-
thetic management and one-year mortality after noncardiac
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5. Reich, D. L., Bodian, C. A., Krol, M., Kuroda, M., Osinski, T.,
and Thys, D. M. Intraoperative hemodynamic predictors of
mortality, stroke, and myocardial infarction after coronary
artery bypass surgery. Anesth. Analg 89: 814, 1999.
6. Sebel, P. S., Bowdle, T. A., Ghoneim, M. M., et al. The
incidence of awareness during anesthesia: A multicenter
United States study. Anesth. Analg 99: 833, 2004.
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8. Daniel, R. K., and Kerrigan, C. L. Skin flaps: An anatomical
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son, G. H. Effects of sodium nitroprusside and phenyleph-
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10. Cordeiro, P. G., Santamaria, E., Hu, Q. Y., and Heerdt, P. Effects
of vasoactive medications on the blood flow of island muscu-
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O’Connor, T. Z., and Braverman, I. M. Peripheral assessment
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12. Suominen, S., Svartling, N., Silvasti, M., Niemi, T., Kuokkanen,
H., and Asko-Seljavaara, S. The effect of intravenous dopamine
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13. Winer, B. J. Multifactor experiments having repeated mea-
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17. Siemionow, M., and Arslam, E. Ischemia/reperfusion injury:
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18. Lee, Y. H., Clarke, K. W., Alibhai, H. I., and Song, D. Effects
of dopamine, dobutamine, dopexamine, phenylephrine,
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1299
IDEAS AND INNOVATIONS
Does Fascia Lata Repair Facilitate Closure and
Does It Affect Compartment Pressures of the
Anterolateral Thigh Flap Donor Site?
Eduardo D. Rodriguez, M.D.,
D.D.S.
Rachel Bluebond-Langner,
M.D.
Julie Park, M.D.
Xiaojun You, B.S.
Gedge Rosson, M.D.
Navin Singh, M.D.
Baltimore, Md.
T
he reliability and versatility of the antero-
lateral thigh flap has been established;
however, reducing donor-site morbidity
continues to be a focus. The major donor-site
difficulties reported include wound complica-
tions related to primary closure (i.e., wound de-
hiscence, muscle bulge, need for skin grafting)
and mild lower extremity weakness.1–3 Tech-
niques to further decrease donor-site morbidity
would further enhance appeal of the anterolat-
eral thigh flap.
Primary fascial closure or imbrication may de-
crease tension on the skin repair and allow pri-
mary closure of larger defects; however, its effect
on compartment pressures has not yet been doc-
umented. We sought to demonstrate that pri-
mary closure or imbrication of the fascia lata
following anterolateral thigh flap harvest could
be performed safely and predictably, achieving
higher rates of primary skin closure.
PATIENTS AND METHODS
We conducted an institutional review board–
approved retrospective review of 86 patients who
underwent 88 anterolateral thigh flap harvests to
reconstruct lower extremity (n ⫽ 65), head and
neck (n ⫽ 15), upper extremity (n ⫽ 4), chest and
abdomen (n ⫽ 3), and penis (n ⫽ 1) defects
between September of 2003 and March of 2006. In
From the R Adams Cowley Shock Trauma Center, University
of Maryland School of Medicine, and the Johns Hopkins
Schools of Medicine and Public Health.
Received for publication September 4, 2006; accepted No-
vember 7, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279347.40506.c6
1300 www.PRSJournal.com
an attempt to achieve higher primary skin closure
rates, the fascia was closed or imbricated in 64 of
88 cases. Fascial imbrication or closure began in
December of 2003 and was attempted in all sub-
sequent patients. Closure or imbrication was aborted
if the fascia began to tear or distal perfusion was
compromised.
To evaluate safety, compartment pressures
were measured in 50 consecutive patients begin-
ning in April of 2003. Data collected included age,
sex, mechanism of injury, body mass index, size of
fascia lata removed, type of donor-site closure,
compartment pressures, flap survival, and donor-
site complications.
All flaps were harvested by a single surgeon
(E.D.R.), based on the technique described by
Song et al.,4 and followed the suprafascial flap
dissection described by Wei et al.5 When possible,
the fascia lata was closed or imbricated and the
skin closed primarily. If the donor site was too
large to close primarily, a meshed split-thickness
skin graft was used (Fig. 1). Approximately 2 cm
of fascia is imbricated when fascia is not taken,
reducing the width of the wound and the volume
of the thigh. We have found that it is not possible
to close the fascia if more than 5 cm has been taken
with the flap.
Compartment pressures were measured by in-
serting the Stryker needle (Stryker Corp., Kalama-
zoo, Mich.) parallel to the floor along three equi-
distant points of the lateral thigh. Measurements
were taken preoperatively, immediately postoper-
atively, and 48 hours postoperatively. Pain, pulses,
and flap viability were monitored every hour for 36
hours.
STATA software (STATA Corp., College Sta-
tion, Texas) was used for all statistical analysis. The
Volume 120, Number 5 • Anterolateral Thigh Flap Closure

Fig. 1. (Left) Muscle bulge following fascia lata incision and (right) imbrication of fascia lata.

t test, Fischer’s exact test, and logistic regression sensory deficits) or Stryker needle measurements.
were used to analyze the relationship of flap size, One patient’s fascial closure was released on the
body mass index, age, sex, fascia harvested, fascial table after the loss of distal perfusion. Pulses re-
closure or imbrication, rate of donor-site closure, turned following fascial release and the flap sur-
and rise in compartment pressure. Patients were vived. In this patient, the donor site measured
stratified into two groups (flap width less than 8 30 ⫻ 10 cm and was subsequently skin grafted.
cm and flap width greater than 8 cm; this cutoff is The average flap size measured 20.9 ⫻ 8.53 cm
based on data from Lipa et al.,2 in which 8 cm was (range, 35 ⫻ 15 cm to 6 ⫻ 6 cm). An average of
the maximal width for predictable primary skin 4.1 cm of fascia lata (range, 0 to 15 cm) was in-
closure) to analyze the effect of fascial imbrication cluded in 35 flaps. The fascia was closed (if fascia
or primary fascial closure on the ability to close the was taken) or imbricated in 64 patients, the skin
skin primarily. All values of p ⬍ 0.05 were consid- was closed primarily in 76 patients, and 12 patients
ered statistically significant. required split-thickness skin grafts. The average
flap size in those patients requiring skin grafts
RESULTS measured 24.3 ⫻ 11.3 cm. In patients with flap
Eighty flaps were for trauma reconstruction,
six were for oncologic reconstruction, and two
were for soft-tissue reconstruction following ne- Table 1. Characteristics of Donor-Site Skin Closure
crotizing fasciitis. There were 18 female patients Rates Using Two-Sample t Test and Two-Sample
and 70 male patients, with an average age of 38.8 Proportion Test*
years (range, 14 to 90 years) and average body mass Split-Thickness Primary Skin
index of 27 kg/m2 [underweight, 18.5 (n ⫽ 4); nor- Skin Graft Closure
mal, 18.5 to 24.9 (n ⫽ 32); overweight, 25 to 29.9 (n ⴝ 12) (n ⴝ 76) p
(n ⫽ 25); obese, ⬎30 (n ⫽ 25)]. Eighty-three of the Flap area, cm 2
24.3 ⫾ 6.5* 20.3 ⫾ 6.3* 0.05*
88 free tissue transfers (93.9 percent) were suc- Flap width, cm 11.3 ⫾ 3.1* 9.0 ⫾ 2.0* 0.00*
Body mass
cessful. None of the failures was related to ipsilat- index, kg/m2 27.3 ⫾ 3.6 27.0 ⫾ 6.1 0.88
eral flap harvest. The five failed free flaps were Age, years 40.1 ⫾ 7.8 38.6 ⫾ 16.0 0.75
replaced with an anterolateral thigh flap from the Fascia taken, cm 2.3 ⫾ 3.4 2.6 ⫾ 3.1 0.76
contralateral leg. There were no patients with ev- Fascial closure/
imbrication 42%* (n ⫽ 5) 78%* (n ⫽ 60) 0.02*
idence of compartment syndrome as measured by Sex 75% (male, 9) 82% (male, 62) 0.70
clinical symptoms (uncontrolled thigh pain, pain *Flap area, flap width, and fascial closure/imbrication are statistically
with passive stretch, significant swelling, motor or significant.

1301
 Plastic and Reconstructive Surgery • October 2007

Table 2. Logistic Regression of Primary Skin Closure Controlling for Fascial Closure, Body Mass Index, Age, and
Sex, Stratified by Flap Width*
-
Flap Width <8 cm Flap Width >8 cm

Donor Site Donor Site

Closed Primarily OR p Closed Primarily OR p
Fascia not closed/imbricated 93.3% 1.0 (ref) 0.28 40% 1.0 (ref) 0.04
Fascia closed/imbricated 97.5% 6.03 83% 9.33
OR, odds ratio; ref, reference.
*Only fascial imbrication in flaps ⬎8 cm affected the ability to close the skin primarily. The interaction term between flap width and fascial
closure/imbrication is not significant (p ⫽ 0.66).

width greater than 8 cm, closure or imbrication of
the fascia made primary skin closure nine times
more likely (p ⫽ 0.035, logistic regression). Flap
area, age, sex, and body mass index did not affect
primary skin closure (p ⬎ 0.05, logistic regression)
(Tables 1 and 2).
The average compartment pressures were 6.67
mmHg preoperatively, 19.29 mmHg immediately
postoperatively, and 14.36 mmHg 48 hours post-
operatively. The curve of the change in pressure
over the 48 hours was the same in patients with
flaps less than 8 cm and flaps greater than 8 cm
(Fig. 2). Forty-one of the 65 patients undergoing
lower extremity reconstruction had ipsilateral an-
terolateral thigh flap harvest. The compartment
pressures were not higher in the ipsilateral donor
site (17.5 versus 19.8 mmHg; p ⫽ 0.31, t test) and
flap survival was not affected (p ⫽ 0.6, t test).
The average follow-up time was 24.8 months
(range, 5 to 49 months). None of the patients with
imbrication or primary fascial closure developed
seroma, wound infection, muscle herniation, or
wound dehiscence at the donor site. Muscle bulge
was seen in seven patients whose donor site was
covered with a split-thickness skin graft and whose
fascia was not closed or imbricated (Fig. 3). All
patients complained of lateral thigh numbness,
but it was not a long-term complaint.
DISCUSSION
Primary closure rates of anterolateral thigh
donor sites range from 6 to 9 cm wide.3–5 Lipa and
Novak recently reported donor-site closure mea-
suring up to 10 cm but with increased donor-site
complications, including wound dehiscence, mus-
cle bulge, and need for skin grafting.2 In our se-
ries, larger donor sites were closed (average, 9 cm;
range, 5 to 13 cm) without donor-site complica-
tions (wound dehiscence and muscle herniation).
Our technique is particularly useful in donor sites
larger than 8 cm, making primary skin closure
nine times more likely (Table 2). Although lateral
compartment pressures increase significantly fol-
lowing primary fascial closure or imbrication, it

Fig. 2. Graph of compartment pressures. The three lines represent the over-
all average, the average for flaps wider than 8 cm, and the average for flaps
narrower than 8 cm. The trend in pressures is the same in patients with both
small and large flaps.

1302
Volume 120, Number 5 • Anterolateral Thigh Flap Closure
Fig. 3. Muscle bulge following approximation but not closure of
the fascia lata and application of a split-thickness skin graft to the
anterolateral thigh donor site.
may be performed safely without adverse clinical
sequelae or increased morbidity, as defined by risk
of compartment syndrome or flap failure follow-
ing ipsilateral flap harvest.
Thigh compartment syndrome is well docu-
mented in the orthopedic literature6 –15 but has not
been documented following anterolateral thigh
flap harvest. However, the potential exists either
from vastus lateralis muscle swelling following dis-
section or from volume reduction of the compart-
ment following fascial repair. Compartment syn-
drome develops when the pressure in the muscle
compartment exceeds the capillary pressure, re-
sulting in microvascular collapse, muscle necrosis,
and nerve ischemia.16 –18 Our study suggests that
compartment pressures do rise but compartment
syndrome does not develop.
CONCLUSIONS
Fascia lata closure or imbrication following
anterolateral thigh flap harvest is safe and re-
duces donor-site morbidity by allowing primary
skin closure of larger defects, decreasing muscle
herniation and wound dehiscence. To further
minimize donor-site morbidity, the thigh of the
injured leg can be used safely, with predictable
results.
Eduardo D. Rodriguez, M.D., D.D.S.
Plastic, Reconstructive, and Maxillofacial Surgery
R Adams Cowley Shock Trauma Center
22 South Greene Street
Baltimore, Md. 21201
erodriguez@umm.edu
DISCLOSURE
None of the authors has a financial interest in any of
the products mentioned in the article or used in the study.
REFERENCES
1. Kimata, Y., Uchiyama, K., Ebihara, S., et al. Anterolateral
thigh flap donor-site complications and morbidity. Plast. Re-
constr. Surg. 106: 584, 2000.
2. Lipa, J. E., Novak, C. B., and Binhammer, P. A. Patient-
reported donor-site morbidity following anterolateral thigh
free flaps. J. Reconstr. Microsurg. 21: 365, 2005.
3. Kuo, Y. R., Jeng, S. F., Kuo, M. H., et al. Free anterolateral
thigh flap for extremity reconstruction: Clinical experience
and functional assessment of donor site. Plast. Reconstr. Surg.
107: 1766, 2001.
4. Song, Y. G., Chen, G. Z., and Song, Y. L. The free thigh flap:
A new free flap concept based on the septocutaneous artery.
Br. J. Plast. Surg. 37: 149, 1984.
5. Wei, F., Jain, C. V., Celik, N., Chen, H. C., Chuang, D. C., and
Lin, C. H. Have we found an ideal soft-tissue flap? An expe-
rience with 672 anterolateral thigh flaps. Plast. Reconstr. Surg.
109: 2219, 2002.
6. Mubarak, S. J., Owen, C. A., Hargens, A. R., Garetto, L. P.,
and Akeson, W. H. Acute compartment syndromes: Diagno-
sis and treatment with the aid of the wick catheter. J. Bone Joint
Surg. (Am.) 60: 1091, 1978.
7. Whitesides, T. E., and Heckman, M. M. Acute compartment
syndrome: Update on diagnosis and treatment. J. Am. Acad.
Orthop. Surg. 4: 209, 1996.
8. Matsen, F. A., III, Winquist, R. A., and Krugmire, R. B. Di-
agnosis and management of compartmental syndromes.
J. Bone Joint Surg. (Am.) 62: 286, 1980.
9. Schwartz, J. T., Jr., Brumback, R. J., Lakatos, R., Poka, A.,
Bathon, G. H., and Burgess, A. R. Acute compartment syn-
drome of the thigh: A spectrum of injury. J. Bone Joint Surg.
(Am.) 71: 392, 1989.
10. Mithofer, K., Lhowe, D. W., Vrahas, M. S., Altman, D. T.,
and Altman, G. T. Clinical spectrum of acute compartment
syndrome of the thigh and its relation to associated inju-
ries. Clin. Orthop. Relat. Res. 425: 223, 2004.
11. Tarlow, S. D., Achterman, C. A., Hayhurst, J., and Ovadia, D.
N. Acute compartment syndrome in the thigh complicating
fracture of the femur: A report of three cases. J. Bone Joint
Surg. (Am.) 68: 1439, 1986.
12. Best, I. M., and Bumpers, H. L. Thigh compartment syn-
drome after acute ischemia. Am. Surg. 68: 996, 2002.
13. Suzuki, T., Moirmura, N., Kawai, K., and Sugiyama, M. Ar-
terial injury associated with acute compartment syndrome of
the thigh following blunt trauma. Injury 36: 151, 2005.
14. Doube, A. An acute compartment syndrome involving the
anterior thighs after isometric exercise. N. Z. Med. J. 108:
413, 1995.
15. Bidwell, J. P., Gibbons, C. E., and Godsiff, S. Acute compart-
ment syndrome of the thigh after weight training. Br. J. Sports
Med. 30: 264, 1996.
1303
 Plastic and Reconstructive Surgery • October 2007

16. Rahm, M., and Probe, R. Extensive deep venous throm-
bosis resulting in compartment syndrome of the thigh and
leg: A case report. J. Bone Joint Surg. (Am.) 76: 1854, 1994.
17. Nadeem, R. D., Clift, B. A., Martindale, J. P., Hadden, W. A.,
and Ritchie, I. K. Acute compartment syndrome of the thigh
after joint replacement with anticoagulation. J. Bone Joint
Surg. (Br.) 80: 866, 1998.
18. Brotman, S., Browner, B. D., and Cox, E. F. MAS trousers
improperly applied causing a compartment syndrome in
lower-extremity trauma. J. Trauma 22: 598, 1982.

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1304
 HAND/PERIPHERAL NERVE

Preoperative Soft-Tissue Distraction for Radial

Longitudinal Deficiency: An Analysis
of Indications and Outcomes
Amir H. Taghinia, M.D.
Ayman A. Al-Sheikh, M.D.
Joseph Upton, M.D.
Boston, Mass.
Background: Preoperative soft-tissue distraction for congenital radial deficiency
is well described, but indications are unclear and long-term outcomes are
lacking.
Methods: This study evaluated one surgeon’s 16-year experience with preop-
erative soft-tissue distraction using uniplanar devices. Eight extremities in seven
consecutive patients (average age, 2.5 years) with type 4 radial deficiency and
severe wrist deformity were distracted before centralization (seven extremities)
or radialization (one extremity).
Results: In the short term, average hand-forearm angle improved by 89 degrees
and average hand-forearm position improved by 31 mm. In the long-term, wrist
deformity recurred commensurate with the degree of initial deformity. Fortu-
itously, one infant experienced unintended epiphyseal distraction that
lengthened the ulna by 15 mm before radialization. One patient required
recentralization; two developed minor pin-track infections. Multiple distrac-
tor readjustments were necessary early in the series.
Conclusions: Preoperative soft-tissue distraction for radial deficiency is in-
dicated in late-presenting or neglected patients or cases with severe, irre-
ducible wrist angulation and displacement. Dramatic correction is possible
using uniplanar distractors. Although minor complications are common,
they diminish with experience. Using this technique, the surgeon avoids skeletal
shortening and undue strain on the nerves and vessels at the time of centralization
or radialization. (Plast. Reconstr. Surg. 120: 1305, 2007.)

C
ongenital radial longitudinal deficiency
represents a spectrum of upper extremity
abnormalities characterized by varying de-
grees of skeletal and soft-tissue hypoplasia.1– 4
The radius, radial carpal bones, and thumb are
hypoplastic or absent, and the radial soft tissues
including the muscles, tendons, and neurovascu-
lar structures are underdeveloped. Bayne and
Klug1 proposed four types of radial longitudinal
deficiency and thus developed the initial classi-
fication system for this condition. The degree of
radial deficiency correlates with the degree of
From the Division of Plastic Surgery, Children’s Hospital
and Harvard Medical School.
Received for publication July 6, 2006; accepted August 31,
2006.
Awarded the Joseph E. Murray Award for best paper at the
46th Annual Meeting of the New England Society of Plastic
and Reconstructive Surgeons, in Mystic, Connecticut, June
4, 2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279474.20167.a8
wrist and hand deviation. Infants with absent
radius (type 4) have the most displaced and
angulated wrists. These extremities, if uncor-
rected, have significant cosmetic stigma and
functional impairment, including a short fore-
arm, a malaligned wrist, and poor extrinsic ten-
don excursion.
Operative goals in radial deficiency are to re-
align and stabilize the wrist during infancy or
early childhood and to lengthen the short fore-
arm during adolescence. Although many meth-
ods have been proposed to realign the wrist,5– 8
centralization gained popularity after several re-
ports confirmed long-term wrist stability.1,5,9 –13
This method promised improved function and ap-
pearance while preserving some wrist motion.14
Earlier reports of centralization advocated rou-
tine skeletal shortening; however, this practice
endangered ulnar growth and decreased wrist
mobility. Thus, surgeons sought to avoid skeletal
shortening by wide soft-tissue mobilization and
fibrous anlage resection,15 and they reserved

www.PRSJournal.com 1305

bony excision for more difficult wrists where the
deformity was fixed, the fibrous tissue was un-
yielding, or the neurovascular structures were
overstretched.6
Buck-Gramcko16 described an alternative pro-
cedure called radialization, in which he strength-
ened the ulnar moment by transferring the ra-
dial motors and stabilizing the wrist over the
ulna in overcorrected ulnar deviation. The al-
leged mechanical advantage of radialization over
centralization is not yet supported by direct clin-
ical evidence. Wrist deformity recurs to a vari-
able extent after all these procedures and ap-
pears to be related to the degree of the initial
deformity.
Kessler17 was the first to use preoperative soft-
tissue distraction to avoid skeletal shortening.
He used a special distractor to gradually stretch
the carpus to neutral before centralization. Be-
fore his report, static splinting and dynamic
stretching therapy programs were the only
means of stretching the short, underdeveloped
radial soft tissues. If these programs were unsuc-
cessful, centralization could still be accomplished
but at the expense of soft-tissue and bone excision.
With his two-step technique, Kessler avoided skel-
etal shortening and overstretching of the neuro-
vascular structures at the time of centralization.
Since Kessler’s original report, several investi-
gators have successfully distracted the wrist into
alignment before stabilization.6,8,18 –20 However,
the indications for preoperative soft-tissue dis-
traction have not been clearly defined. This re-
port summarizes one surgeon’s experience with
preoperative soft-tissue distraction before cen-
tralization or radialization in the most severe
cases of type 4 radial longitudinal deficiency.
Analysis of short-term and long-term outcomes is
presented. In addition, indications for distrac-
tion are suggested; these include late or ne-
glected cases with fixed deformity, or cases with
severe, irreducible angulation and displacement.
Table 1. Patient Demographics and Clinical Features
Patient* Age† Sex Side
1 1 day Male Right
2 3 days Male Left
3 1.5 yr Male Right
4 14 days Male Left
5 4 yr Male Left
6 (left) 6 yr Male Right
6 (right) 8 yr Male Left
7 6 mo Female Left
VACTERL, vertebral anomalies, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb anomalies.
*All patients had the primary diagnosis of type 4 radial longitudinal deficiency.
†Age at the time of soft-tissue distraction.
1306
Plastic and Reconstructive Surgery • October 2007
PATIENTS AND METHODS
Medical records of seven patients were re-
viewed who underwent eight consecutive soft-
tissue distraction procedures for type 4 radial
longitudinal deficiency from 1988 to 2004. Once
soft-tissue distraction was adequate, the wrist was
centralized in seven cases and radialized in one
case (Table 1).
All patients underwent thorough medical eval-
uations before any intervention, including sub-
specialty assessment if necessary. Medical condi-
tions permitting, once the need for distraction was
determined, it was started as early as possible to
take maximum advantage of early tissue pliability.
The average age at the time of distraction was 2.5
years. Three patients presented within the first few
days of life (Table 1). Another patient (patient 7)
presented at 4 months of age; the rest presented
much later (patients 3, 5, and 6 at ages 1.5, 4, and
5 years, respectively). The younger patients had
severe wrist angulation and deformity. The older
ones were late-presenting or neglected cases with
relatively fixed deformity and tough, inelastic fore-
arm tissues.
At the time of distraction, all patients had ad-
equate active and passive range of motion of the
elbow. In one patient (patient 6) with congenital
absence of bilateral elbow flexors, pectoralis mus-
cle transfers were performed to provide elbow
flexion before distraction.
Technique
In all patients, the apparatus was placed as the
first procedure (Fig. 1). A transverse skin incision
at the level of the ulnocarpal joint was used to
expose and excise the radial fibrous tissue. Distal
pins for the distraction device were then placed
into predrilled holes in the second or third meta-
carpal under direct vision. Larger pins were in-
troduced into the midproximal ulna under fluo-
roscopic guidance.
Associated Diagnoses Distraction Device Definitive Procedure
VACTERL Kessler Centralization
Holt-Oram syndrome Kessler Centralization
VACTERL Kessler Centralization
VACTERL Kessler Centralization
VACTERL Synthes Centralization
Absent elbow flexors Orthofix Centralization
Absent elbow flexors Orthofix Centralization
None Orthofix Radialization
Volume 120, Number 5 • Radial Longitudinal Deficiency

Fig. 1. Schematic depictions of the technique. The tough radial fibrous tis-
sues and tendinous units are released and the distractor is placed once the
pins are inserted under direct vision.

The Orthofix uniplanar device (Orthofix,

Inc., McKinney, Texas) (Fig. 2, above) distracted
four extremities; the Kessler apparatus (Fig. 2,
below) distracted three extremities; and the Syn-
thes metacarpal level device (Synthes, Inc., West
Chester, Pa.) distracted one extremity. Parents be-
gan distraction at a rate of 1 mm/day approxi-
mately 4 to 5 days after the operation. They sus-
pended distraction in case of pain or swelling. The
patients were observed with weekly clinic visits and
radiographs. Distraction was continued until the
hand could be passively repositioned into neutral.
Centralization or radialization was then per-
formed through the same ulnocarpal incision by
means of standard techniques outlined by the se-
nior author (J.U.) elsewhere.21 Skeletal shortening
or carpectomy was not necessary; and the distal
ulnar growth plate was preserved in all cases.
Once all the procedures were completed, the
children were fitted with night splints to decrease
recurrence of deformity. The importance of night
splinting was repeatedly stressed to the parents.
The children were followed closely and splints
were adjusted to accommodate their growing fore-
arms.
Preoperative, early postoperative, and long-
term postoperative radiographs were compared
using measurements of hand-forearm angle and
hand-forearm position as outlined by Manske et Fig. 2. (Above) The Orthofix uniplanar distractor on patient 7.
al.12 (Fig. 3). Early postoperative radiographs were (Below) The Kessler distractor on patient 3.

1307
 Plastic and Reconstructive Surgery • October 2007

Fig. 3. Measurements of hand-forearm angle (left) and hand-forearm position (right). Using a stan-
dard anteroposterior radiograph, a line drawn perpendicular to the distal ulnar physis determines
the distal ulnar axis (ab). The intersection of this axis with the long finger metacarpal axis (cd) de-
termines the hand-forearm angle (in degrees). A positive hand-forearm angle indicates radial an-
gulation; a negative hand-forearm angle indicates ulnar angulation. In this case, the hand-forearm
angle is 76 degrees. The hand-forearm position is the distance in millimeters between the base of
the small finger metacarpal and the distal ulnar axis (ef). A positive hand-forearm position indicates
ulnar displacement; a negative hand-forearm position indicates radial displacement. In this case,
the hand-forearm position is ⫺16 mm.

taken within 6 months of the index operation and
long-term postoperative radiographs were taken
at 5 years or later. Long-term postoperative radio-
graphs were only available for four of the eight
extremities. Results are presented below in text,
tables, and radiographs.
RESULTS
The results are summarized in Table 2. The
average duration of distraction was 44 days (range,
21 to 63 days). This duration was shorter in the
younger patients. At early postoperative follow-up,
the average preoperative hand-forearm angle of
96 degrees (range, 76 to 110 degrees) improved
by 89 degrees to a postoperative average of 7
degrees (range, ⫺30 to 26 degrees). The aver-
age preoperative hand-forearm position of ⫺20
mm (range, ⫺27 to ⫺12 mm) improved by 31
mm to a postoperative average of ⫹11 mm
(range, ⫹3 to ⫹18 mm).
Long-term (5 years or longer) follow-up ra-
diographs were available in four of eight cases
(Table 2). In these cases, the ulna grew and the
distal ulna widened to accommodate the carpus.
Mild deformity recurred but alignment remained
satisfactory (average long-term hand-forearm an-
gle, 18 degrees; hand-forearm position, ⫹9 mm).
Long-term improvement in hand-forearm angle
and hand-forearm position were 78 degrees and
29 mm, respectively. The degree of long-term de-
formity was commensurate with the degree of pre-
operative deformity. For example, in patient 1, the
wrist had the least angular and translational de-
formity and the best long-term outcome. In con-
trast, the left wrist in patient 6 had the worst initial
deformity and worst long-term outcome.
Of the four patients whose long-term (⬎5
years) radiographs were unavailable, one (patient
5) died 4 years after centralization because of air-
way-related complications. At 3-year follow-up, his
clinical examination showed the hand in moder-
ate radial deviation, but no radiographs were taken.
Patient 2 died unexpectedly as a result of cardiac
complications before long-term radiographic exam-
ination could be performed. Another patient (pa-
tient 4) had significant recurrence of hand deviation
and required recentralization 2 years after the orig-
inal operation. Five years after his second central-
ization procedure, he had mild recurrence of the
deformity.
Patient 7 had the index operation 1.5 years
previously. Although the patient’s wrist remains

1308
Volume 120, Number 5 • Radial Longitudinal Deficiency

HFA, hand-forearm angle (degrees); HFP, hand-forearm position (millimeters). Improvement in these parameters is indicated in parentheses. No long-term radiographs were available for
Follow-Up
corrected, long-term follow-up is not yet available.
Interestingly, this patient demonstrated signifi-

(yr)
16
14
12
7
3
7

5
1
cant bone lengthening during soft-tissue distrac-
tion. After 3 weeks of distraction, the wrist was
adequately repositioned; however, a delay in the
schedule postponed radialization for another 3
HFA (°) and

27 and ⫹20

36 and ⫺11
Long-Term

HFP (mm)
3 and ⫹12

4 and ⫹13
weeks. Meanwhile, the mother continued to dis-
tract the limb, thus producing a dramatic and
None

NA
NA
unexpected 15 mm of ulnar lengthening (Fig. 4).

NA
Inadvertent epiphyseal distraction induced signif-
icant bony growth.
All patients tolerated the distraction process
Apparatus broke twice

pin-track infection

well. Two patients developed pin-track infections

Pin-track infection
Complications

Multiple refitting;

at the end of the distraction period. Another pa-

Recentralization

tient, a very active child, broke the distraction

apparatus twice, both times requiring general an-
esthesia for repair and replacement. There were
None

None

None
None

no cases of osteomyelitis, neurovascular injury, or

growth plate damage.

DISCUSSION
(difference) (mm)
⫺18 ¡ ⫹15 (33)
⫺20 ¡ ⫹16 (36)
⫺16 ¡ ⫹18 (34)

⫺27 ¡ ⫹10 (37)

⫺23 ¡ ⫹14 (37)
⫺12 ¡ ⫹3 (15)

⫺24 ¡ ⫹9 (33)
⫺16 ¡ ⫹5 (21)

Since Kessler’s original report in 1989,17 five

Postop HFP
Preop ¡

investigators have published their experiences with

soft-tissue distraction in radial deficiency.6,8,18 –20 All
of these reports consisted of small groups of pa-
tients with little long-term follow-up and no clearly
defined indications for using distraction. Interest-
ingly, our first distraction was performed in 1988
93 ¡ ⫺30 (123)

using Kessler’s original apparatus (Fig. 2, below) 1

(difference) (°)

76 ¡ ⫺16 (92)
110 ¡ 10 (100)
Postop HFA

103 ¡ 26 (77)

98 ¡ 12 (86)

107 ¡ 5 (102)

year before his landmark report. Since that time,

100 ¡ 8 (92)

79 ¡ 8 (71)
Preop ¡

we have followed several patients long term. Our

report augments the growing body of literature
on the techniques and long-term outcomes of
soft-tissue distraction for radial longitudinal defi-
ciency. In addition, we advocate that preoperative
soft-tissue distraction is indicated in severe cases of
Table 2. Patient Demographics and Clinical Features

Centralization
Centralization
Centralization
Centralization
Centralization
Centralization

Centralization
Radialization

type 4 deficiency; these include late-presenting or

Procedure
Definitive

neglected cases with fixed deformity, or those with

severe, irreducible wrist angulation and displace-
ment. In these cases, distraction helps the surgeon
avoid skeletal shortening and excessive tension on
the nerves and vessels during centralization or
Distraction

radialization.
Duration

*Age at the time of soft-tissue distraction.

(Days)

We used soft-tissue distraction to reposition

21
24
43
44
55
61

63
42

the wrist only in the most severe cases of radial

patients 2, 4, 5, and 7 (see text).

deficiency. Many patients were late presenting (av-

erage age, 2.5 years) or neglected, with fixed de-
formity. The wrists were severely angulated and
3 days

14 days
1 day

6 mo
Age*

displaced (average preoperative hand-forearm an-

4 yr
6 yr

8 yr
1.5 yr

gle, 96 degrees; hand-forearm position, ⫺20 mm)

and the forearm tissues were fibrotic and inelastic.
Buck-Gramcko16 advocated that carpal resection
6 (right)

can be avoided if the wrist is manipulated early.

Patient

6 (left)

However, Nanchahal and Tonkin6 found that even

with early manipulation, wrist mobility was not
1
2
3
4
5

1309
 Plastic and Reconstructive Surgery • October 2007

Fig. 4. Serial radiographs of patient 7. (Left) Severe preoperative deformity with a hand-forearm angle of 93 degrees and a
hand-forearm position of ⫺16 mm. After 3 weeks of distraction, the wrist was adequately repositioned (second from left);
however, surgery was unintentionally delayed and the mother continued to distract. Three weeks later, the distal ulna had
lengthened by 15 mm (second from right). Postoperatively, the hand-forearm angle had improved by 123 degrees to ⫺30
degrees and the hand-forearm position had improved by 21 mm to ⫹5 mm (right).

sufficient to avoid carpal resection in some cases.
The senior author’s experience was similar, and
thus we have developed the aforementioned in-
dications for preoperative soft-tissue distraction to
avoid carpal resection.
The distraction process is started as soon as
possible to take advantage of early tissue pliabil-
ity, although this was not possible in the late-
presenting, older children. As advocated by other
investigators,6,16,18 early soft-tissue manipulation al-
lows maximal soft-tissue stretching with less injury
to important structures. The musculotendinous
units can be stretched more easily with less dam-
age to the actin-myosin connections, thus retain-
ing more function. In addition, the endpoint of
distraction is reached more quickly, as seen in our
younger patients (Table 2). This strategy mini-
mizes the length of time that the distractor is on
and decreases associated complications such as
pin-related infections and skin irritation. Finally, it
is best to realign the wrist before the first year of
life to give the child an early pattern of radial
prehension and improve wrist position for subse-
quent pollicization.5,11,16,21
Although the Kessler, Synthes, and Orthofix
devices were all used in this series, the Orthofix
uniplanar apparatus provided the most consistent
results with the fewest device-related mechanical
difficulties. Nanchahal and Tonkin6 used the
Kessler device for six radial club hands (average
age, 8 months), but improvement in radiographic
parameters was not striking. Their cohort started
with less severe deformity (average preoperative
hand-forearm angle, 53 degrees) and showed only
mild improvement (38 degrees) in the short term
(follow-up, 20 months). Furthermore, two limbs in
this series required carpal resection to achieve
centralization. Smith and Greene19 used the Or-
thofix device in three limbs with radial deficiency,
but they did not outline corrective radiographic
parameters.
Most recently, Sabharwal et al.18 used the more
elaborate Ilizarov distractor for preoperative soft-
tissue distraction. Noting that this technique pro-
vides a more physiologic distraction, they treated
four radial club hands in infants with an average
age of 18.3 months. At 26-month follow-up, they
noted an average improvement in hand-forearm
angle of 72 degrees and hand-forearm position of
19 mm. In contrast, Goldfarb et al.20 achieved
relatively better results using a ring-type multipla-
nar distractor in eight extremities; however, their
average follow-up was only 17 months. Although
these methods provide multiplanar distraction,
the equipment is cumbersome and bulky. With
many more parts than their uniplanar counterparts,
these devices are also more prone to mechanical
difficulties, especially in children. Furthermore, per-

1310
Volume 120, Number 5 • Radial Longitudinal Deficiency
cutaneous techniques risk neurovascular injury,
particularly in these cases, where anatomical in-
consistency is the rule.14 The authors do not men-
tion such injury in their patients, but detecting
occult neurosensory injury in a child is difficult.
We place all distal pins under direct vision and
proximal pins under fluoroscopic guidance. We
prefer not to risk neurovascular injury and not
to apply a large, cumbersome apparatus when
uniplanar distraction provides similar if not better
results. Indeed, despite the severe initial deformi-
ties in this series, our results compare favorably
with other published reports.
Long-term outcomes after soft-tissue distrac-
tion and wrist realignment are lacking in the lit-
erature. Vilkki8 is the only author who reported
long-term outcomes after preoperative distrac-
tion. He used a uniplanar device to distract pa-
tients with type 4 radial deficiency before a mi-
crovascular toe transfer for wrist stabilization and,
notably, the senior author of this report has ex-
amined several of these patients. This innovative
and technically challenging reconstructive tech-
nique provided excellent short-term outcomes.
Although long-term results (average, 6 years)
showed mild recurrence of deformity (average
hand-forearm angle, 20 degrees), there was no
basis of comparison because preoperative defor-
mity measurements were not reported. In another
study, Geck et al.22 found that preoperative defor-
mity affected neither final wrist position nor revi-
sion risk. Although their average clinical follow-up
was 50 months, they based their statistics on ra-
diographic follow-up of only 11 to 12 months.
In our limited series, the degree of long-term
recurrence correlated to the degree of preoper-
ative deformity. It is important to note that recur-
rence of deformity does not indicate a failure of
distraction. All described methods to realign the
wrist show some recurrence of deformity in the
long term. Deformity recurrence may reflect fail-
ure of wrist stabilization or may be an unavoidable
outcome despite uncompromised night splinting.
As the forearm grows, a previously neutral wrist
can slip back into radial angulation either because
the underdeveloped soft tissue cannot grow well
or because the radial muscles and tendons force
the wrist back into angulation. Recurrence may be
accelerated if the initial wrist deformity was severe.
Perhaps stabilizing the wrist in a more ulnar po-
sition will rebalance the tendon forces and im-
prove long-term stability as the forearm grows.
This reasoning is invoked by advocates of radial-
ization and is supported by indirect clinical evi-
dence. Indeed, Geck et al.22 compared centraliza-
tion with radialization in 29 limbs and found that
repositioning in ulnar angulation and translation
reduced the incidence of recurrence and need for
revision. The senior author has found similar out-
comes in his experience and has modified his
practice to perform radialization exclusively.
Epiphyseal distraction is the newest technique
in bone lengthening. Success is reported in lower
extremity lengthening, with only a few case reports
of application to the upper extremity.23–25 Initial
excitement for this technique was quelled by iso-
lated reports of growth arrest in animals. Although
the literature is replete with data, no consensus
exists regarding the growth safety of this technique.
One of our patients experienced unintended epiph-
yseal distraction that yielded dramatic ulnar length-
ening in just a few weeks. Furthermore, this pa-
tient’s distal ulna has continued to grow since
radialization. Although excitement about this sol-
itary result remains guarded, the considerable po-
tential of epiphyseal distraction needs recognition
and further study.
Functional outcomes after soft-tissue distrac-
tion and wrist stabilization are lacking. Wrist neu-
tralization is thought to improve function by cor-
recting the misdirected forces of the long tendons,
creating early radial prehension and improving
wrist position for subsequent pollicization. Never-
theless, objective long-term data are unavailable.
Although neutralization creates a more physio-
logic wrist position, the obligatory stretching may
alter the delicate balance of the forearm muscu-
lotendinous units. This imbalance may be accen-
tuated by distraction lengthening of the muscles
and tendons. Nevertheless, the practice of wrist
neutralization continues because of anecdotal ev-
idence of improved function and the inarguable
cosmetic improvement. This improvement is very
important to these children and their parents, as
their deformed wrists are a significant social
stigma. Indeed, children adapt miraculously to
different upper extremity positions—sometimes
with little functional deficit. Thus, even if there is
little functional gain after these procedures, there
is a significant psychosocial benefit to the patients
and their families.
CONCLUSIONS
Soft-tissue distraction is a powerful technique
for repositioning the wrist in radial longitudinal
deficiency. It is indicated in late or neglected cases
with fixed deformity or in cases with severe angu-
lation and displacement. Although radialization
likely provides the best stability, long-term recur-
rence partially depends on the degree of pre-
1311
 Plastic and Reconstructive Surgery • October 2007
operative deformity. Using this technique, the
surgeon can reposition the wrist and maintain
maximum skeletal length and wrist mobility with-
out overstretching nerves and vessels and without
sacrificing growth potential.
Joseph Upton, M.D.
830 Boylston Street, Suite 212
Chestnut Hill, Mass. 02467-2502
jupton3@earthlink.net
DISCLOSURES
The authors have no financial interest or commercial
association with any of the subject matter or products
mentioned in this article. This research was not sup-
ported by any outside funds.
REFERENCES
1. Bayne, L. G., and Klug, M. S. Long-term review of the surgical
treatment of radial deficiencies. J. Hand Surg. (Am.) 12: 169,
1987.
2. D’Arcangelo, M., Gupta, A., and Scheker, L. R. Radial club
hand. In A. Gupta, S. P. J. Kay, and L. R. Scheker (Eds.), The
Growing Hand: Diagnosis and Management of the Upper Extremity in
Children, 1st Ed. London: Harcourt Publishers, 2000. P. 147.
3. James, M. A., and Bednar, M. Deformities of the wrist and
forearm. In D. P. Green, R. N. Hotchkiss, W. C. Pederson, and
S. W. Wolfe (Eds.), Green’s Operative Hand Surgery, 5th Ed. New
York: Churchill Livingstone, 2005. P. 1469.
4. James, M. A., McCarroll, H. R., Jr., and Manske, P. R. The
spectrum of radial longitudinal deficiency: A modified clas-
sification. J. Hand Surg. (Am.) 24: 1145, 1999.
5. Lamb, D. W. Radial club hand: A continuing study of sixty-
eight patients with one hundred and seventeen club hands.
J. Bone Joint Surg. (Am.) 59: 1, 1977.
6. Nanchahal, J., and Tonkin, M. A. Pre-operative distraction
lengthening for radial longitudinal deficiency. J. Hand Surg.
(Br.) 21: 103, 1996.
7. Riordan, D. C. Congenital absence of the radius. J. Bone Joint
Surg. (Am.) 37: 1129, 1955.
8. Vilkki, S. K. Distraction and microvascular epiphysis transfer
for radial club hand. J. Hand Surg. (Br.) 23: 445, 1998.
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meromelia: The deformity and its treatment. J. Bone Joint
Surg. (Am.) 52: 966, 1970.
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10. Bora, F. W., Jr., Osterman, A. L., Kaneda, R. R., et al. Radial
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(Am.) 63: 741, 1981.
11. Lamb, D. W. The treatment of radial club hand: Absent
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tralization of the radial club hand: An ulnar surgical ap-
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13. Sayre, R. H. A contribution to the study of club-hand. Trans.
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Quality Medical, 1994. P. 366.
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procedure for radial clubhand. J. Hand Surg. (Am.) 9: 541,
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16. Buck-Gramcko, D. Radialization as a new treatment for radial
club hand. J. Hand Surg. (Am.) 10: 964, 1985.
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 DISCUSSION
Preoperative Soft-Tissue Distraction for Radial Longitudinal
Deficiency: An Analysis of Indications and Outcomes
Kevin C. Chung, M.D., M.S.
Ann Arbor, Mich.

T reatment of radial longitudinal deficiency is

difficult. In type 4 deformity in which no
radius is present, radial deviation of the hand
result of cardiac disease. The two children with
modest results underwent multiple distraction
procedures but eventually developed recurrence
occurs because of the tendons inserting eccen- of radial wrist deviation. Another series applied
trically over the radial wrist. Radial curvature of ring distractors at a mean age of 5 years and
the ulna further accentuates the deformity. reported rather good outcomes.2 The authors
The traditional method of treating this condi- preferred the ring device because they had prob-
tion is to release the fibrous tissue tethering the lems with pin pull-out using uniplanar distrac-
hand radially and to transfer the eccentrically tors. They also pointed out the need to simulta-
positioned radial tendons to the ulnar hand. neously correct volar and radial subluxation of
However, the finger flexor tendons and the me- the carpus, which may not be achieved with lon-
dian nerve are positioned radially and may not gitudinal traction using the uniplanar device.
stretch sufficiently during the repositioning pro-
cedure. Although the soft-tissue deficiency over
the radial wrist can be treated with a bilobe flap
(Figs. 1 and 2), the flexor tendons and the me-
dian nerve cannot be lengthened without short-
ening of either the carpus or the ulna. Skeletal
shortening in an arm that is already underdevel-
oped may further hamper the growth of the
limb.
The use of preoperative distraction to stretch
tight radial tissue is an attractive idea. The soft
tissue in children is quite pliable, and a skeletal
distractor device can provide gentle stretching
of the soft tissue after initial release of the
fibrous tethering bands over the radial wrist.
This mode of treatment appears to be more
Fig. 1. A child with type 4 longitudinal radial deficiency.
effective than serial casting and passive stretch-
ing by parents or hand therapists. Intermittent
passive stretching by parents or therapists is
not particularly effective because of their fear
of hurting the child in these exercises. The
constant tension placed over the radial tissues
by the distraction device is more effective and
may be tolerable to a child.
In type 2 and 3 deficiency in which the
radius is hypoplastic, distraction osteotomy of
the radius to gain additional length has been
attempted.1 In four children treated with this
technique, two had modest results, one devel-
oped resorption of the distal radius and the
procedure was abandoned, and one died as a

Received for publication September 26, 2006. Fig. 2. Use of a bilobe flap transfers redundant tissue from the
Copyright ©2007 by the American Society of Plastic Surgeons ulnar wrist to augment the soft-tissue deficiency over the radial
DOI: 10.1097/01.prs.0000279494.35712.1e wrist after centralization.

www.PRSJournal.com 1313
 Plastic and Reconstructive Surgery • October 2007
This article emphasizes that the distraction de-
vice can be placed early in the child’s life when the
procedure is coordinated with the performance of
other operations. Longitudinal radial deficiency is
associated with other congenital problems, and
many of these problems require urgent surgical
treatments. Placement of the distraction device in
concert with other surgical procedures is logical. It
is quite possible that early placement of the distrac-
tor device can take advantage of the pliability of
the soft tissue in a young child. However, a few
devices were placed in the newborn period, which
may be a bit early. The centralization procedure
does not need to be performed until the child is
approximately 2 years old, when the structures in
the hand are larger, which makes the surgical pro-
cedure easier. There is no advantage to placing
these fixators in a newborn when the bones are
small and complications relating to pin place-
ment may occur. In addition, this series re-
ported that some of the children did die as a
result of other congenital problems after the
distraction procedures. It may be prudent to
wait until life-threatening conditions can be
solved before contemplating reconstruction.
Placement of the distraction device at 1 or 1.5
years of age in preparation for the centraliza-
tion procedure at 2 years of age is reasonable.
Recurrence of radial deviation after correction
of this deformity is not uncommon. It is difficult to
predict which child will develop recurrence. De-
spite relapse of the hand posture, many children
still function very well. It has been observed that
children with congenital hand problems can adapt
despite marked deformities. Even with the uncer-
tainty of outcomes, parents are generally pleased
with the efforts and the initial operative results and
will insist on attempting to correct this problem.
1314
Overall, the authors have presented a thought-
ful series in the treatment of type 4 longitudinal
deficiency of the radius. This article and others
have shown that placement of a preoperative
distraction device makes a subsequent centraliza-
tion procedure easier. Although multiplanar de-
vices have been used, they are more cumbersome
to adjust and may be unnecessarily complicated for
this problem. The use of a uniplanar device, as
advocated in this article, is simpler and achieves
the same outcome, provided that distraction is be-
gun early. Although the long-term result of cen-
tralization may be unpredictable, it is certainly a
worthwhile surgical procedure that is undertaken
by experienced pediatric hand surgeons. This re-
constructive effort gives the child a chance of a
better appearing hand and may ameliorate the
social stigmata associated with this congenital
problem.
Kevin C. Chung, M.D., M.S.
Section of Plastic Surgery
University of Michigan Health System
2130 Taubman Center
1500 East Medical Center Drive
Ann Arbor, Mich. 48109-0340
kecchung@med.umich.edu
DISCLOSURES
No funds were used to support this project. The
author has no financial interest in this article.
REFERENCES
1. Matsuno, T., Ishida, O., Sunagawa, T., Suzuki, O., Ikuta, Y.,
and Oshi, M. Radius lengthening for the treatment of Bayne
and Klug type II and type III radial longitudinal deficiency.
J. Hand Surg. (Am.) 31: 822, 2006.
2. Goldfarb, C. A., Murtha, Y. M., Gordon, J. E., and Manske, P.
R. Soft-tissue distraction with a ring external fixator before
centralization for radial longitudinal deficiency. J. Hand Surg.
(Am.) 31: 952, 2006.
IDEAS AND INNOVATIONS
A Prefabricated, Tissue-Engineered Integra
Free Flap
John M. Houle, M.D.
Michael W. Neumeister, M.D.
Springfield, Ill.
P
refabricated flaps were first described by
Yao in 1981.1 A vascular pedicle is trans-
ferred from its native site to another area of
the body and placed under the skin. The overlying
skin obtain its blood supply from vessels sprouting
from the vascular pedicle. The overlying paddle of
skin can then be subsequently transferred as an
axial or free flap based solely on the repositioned
vascular pedicle.
Some patients, such as those who are severely
burned, may not have adequate normal skin to
allow prefabrication of a flap. We present a case
of prefabrication of Integra (Life Sciences Corp.,
Plainsboro, N.J.) that was then successfully mi-
crosurgically transferred as a free flap following
contracture release of the left elbow.
CASE REPORT
A 36-year-old man suffered 80 percent total body surface area
full-thickness burns and anoxic brain injury in an explosion. He
underwent excision and grafting of the burns but subsequently
developed flexion contractures of all joints, especially the el-
bows, wrists, hips, and knees. His left elbow and wrist contrac-
ture (Fig. 1) caused his fingernails to dig into his chest, resulting
in a chronic ulcer. The patient underwent physical and occu-
pational therapy, but the contractures failed to improve with
conservative measures.
Release of the elbow contracture would result in exposure of
vital structures and therefore required free tissue flap coverage.
Donor sites for free flaps were very limited because of his ex-
tensive burn scarring. An anterolateral thigh free flap from the
right thigh was chosen as the donor site because it had been
relatively spared in the initial injury; it had served as a skin graft
donor site during his initial hospitalization.
The perforator vessels for the free flap were located with a
Doppler probe. The flap was elevated and the perforator was
found. However, the flap immediately began to look blue and
congested. The flap was therefore sutured back into place on
the leg and the wounds dressed. There were no outflow veins
available to attempt salvage of the venous congested flap. Dis-
section of the pedicle did not proceed at this setting. The
patient was returned to the operating room 48 hours later as the
From the Division of Plastic Surgery, Southern Illinois Uni-
versity School of Medicine.
Received for publication September 27, 2006; accepted Jan-
uary 5, 2007.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279495.73662.ca
1322 www.PRSJournal.com
flap was necrotic (Fig. 2). The flap was débrided, but the de-
scending branch of the lateral femoral circumflex vessels was
viable. It was felt that these vessels could be used for flap pre-
fabrication to avoid wasting the pedicle. Because the donor site
was limited, an attempt at prefabrication of Integra was enter-
tained. The pedicle was then isolated, along with its vena co-
mitans, and a small segment of muscle was maintained on the
distal pedicle. The muscle measured 1.5 ⫻ 1.5 cm. The pedicle
was placed on the vastus lateralis muscle. A cuff of Gore-Tex
(W. L. Gore & Associates, Flagstaff, Ariz.) vascular graft was
placed around the origin of the vessels to make future dissection
of the pedicle easier. The pedicle and the exposed vessels were
then covered with Integra (Fig. 3).
Two weeks later, the Integra was covered with a split-thick-
ness skin graft and healed completely. Five months later, the left
elbow contracture was released. The prefabricated Integra flap
was again outlined and raised as a flap based on the incorpo-
rated descending branch of the lateral femoral circumflex ves-
sels. The flap consisted of the previously placed Integra and a
surrounding strip of normal thigh skin 1.5 cm wide. An extra
cuff of native thigh skin was maintained with the flap because
this extra amount of tissue was required to fill the defect in the
left antecubital fossa. The flap was raised on its pedicle and
transferred as a free flap successfully (Fig. 4). Postoperatively,
the Integra remained healthy and viable. The surrounding strip
of native skin, however, did not survive beyond the limits of the
Integra (Fig. 5). This area peripherally was debrided and al-
lowed to heal by secondary intention. The Integra flap has
remained soft and pliable, preventing secondary contractures.
The flap’s artery had been anastomosed end-to-side to the bra-
chial artery and the vein had been anastomosed end-to-end to
a vena comitans. The Gore-Tex surrounding the pedicle was
removed on flap transfer.
DISCUSSION
Flap prefabrication is a successful way to ex-
pand the number of options available to the
surgeon for reconstruction of a wide variety of
defects.2–15 Some patients, however, may not have
adequate normal skin to allow prefabrication of a
flap. Prefabrication involves altering the blood sup-
ply of an area of native skin—specifically, transpos-
ing a vascular pedicle under the skin and subcuta-
neous tissue and waiting for the vascular sprouts
from the pedicle to supply the overlying skin. This
process may take weeks to months. The pedicle is
completely incorporated into the overlying tissues.
The overlying skin and subcutaneous tissue are sub-
sequently elevated on the vascular pedicle and trans-
ferred as either an axial or a free tissue transfer.
Volume 120, Number 5 • Prefabricated Integra Free Flap
Fig. 1. Flexion contracture of the left elbow in an 80 percent total
body surface area burn patient.
Fig. 2. Necrotic anterolateral thigh flap in situ.
In our case, we prefabricated a synthetic skin sub-
stitute matrix (Integra) and transferred the “tissue-
engineered constructs” as a free flap. Soft stable cov-
erage of the defect resulted. The initial anterolateral
thigh flap was likely devoid of appropriate perfora-
tors and subsequently not viable on the patent de-
scending branch of the lateral femoral circumflex
pedicle. Occasionally, arterial and venous perfora-
tors do not accompany each other as they emerge
from the main pedicle. This will lead to either ve-
nous or arterial insufficiency of the flap, which is
usually observed immediately on flap elevation as
was the case with our anterolateral thigh flap. How-
ever, to avoid waisting the pedicle and because there
were limited donor sites, prefabrication was enter-
tained. Because the defect on the thigh needed to be
closed with a skin graft, it was felt that we could still
use this donor site and the pedicle by using Integra.
Integra is an advanced wound care device
composed of a porous matrix of cross-linked
Fig. 3. Descending branch of the lateral femoral circumflex ar-
tery dissected free and covered with Integra.
bovine tendon collagen and glycosaminoglycan
and a semipermeable polysiloxane (silicone) layer.
The semipermeable silicone membrane con-
trols water vapor loss, provides a flexible adher-
ent covering for the wound surface, and adds
increased tear strength to the device. The col-
lagen-glycosaminoglycan biodegradable matrix
provides a scaffold for cellular invasion and cap-
illary growth.16 It has two interrelated modes of
use: as an effective acute skin substitute and as
a matrix for autogenous skin regeneration. It is
an effective means of treating multiple types of
wounds including those caused by macroarte-
rial, micro-occlusive, diabetic, venous, immuno-
pathic mechanical/traumatic, infectious, irradi-
ated, and malignant abnormalities and lymphedema.
Integra normally becomes vascularized from the
wound bed and can heal over areas of devascu-
larized tissue as well.17
Tark et al. have shown that prefabricated flaps
can be created by burying AlloDerm under the
skin. The AlloDerm (LifeCell Corp., The Wood-
1323
 Plastic and Reconstructive Surgery • October 2007
Fig. 4. Prefabricated Integra flap was marked out on the thigh,
elevated, and transferred to the antecubital fossa.
lands, Texas) revascularized and was then used as
a turnover flap to cover adjacent full-thickness skin
defects.4 This technique has limited uses, however,
as it does not allow for distant transfer and re-
quires the AlloDerm to be buried in a subcutane-
ous plane during the revascularization. MacLeod
et al. showed that Permacol (Conco Medical Co.,
Bridgeport, Conn.) could be vascularized by an
1324
Fig. 5. Successfully transferred, healed prefabricated Integra
free flap.
inferior epigastric artery and vein pedicle and
transferred as a pedicled flap12 but again required
that the Permacol matrix be buried in the subcu-
taneous plane during revascularization before be-
ing covered by a skin graft and transferred.
CONCLUSIONS
We have developed a method of prefabricat-
ing a sheet of Integra that can then be microsur-
gically transferred as a free flap. This represents
another option in the patient with limited flap
donor sites available who may require vascularized
stable tissue for wound coverage.
Michael W. Neumeister, M.D.
Division of Plastic Surgery
Southern Illinois University School of Medicine
P.O. Box 19653
Springfield, Ill. 62794-9653
mneumeister@siumed.edu
DISCLOSURE
The authors have not received any compensation or
support from Integra Life Sciences for this work.
Volume 120, Number 5 • Prefabricated Integra Free Flap

REFERENCES 9. Staudenmaier, R., Hoang, T. N., and Kleinsasser, N. Flap

1. Yao, S. T. Vascular implantation into skin flaps: Experimental
study and clinical application. A preliminary report. Plast.
Reconstr. Surg. 68: 404, 1981.
2. Tanaka, Y., Sung, K. C., Fumimoto, M., et al. Prefabricated
engineered skin flan using an arteriovenous vascular bundle as
a vascular carrier in rabbits. Plast. Reconstr. Surg. 117: 1860, 2006.
3. Teng, M. S., Malkin, B. D., and Urken, M. L. Prefabricated
composite free flaps for tracheal reconstruction: A new tech-
nique. Ann. Otol. Rhinol. Laryngol. 114: 822, 2006.
4. Nguyen, T. H., Kloeppel, M., Staudenmaier, R., et al. Study
of the neovascularization of prefabrication of flaps using a
silicone sheet and an isolated arterial pedicle: experimental
study in rabbits. Scand. J. Plast. Reconstr. Surg. Hand Surg. 29:
326, 2006.
5. Silistreli, O. K., Demirdover, C., Ayhan, M., et al. Prefabri-
cated nasolabial flap for reconstruction of full-thickness dis-
tal nasal defects. Dermotol. Surg. 31: 546, 2005.
6. Hoang, N. T., Kloeppel, M., Staudenmaier, R., et al. Prefab-
rication of large fasciocutaneous flaps using an isolated ar-
terialized vein as implanted vascular pedicle. Br. J. Plast. Surg.
58: 632, 2005.
7. Prakash, V., Mishra, L. K., and Mantri, R. Management of
deep palmar burns with reverse prefabricated radial fascial
flaps. Plast. Reconstr. Surg. 115: 1220, 2005.
8. Hoang, N., Kloeppel, M., Staudenmaier, R., et al. Neovascular-
ization in prefabricated flaps using a tissue expander and an
implanted arteriovenous pedicle. Microsurgery 25: 213, 2005.
prefabrication and prelamination with tissue-engineered car-
tilage. J. Reconstr. Microsurg. 20: 555, 2004.
10. Maitz, P. K., Khot, M. B., Mayer, H. F., et al. Continuous and
real-time blood perfusion monitoring in prefabricated flaps.
J. Reconstr. Microsurg. 20: 35, 2004.
11. Garfein, E. S., Orgill, D. P., and Pribaz, J. J. Clinical appli-
cation of tissue engineered constructs. Clin. Plast. Surg. 30:
485, 2003.
12. MacLeod, T. M., Williams, G., Sanders, R., and Green, C.
J. Prefabricated skin flaps in a rat model based on a dermal
replacement matrix Permacol. Br. J. Plast. Surg. 56: 775,
2003.
13. Pribaz, J. J., and Fine, N. A. Prefabricated and prelaminated
flaps for head and neck reconstruction. Clin. Plast. Surg. 28:
261, 2001.
14. Akin, S. Burned ear reconstruction using a prefabricated free
radial forearm flap. J. Reconstr. Microsurg. 17: 233, 2001.
15. Teot, L., Cherenfant, E., Otman, S., and Giovannini, U. M.
Prefabricated vascularized supraclavicular flaps for face re-
surfacing after postburns scarring. Lancet 355: 1695, 2000.
16. Integra Life Sciences Corporation (web page). Avail-
able at: http://www.integra-ls.com/products/?product⫽122.
Accessed August 15, 2005.
17. Tark, K. C., Chung, S., Shin, K., and Park, B. Y. Skin flap
prefabrication using acellular dermal matrix and cultured
keratinocytes in a porcine model. Ann. Plast. Surg. 44:
392, 2000.

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1325
 PEDIATRIC/CRANIOFACIAL

The Diagnosis and Treatment of Single-Sutural

Synostoses: Are Computed Tomographic
Scans Necessary?
Jeffrey A. Fearon, M.D.
Background: Computed tomographic scan evaluation is the current standard of
Davinder J. Singh, M.D. care for diagnosing craniosynostosis. Recent publications, and the National
Stephen P. Beals, M.D. Cancer Institute, have raised concerns about ionizing radiation associated with
Jack C. Yu, D.M.D., M.D. computed tomographic scans in children (e.g., developmental delays, tumor
Dallas, Texas; Philadelphia, Pa.; induction). The authors sought to ascertain the diagnostic accuracy of the
Phoenix, Ariz.; and Augusta, Ga. physical examination in evaluating single-sutural craniosynostosis and assess the
need for computed tomographic scans in surgical correction.
Methods: This prospective, multicenter, outcome assessment included children
clinically diagnosed with a single-sutural synostosis by craniofacial surgeons (with 1
to 18 years’ experience) at four centers over a 1-year period. Clinical diagnoses were
compared with computed tomographic scan evaluations. All surgeons scored the
utility of computed tomographic scans during surgical repair.
Results: Sixty-seven patients were clinically diagnosed with single-sutural cranio-
synostosis (mean age, 7 months; range, 1 week to 48 months). Sixty-six of 67 patients
were diagnosed with craniosynostosis by computed tomographic scan (sagittal, 40
percent; metopic, 31 percent; right unilateral coronal, 16 percent; left unilateral
coronal, 6 percent; and right lambdoid, 6 percent), for a diagnostic accuracy
exceeding 98 percent. One patient with suspected lambdoid synostosis was radio-
logically diagnosed with positional plagiocephaly. Three of four craniofacial sur-
geons scored computed tomographic scans as “unnecessary” for surgical correction;
one scored scans as “sometimes helpful.”
Conclusions: Craniofacial surgeons with various experience levels were able to
accurately diagnose single-sutural synostosis by physical examination alone. Con-
sidering potential side effects from ionizing radiation, risks of sedation, and costs,
surgeons may wish to reserve computed tomographic scans only for infants with
suspected single-sutural craniosynostosis in whom the physical examination is not
clearly diagnostic. (Plast. Reconstr. Surg. 120: 1327, 2007.)

T
he current standard of care for diagnosing
craniosynostosis is to obtain a computed
tomographic scan. Early craniofacial sur-
geons relied on plain radiographs to diagnose
sutural fusion, but with the introduction of the
computed tomographic scan came an improve-
ment in diagnostic accuracy. Three-dimensional
computed tomographic scans permit excellent
visualization of the underlying bony architec-
From the Craniofacial Center, Medical City; Division of
Plastic Surgery, University of Pennsylvania; The Southwest
Craniofacial Center; and Division of Plastic Surgery, Med-
ical College of Georgia.
Received for publication January 28, 2006; accepted March
28, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279477.56044.55
ture, helping surgeons appreciate bony anoma-
lies and plan surgical correction. Three-dimen-
sional models can be created from computed
tomographic scans, permitting the use of trial
osteotomies, and may further assist with surgical
planning. At a time when craniofacial surgeons
have come to develop a greater reliance on com-
puted tomographic scans, some recent studies
have evaluated potential problems associated
with ionizing radiation, calling the ubiquitous
use of computed tomographic imaging into
question.1–7 Motivated by the concerns raised by
recent publications, which have explored possi-
ble negative effects on the developing brain
caused by the ionizing radiation associated with
computed tomographic scans, this prospective,
multicenter study was undertaken to evaluate
the diagnostic accuracy of the physical examina-

www.PRSJournal.com 1327
 Plastic and Reconstructive Surgery • October 2007

tion for single-suture synostoses and to evaluate with a posterior plagiocephaly suspicious for lamb-
the roll of these scans in the surgical correction doid synostosis but was subsequently demon-
for these conditions. strated to have a positional plagiocephaly. The
mean age at presentation for all patients was 7
PATIENTS AND METHODS months, and the ages ranged from 1 week to 48
This prospective, multicenter, clinical out- months. The distribution of involved sutures was
come study was undertaken following exemption as follows: 27 sagittal sutures (40 percent), 21
approval from the Institutional Review Committee metopic sutures (31 percent), 11 right unilateral
at Medical City Dallas Hospital. In addition to the coronal sutures (16 percent), four left unilateral
Dallas Center, data were also collected from three coronal sutures (6 percent), and four right lamb-
other craniofacial centers (listed by the order in doid sutures (6 percent). The data from the four
which the data were received): The Children’s centers are summarized in Table 1. After surgical
Hospital of Philadelphia, the Southwest Cranio- correction, three of the four craniofacial surgeons
facial Center in Phoenix, and the Medical College agreed that the computed tomographic scan was
of Georgia in Augusta. Craniofacial surgeons at not required during the surgical correction and
these four centers ranged in experience from 1 to that their patients’ treatment would not have been
over 18 years of clinical practice at the start of the compromised if a scan had not been performed.
study period. Only one craniofacial surgeon par- However, one of the four surgeons believed that
ticipated in this study from each of these four computed tomographic scans were slightly helpful
centers. Over a 1-year period, all children present- at surgery. There were no patients, over this same
ing with an abnormal skull shape diagnosed as a time period, who were shown to have craniosyn-
single-sutural synostosis on the basis of a physical ostosis by computed tomographic scan after hav-
examination (by a single craniofacial surgeon at ing been diagnosed, by physical examination, with
each center), and subsequently undergoing a possible positional plagiocephaly.
computed tomographic scan to corroborate the
diagnosis, were entered into this study. The sur-
geon recorded initial diagnostic impressions and, DISCUSSION
subsequent to this, a computed tomographic scan In the evaluation of a child with a suspected
was reviewed. The results of the radiologic evalu- single-sutural craniosynostosis, the current stan-
ation were then compared with the recorded ini- dard of care is to obtain a computed tomographic
tial diagnostic impressions to assess the diagnostic
accuracy of the physical examination. After surgi- Table 1. Combined Data from Four Craniofacial
cal intervention, all surgeons were asked to doc- Centers*
ument how helpful, or necessary, they found the
computed tomographic scan to be in the surgical Average Correlation between
Distribution of Age Clinical and CT
correction. Thirteen patients, all from center 2, Clinical Diagnoses No. (mo) Diagnoses
were not included in this study because they were
Center 1 (n ⫽ 27) 7 27/27
diagnosed with a single-sutural synostosis and sub- Sagittal 12
sequently treated surgically, without a computed Metopic 9
tomographic scan. In none of these 13 patients was Unilateral coronal 4
Lambdoid 2
the clinical diagnosis of craniosynostosis found to Center 2 (n ⫽ 13) 13 12/13
be incorrect during surgery. Sagittal 3
Metopic 4
Unilateral coronal 5
RESULTS Lambdoid 1
Over a 1-year period, 67 patients were diag- Center 3 (n ⫽ 18) 5 18/18
nosed with a single-sutural craniosynostosis by Sagittal 7
Metopic 7
craniofacial surgeons at one of four different cen- Unilateral coronal 3
ters based on physical examination. Sixty-six of Lambdoid 1
these 67 patients received the diagnosis of cranio- Center 4 (n ⫽ 9) 6 9/9
Sagittal 5
synostosis by computed tomographic scan, for a Metopic 1
diagnostic accuracy of just over 98 percent. Only Unilateral coronal 3
one of 67 patients given the preliminary diagnosis Lambdoid 0
of craniosynostosis on examination was subse- CT, computed tomographic.
*Center 1, Medical City Dallas Hospital; center 2, The Children’s
quently shown by computed tomographic scan to Hospital of Philadelphia; center 3, the Southwest Craniofacial Center
have open sutures; this single patient presented in Phoenix; and center 4, the Medical College of Georgia in Augusta.

1328
Volume 120, Number 5 • Single-Sutural Synostoses
scan. Many experienced craniofacial centers ob-
tain detailed three-dimensional imaging to more
fully evaluate suspected craniosynostosis. Re-
cently, a number of studies have raised questions
about the risks of ionizing radiation in children,
including the potential for tumor induction and
developmental delays. Although many environ-
mental agents are hypothesized to induce brain
tumors, only ionizing radiation has a proven eti-
ologic role.1 The human brain continues to grow
for 2 to 3 years after birth, and the fetal brain has
been shown to be less able to repair any alkylated
DNA that may have been induced by various mu-
tagens; the result of this deficiency of repair, com-
bined with a period of rapid cell division, makes
the infant’s brain more likely to replicate muta-
tional errors.1 Ron et al. have reported a seven-fold
increase in neoplasms of the nervous system in
children who had undergone radiation for the
treatment of tinea capitis, compared with a con-
trol group.2 Brenner et al. estimated the lifetime
cancer mortality risk attributable to the radiation
exposure from a single head computed tomo-
graphic in a 1-year-old was one in 1500, and cal-
culated that among the 600,000 head and abdom-
inal computed tomographic scans performed
yearly in children younger than 15 years, 500
might ultimately die as a result of cancer attrib-
utable to these scans.3 In addition to the risks of
tumor development, questions have been raised
about the negative effects of ionizing radiation on
cognitive function.4 In comparing children
younger than 5 years who had undergone radia-
tion therapy with chemotherapy, chemotherapy
alone, and a control group, Anderson et al. found
that those who had received radiation had cumu-
lative deficits in nonverbal and information pro-
cessing skills.5 Hall et al. examined the possibility
that ionizing radiation in infancy might affect cog-
nitive function in later adulthood.6 They per-
formed a retrospective population-based cohort
study and found that there was an adverse affect
on adult cognitive function for those children
(younger than 18 months) receiving moderate
doses of ionizing radiation (estimated to be similar
to that of a head computed tomographic scan) for
the treatment of vascular lesions of the scalp.
Many studies suggest a dose-dependant effect
of ionizing radiation with respect to both cognitive
dysfunction and the subsequent development of
tumors. However, no minimal safe dose has been
established.7 The actual dose of ionizing radiation
from a computed tomographic scan varies signif-
icantly according to the machinery, techniques,
protocols, and desired image quality.8 The Na-
tional Cancer Institute has recognized the risks of
radiation in infants and small children and has
made a number of recommendations, including
the following: guidelines based on size and weight
parameters should be used in children, the region
scanned should be limited to the smallest neces-
sary area, the lowest resolution scan needed for
diagnosis should be used, and other imaging mo-
dalities should be considered.9 Recently, some in-
vestigators have examined the use of ultrasound in
the diagnosis of craniosynostosis.10,11 In addition
to concerns about risks associated with ionizing
radiation, an additional risk is introduced with the
sedation, or anesthesia, that many centers rou-
tinely use in infants and small children undergo-
ing computed tomographic scans.
One final consideration is the cost of obtain-
ing a scan. As health care expenditures rise, many
states seek to contain costs by raising qualifying
income levels for Medicaid coverage, which results
in more children being uninsured. If craniofacial
surgeons are confident of their diagnosis, elimi-
nating a computed tomographic scan makes eco-
nomic sense; theoretically, these savings might be
used to provide health care to other needy indi-
viduals. Patients undergoing a craniofacial com-
puted tomographic scan at Medical City Dallas
Hospital in 2005 were billed $2195, which in-
cluded the scan, anesthesia, and interpretation by
a neuroradiologist.
Computed tomographic scans can provide sur-
geons valuable information, in terms of both the
diagnosis and the treatment of the craniosynos-
toses. Both syndromic and complex (e.g., nonsyn-
dromic, multiple suture) craniosynostoses may
have related intracranial findings, and a radiologic
assessment (by either computed tomography or
magnetic resonance imaging) is required to eval-
uate the brain parenchyma and ventricular size
and to assess possible cerebellar tonsillar hernia-
tion and other factors. Aside from diagnostic con-
siderations, computed tomographic scans can sup-
ply information helpful during surgical repair in
certain cases; for example, in children older than
1 year, cranial bone graft harvest is required to fill
in any calvarial defects. The coronal sections pro-
vided by computed tomographic scans may offer
valuable insight into potential bone graft harvest
locations. Scans can also help to reveal the loca-
tion of artificial materials that many surgeons use
in reconstruction, which is important for surgeons
performing repeat procedures. Scans also provide
a three-dimensional image of bony architecture
that may be helpful to many surgeons in surgical
planning. Finally, over a decade ago, many infants
1329
 Plastic and Reconstructive Surgery • October 2007
believed to have craniosynostosis on the basis of a
physical examination and/or plain radiographs
and who were subsequently diagnosed with a de-
formational plagiocephaly underwent unneces-
sary surgery. Much has been subsequently learned
about the physical presentation of single-sutural
synostosis, particularly the rare presentation for
lambdoid synostosis, in part because of the excel-
lent anatomical visualization provided by three-
dimensional computed tomographic scans.12
This current study was designed to examine
the diagnostic accuracy of the physical examina-
tion in the evaluation of the single-sutural cranio-
synostoses. These isolated synostoses were selected
for review because they are not commonly asso-
ciated with any intracranial problems that might
require imaging. Many senior physicians bemoan
that the art of the physical examination has been
lost to technology. How many of us in our training
heard the phrase: “when all else fails, look at the
patient”? The scalp in infants is quite thin, per-
mitting accurate visualization of the underlying
skull. The results of our prospective analysis sug-
gest that craniofacial surgeons, even with differing
levels of experience, can accurately diagnose sin-
gle-sutural craniosynostosis without the use of a
computed tomographic scan. This study also
showed that most surgeons did not believe that a
computed tomographic scan was useful during the
surgical correction of the single-sutural synosto-
ses. The diagnostic accuracy of the physical exam-
ination pooled from all centers was 98 percent
overall and 100 percent for surgeons with 10 or
more years of experience. The sole case in this
series of 67 patients in which the clinical diagnosis
differed from the radiologic diagnosis was a pa-
tient with a posterior positional plagiocephaly. We
recognize that the diagnosis of lambdoid synosto-
sis can be challenging even for the most experi-
enced craniofacial surgeons. Most craniofacial
surgeons would probably agree that for the single-
sutural synostoses, the computed tomographic
scan is almost always more a confirmatory tool
than a diagnostic one. The metopic suture, which
can close prematurely without causing overt trig-
onocephaly, teaches us that not all craniosynos-
tosis requires correction. It is not the fused suture
that demands treatment, it is the resultant alter-
ation in the shape and size of the calvaria. Mildly
affected skulls, despite closed sutures, may argu-
ably not require surgical intervention. Therefore,
if treatment is dependant on the degree of devi-
ation from normal, this should be readily identi-
fiable on examination.
1330
Obviously, surgeons must balance the cost-to-
benefit ratio for each patient. Are the small risks
associated with ionizing radiation and anesthesia,
and associated costs, outweighed by the potential
for a misdiagnosis (including the potential for
unnecessary surgery)? We suspect that this bal-
ance is influenced not only by the phenotypic
presentation of the child (e.g., severity) but also by
the experience level of the surgeon. We do not
recommend that all surgeons should abandon
computed tomographic imaging for all patients
with presumed single-sutural synostosis. However,
we do believe that the results of this study suggest
that those who treat single-suture craniosynostoses
should reexamine the need for imaging studies for
these otherwise uncomplicated conditions, and
that the standard of care should not dictate that
scans be obtained on all patients. Craniofacial sur-
geons might consider reserving the use of com-
puted tomographic scans for those patients with a
suspected single-sutural synostosis in whom the
physical examination does not provide a clear di-
agnosis; for patients with syndromic synostoses,
consideration should be given to substituting mag-
netic resonance imaging scans for computed to-
mographic scans for evaluating and monitoring
intracranial abnormality.
CONCLUSIONS
We found that the physical examination is a
very sensitive tool in the diagnosis of the single-
sutural craniosynostoses. On the basis of these
findings and concerns raised by others about the
effects of ionizing radiation on infants, surgeons
may wish to reexamine the routine use of com-
puted tomographic imaging for these patients.
Jeffrey A. Fearon, M.D.
Craniofacial Center
7777 Forest Lane, C-700
Dallas, Texas 75230
cranio700@aol.com
DISCLOSURES
None of the authors involved in the production of
this article has any commercial associations that might
pose or create a conflict of interest with the information
presented herein. Such associations include consulta-
tions, stock ownership or other equity interests, patent
licensing arrangements, and payments for conducting or
publicizing a study described in the article. No intra-
mural or extramural funding supported any aspect of
this work.
Volume 120, Number 5 • Single-Sutural Synostoses
REFERENCES
1. Baldwin, R. T., and Preston-Martin, S. Epidemiology of brain
tumors in childhood: A review. Toxicol. Appl. Pharmacol. 199:
118, 2004.
2. Ron, E., Modan, B., Boice, J. D., et al. Tumors of the brain
and nervous system after radiotherapy in childhood. N. Engl.
J. Med. 319: 1033, 1988.
3. Brenner, D. J., Elliston, C. D., Hall, E. J., and Berdon, W. E.
Estimated risks of radiation-induced fatal cancer from pedi-
atric CT. A.J.R. Am. J. Roentgenol. 176: 289, 2001.
4. Gamache, G. L., Levinson, D. M., Reeves, D. L., et al. Lon-
gitudinal neurocognitive assessments of Ukrainians exposed
to ionizing radiation after the Chernobyl nuclear accident.
Arch. Clin. Neuropsychol. 20: 81, 2005.
5. Anderson, V. A., Godber, T., Smibert, E., et al. Cognitive and
academic outcome following cranial irradiation and chemo-
therapy in children: A longitudinal study. Br. J. Cancer 82:
255, 2000.
6. Hall, P., Adami, H.-O., Trichopoulos, D., et al. Effect of low
doses of ionising radiation in infancy on cognitive function
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in adulthood: Swedish population base cohort study. B.M.J.
328: 19, 2004.
7. Schull, W. J., and Otake, M. Cognitive function and prenatal
exposure to ionizing radiation. Teratology 59: 222, 1999.
8. Seibert, J. A. Tradeoffs between image quality and dose.
Pediatr. Radiol. 34 (Suppl. 3): S183, 2004.
9. National Cancer Institute. Radiation Risks and Pediatric
Computed Tomography (CT): A Guide for Health Care Pro-
viders. Available at: www.cancer.gov/cancertopics/causes/
radiation-risks-pediatric-ct. Accessed August 1, 2007.
10. Soboleski, D., Mussari, B., McCloskey, D., et al. High-reso-
lution sonography of the abnormal cranial suture. Pediatr.
Radiol. 28: 79, 1998.
11. Sze, R. W., Parisi, M. T., Sidhu, M., et al. Ultrasound screen-
ing of the lambdoid suture in the child with posterior pla-
giocephaly. Pediatr. Radiol. 33: 630, 2003.
12. Huang, M. H., Gruss, J. K., Clarren, S. K., et al. The differ-
ential diagnosis of posterior plagiocephaly: True lambdoid
synostosis versus positional molding. Plast. Reconstr. Surg. 98:
765, 1996.
1331
PEDIATRIC/CRANIOFACIAL

Use of Calcium-Based Bone Cements in the

Repair of Large, Full-Thickness Cranial Defects:
A Caution
James E. Zins, M.D.
Andrea Moreira-Gonzalez,
M.D.
Frank A. Papay, M.D.
Cleveland, Ohio
Background: Calcium-based bone cements have increased in popularity for the
correction of craniofacial contour defects. The authors’ experience with them
in more than 120 patients has resulted in the establishment of strict criteria for
their use. Although the authors’ overall complication rate with these cements
has been low, certain patient groups have an unacceptably high complication
rate. The authors describe their experience with the repair of large, full-thick-
ness cranial defects using calcium-based bone cements.
Methods: The study group comprised 16 patients who underwent correction of
large, full-thickness (⬎25 cm2) skull defects. The surgical technique included
reconstruction of the floor of the defect with rigid fixation to the surrounding
native bone, interposition of the cement to ideal contour, and closure of the
defect.
Results: The mean patient age was 35 years (range, 1 to 69 years). The mean
defect area was 66.4 cm2 (range, 30 to 150 cm2). Cases were equally divided
between BoneSource and Norian CRS. The mean amount of bone cement used
was 80 g. Follow-up varied between 1 and 6 years (mean, 3 years). Major
complications occurred in eight of 16 patients, with one occurring as late as 6
years postoperatively. Complications occurred throughout the course of review,
indicating that they were not caused by a learning curve.
Conclusion: Because of the unacceptably high complication rate with the use of
calcium-based bone cements in large skull defects, the authors believe that their use
is contraindicated and have returned to using autogenous split skull cranial bone
reconstruction for these patients. (Plast. Reconstr. Surg. 120: 1332, 2007.)

R
econstruction of individuals with large cal-
varial defects can be especially challeng-
ing. These patients often have had a com-
plex course including multiple operations
complicated by previous infection, osteonecro-
sis, and/or radiotherapy. Moreover, large
amounts of reconstructive material are fre-
quently needed, adding to the difficulty of the
reconstructive effort.
Before 1998, cranial bone reconstruction was
our method of choice for such large defects.
However, the harvesting of cranial bone has its
From the Department of Plastic Surgery, Cleveland Clinic
Foundation.
Received for publication January 18, 2006; accepted April
20, 2006.
Presented at the 84th Annual Meeting of the American
Association of Plastic Surgeons, in Scottsdale, Arizona, May
8 through 11, 2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279557.29134.cd
drawbacks. It is not without complications and
there is a limit to the amount of autogenous
bone stock available. Therefore, materials such
as the calcium-based bone cements were initially
attractive to us. Calcium-based bone cements are
said to be biocompatible and osteoconductive,
and to have potential for bone replacement (up
to 60 to 70 percent in some series).1–5 Further-
more, reports have shown that calcium-based
bone cements have high tissue tolerance and few
complications.1,2,4,6 The U.S. Food and Drug Ad-
ministration has approved calcium-based ce-
ments for bony defects up to 25 cm2. The com-
plications rates in these studies vary widely.1,7–10
Some recent publications allude to a high com-
plication rate in large defects, whereas others
question the biomechanical strength of these
constructs.10,11
Over the past 8 years, our experience with
calcium-based bone cements in over 120 patients
has resulted in the establishment of strict criteria
for their use. Although our overall complication

1332 www.PRSJournal.com
Volume 120, Number 5 • Calcium-Based Bone Cements
rate with bone cements was low, certain patient
groups have an unacceptably high complication
rate.
The object of this report is to describe our
experience with the reconstruction of large, full-
thickness cranial defects using calcium phos-
phate-based bone cements. On the basis of this
experience, we hope to refine and define the
indications for their safe use.
PATIENTS AND METHODS
Between 1996 and 2004, 121 patients with an
average age of 24 years were treated with bone
cements at our institution. Of these 121 patients,
16 underwent reconstruction for large, full-thick-
ness skull defects. Large defects were described as
greater than 25 cm2. Each of the 16 patients were
clearly informed that the calcium-based bone ce-
ments were not approved for defects larger than
25 cm2 and that these materials were, therefore,
being used off label (i.e., they were being used in
situations not recommended by the U.S. Food and
Drug Administration or the manufacturer). How-
ever, after full discussion, each patient or legal
guardian agreed to proceed. These 16 patients
were reviewed retrospectively and data relevant to
each case were collected and evaluated. All pa-
tients were referred to us by neurosurgical services
at our own institution or elsewhere for the cor-
rection of postcraniectomy defects.
Patients were operated on by two surgeons
(J.Z. and F.P.). The surgical technique consisted
of subperiosteal exposure of the operative site
through the previous incision. Occasionally, the
original incision was extended for better access. A
subperiosteal dissection of the skull defect was
performed exposing all free edges. Any dural de-
hiscence or loss was first repaired; patched with
pericranium, temporalis fascia, or fascia lata if nec-
essary; and sealed with fibrin glue. Titanium mesh
was trimmed to a size that overlapped the edges of
the defect and “molded” to fit its exact contour.
That is, the free edges of the titanium overlapped
the periosteal (superficial) surface of the skull and
the remainder of the titanium mesh was adjusted
to conform to the dural surface of the skull defect.
Thus, no dead space remained. The mesh was
then fixed with “relative” rigid fixation using mi-
cro screws to the surrounding superficial surface
of the native bone. When the cranioplasty was
performed in the growing skeleton, resorbable
mesh was used rather than titanium (two cases).
For hydroxyapatite paste application, the manu-
facturer’s recommendations were strictly fol-
lowed. BoneSource (Stryker-Leibinger, Kalama-
zoo, Mich.) was prepared by mixing either water
or sodium phosphate with the powder until a
workable paste was obtained. Early in our experi-
ence, water was used; whereas later, sodium phos-
phate replaced water, because sodium phosphate
has been found to reduce the setting time. The
Norian Craniofacial Repair System (Synthes, Inc.,
Westchester, Pa.) was placed in the Norian pneu-
matic mixer provided by Synthes and agitated for
2 minutes. The bone cement was then placed into
the defect to ideal contour. The volume used was
predicated on this ideal contour. The cement was
then allowed to set until hardened. Applying ad-
ditional paste (layering) once the initial cement
was dry was strictly avoided. Closure was per-
formed once dry. Suction drains were used in all
cases and removed postoperatively when the
drainage was less than 30 cc/24 hours. All patients
received antibiotic therapy for 7 days after surgery.
After discharge, they were seen in the plastic sur-
gery clinic 1 week, 1 month, 3 months, 6 months,
and yearly after surgery.
Data were summarized using descriptive sta-
tistics. Categorical factors were described using
frequencies and percentages, and continuous
measures were summarized using mean and
ranges.
RESULTS
The age range for the 105 patients who had
reconstruction with calcium-based cements for de-
fects smaller than 25 cm2 or for whom cement was
used as an onlay was 22 months to 63 years. Pa-
tients were followed after reconstruction for a
mean of 19 months (range, 8 to 36 months). In
this group, the complication rate was 12 percent.
Of the 16 patients operated on for large (⬎25
cm2) full-thickness defects, 11 were male patients
and five were female patients. The mean age was
35 years (range, 1 to 69 years). The majority of the
cases (n ⫽ 9) had calvarial reconstruction with
calcium-based bone cements after removal of in-
fected or osteonecrotic cranial bone flaps second-
ary to their neurosurgical procedures; there were
five posttrauma reconstructions and two immedi-
ate reconstructions after tumor removal. A total of
19 cranioplasties were performed using bone ce-
ments. Three patients had two procedures for re-
construction using bone cement. The mean time
between infected bone flap removal and definitive
cranial reconstruction was 12.6 months (range, 6
to 21 months).
The reconstructive procedures involved the
frontoparietal region in 25 percent (n ⫽ 4), the
frontal bone in 18.75 percent (n ⫽ 3), the tem-
1333
 Plastic and Reconstructive Surgery • October 2007

Cement fragmentation
Cement fragmentation

Cement fragmentation

Cement fragmentation
Cement fragmentation

Cement fragmentation
Cement fragmentation

Cement fragmentation
Complications

plus infection

plus infection

plus infection
Commercial

BoneSource

BoneSource

BoneSource

BoneSource
Preparation

Norian

Norian

Norian

Norian
Amount

Fig. 1. The mean time between the reconstruction with calcium

(cc)
60
30

40

20
50

10
35

25

phosphate cement and the occurrence of major complication

was 27.2 months (2.5 years). The graph depicts the occurrence of
major complications over time. The patient numbers correlate
with those in Table 1. The majority of complications (five of
Temporoparietal

Parietotemporal
Frontotemporal

eight) occurred 1 years or more after surgery.

Region
Defect

*Of the 16 patients with large full-thickness defects, eight developed major complications requiring reoperation.
Occipital
Parietal

Parietal

Parietal
Frontal

poroparietal region in 18.75 percent (n ⫽ 3), the

parietal bone in 18.75 percent (n ⫽ 3), the fron-
totemporal region in 12.5 percent (n ⫽ 2), and the
occipital bone in 6.25 percent (n ⫽ 1) of the cases.
Defect
(cm2)

42.2

All defects measured greater than 25 cm2, with a

63
72

108

63
63

132

81

mean size of 66 cm2 (range, 30 to 150 cm2) (Table

1). The mean amount of bone cements used in the
reconstruction was 80 g. BoneSource was used in
Osteoradionecrosis
Cement infection

nine and Norian in 10 of the 19 reconstructive

reconstruction
Indication for
Cranioplasty

procedures. Follow-up varied between 1 and 6

Osteomyelitis
Osteomyelitis

Osteomyelitis

Osteomyelitis

Osteomyelitis
Immediate

years, with a mean of 3 years.

Of the 16 patients, 10 required reoperation
(62.5 percent). Two patients had minor problems:
one had contour irregularities and needed con-
Table 1. Characteristics of Each Case in the Study*

touring of the area; the other had some resorption

of the alloplast and had more cement implanted.
plus radiotherapy
Intractable seizure
Meningioma plus

Eight patients had major complications, with one

radiotherapy
Diagnosis

occurring as late as 6 years postoperatively (range,

Primary

Hemangioma

Brain tumor
Brain tumor

Brain tumor

2 months to 6 years; mean, 28 months) (Fig. 1)

Aneurysm

Aneurysm

(Table 1). Of these eight patients with major com-

plications (Figs. 2 through 7), three presented
with fragmentation of the bone cement and in-
fection (positive cultures) and five presented with
fragmentation with negative cultures. In this sub-
Sex

M
M

M
F
F

group of patients with major complications, the

mean defect size was 86.6 cm.2 The frontal bone
F, female; M, male.

was affected in four, the parietal bone in three

Age
(yr)
58
39

69
36

20
54

62

patients, and the occipital bone in one patient.

When fragmentation or fracture occurred,
the cement was completely removed in all cases.
Patients

No further reconstruction was performed at the

1
2

4
5

6
7

time of debridement. Secondary reconstruction

1334
Volume 120, Number 5 • Calcium-Based Bone Cements

Fig. 2. Case 8. (Above) Preoperative views of a 62-year-old man after removal of an infected
cranial bone flap. He had previously undergone meningioma resection and radiotherapy. The
defect measured 41 cm2. (Below, left) View of the patient at 6-year follow-up after calcium-based
bone cement reconstruction; he presented with fluid collection over the reconstructed area.
(Below, right) Computed tomographic scan shows displacement of the cement, fragmentation,
and fluid over the area.

was performed in four cases, with autogenous DISCUSSION

split cranial bone used in three cases and bone
cement in one. In four patients, no further re-
construction was performed. If cultures proved
to be positive at the time of alloplast removal,
secondary reconstruction with bone cement was
delayed for 1 year.
Plastic surgeons continue to search for the
ideal material for reconstruction of the cranio-
facial skeleton. The best material for use today
remains hotly debated. The adult skull provides
a large amount of bone stock for grafting pur-
poses and is generally the material of choice

1335
 Plastic and Reconstructive Surgery • October 2007

Fig. 3. Case 3. (Above, left) Preoperative view of a 4-year-old boy who had undergone hemi-
spherectomy for intractable seizures. Bone flap was removed because of infection. (Above, right)
The resultant full-thickness skull defect measured 108 cm2. (Below, left) The floor of the defect was
reconstructed using resorbable (LactoSorb; Lorenz Surgical, Jacksonville, Fla.) plates. (Below, right)
The calcium-based bone cement was placed into the defect to provide ideal contour.

among craniofacial surgeons.12–15 However, au-
togenous reconstructions may undergo long-
term resorption and graft harvest may result in
rare but significant morbidity.16,17 At least one
death has been reported secondary to cranial
graft harvest.18 Although alloplasts do not
resorb, they can extrude or become exposed at
any time during the lifetime of the patient. Fur-
thermore, when used in a patient with a previous
bone infection, the literature clearly documents the
need for a 12-month hiatus between bone flap re-
moval and alloplastic reconstruction.19 This there-
fore delays definitive reconstruction significantly.
A variety of calcium-based ceramics have been
available for craniofacial reconstruction for over 30
years. These include hydroxyapatite granules, cor-
alline hydroxyapatite and, more recently, calcium-
based bone cements.4,5 Initial clinical experience was
with ceramic hydroxyapatite and hydroxyapatite
granules. Although ceramic hydroxyapatite revascu-

1336
Volume 120, Number 5 • Calcium-Based Bone Cements

Fig. 4. Case 3. (Left) Three years after reconstruction, the patient returned with marked contour
irregularities and was operated on again. The calcium-based bone cement had fractured and was
removed. (Right) Postoperative anterior view. This patient had a previous history of multiple falls.

larized to some degree and was osteoconductive, it

was also brittle and therefore difficult to contour.4
Block hydroxyapatite found perhaps its best use as
an interposition implant following orthognathic or
genioplasty surgery.20,21 Hydroxyapatite granules
also saw limited application as bone filler. These
were predominantly replaced by fibrous tissue and,
if the defect was not carefully prepared, the granules
tended to migrate.22
Hydroxyapatite cement and ceramic hydroxy-
apatite share many similar characteristics but vary
greatly in their physical architecture and biolog-
ical behavior. A critical difference between hy-
droxyapatite cement and coralline hydroxyapatite
relates to their respective difference in pore size.23
The pore size of coralline hydroxyapatite is 100 to
500 ␮m, which is much greater than the 2 to 5 ␮m
found in hydroxyapatite cement.1,4,24 This differ-
ence in pore size probably accounts for the greater
vascularization and osteoconduction seen with
coralline hydroxyapatite.4 Conversely, the small
pore size seen with hydroxyapatite cement pre-
vents any significant revascularization of the
cement.24,25 This lack of revascularization probably
explains the minimal bone replacement seen with Fig. 5. Case 7. Preoperative view of a 54-year old man under-
the cements clinically. went surgery for brain tumor removal and immediate recon-
Hydroxyapatite cement (BoneSource) is struction with calcium-based bone cement elsewhere. The ce-
formed when tetracalcium phosphate and anhy- ment became exposed, and two attempts to close the area using
drous dicalcium phosphate react in the presence local flaps were performed. The patient was then referred to us
of water. The two salts undergo an isothermic for free flap coverage.

1337
 Plastic and Reconstructive Surgery • October 2007
Fig. 6. Case 7. (Above) The patient underwent reoperation, and
all calcium-based bone cement plus the titanium mesh used for
reconstruction was removed. (Center) Part of the dura had to be
excised because it was attached to the calcium-based bone ce-
ment. (Below) A dural patch was used for reconstruction. Calci-
um-based bone cement was used to reconstruct a 132-cm2 cra-
nial defect 21 months later.
reaction to form the cement paste.1,4,5,24,25 Norian
CRS is composed of monocalcium phosphate mo-
nohydrate, ␣-tricalcium phosphate, and calcium
carbonate. When mixed with sodium phosphate
solution, the material converts to 90% dahllite,
which closely resembles the mineral component
1338
Fig. 7. Case 7. Postoperative view of the reconstruction. Unfor-
tunately, this patient underwent a fifth operation and the calci-
um-based bone cement was once again removed 2 years later
because of infection and wound breakdown.
of bone.8 The calcium-based bone cements are
easily molded into a desired shape and contoured
intraoperatively. Setting times vary from 5 to 30
minutes, depending on the solution mixed with
the powder. Early on, the prolonged setting times
associated with the calcium-based bone pastes
were problematic and may have been responsible
for the high incidence of particulation seen. The
substitution of sodium phosphate and the devel-
opment of fast-set putties improved on these initial
formulations.1,4,5,8,25 Once the cement is set, the
chemical conversion of calcium phosphate in hy-
droxyapatite continues for 4 to 6 hours.1,4,25 The uses
of calcium-based bone cements in full-thickness skull
defects have been reported extensively.1–3,7–10,21,26,27
However, many of these studies report small defects
only. Burstein et al. reviewed their use of hydroxy-
apatite in 67 patients with minimal complications.26
Ten of these patients had full-thickness defects, but
these were all small (mean, 1 ⫻ 3 cm). Costantino
et al. described the use of hydroxyapatite in full-
thickness defects but failed to detail the size of these
defects.1 However, the mean amount of bone source
used was 12 g, suggesting that small defects were
repaired. Several articles do address the use of bone
cements in the reconstruction of large full-thickness
defects. Ducic reported the use of bone cements in
20 patients who underwent reconstruction for cra-
Volume 120, Number 5 • Calcium-Based Bone Cements
nial defects that varied in size from 10 to 150 cm.7
There were no complications during the 3-year fol-
low-up period. Durham et al. also reported the use
of hydroxyapatite cement in large defects.10 They
reconstructed defects larger than 25 cm2 (range, 40
to 196 cm2) in eight patients using hydroxyapatite
cement and titanium mesh with 2 to 33 months’
follow-up. They described two postoperative in-
fections at 1 and 3 months after reconstruction,
resulting in a 25 percent complication rate. In
both patients with complications, the cement
was completely removed and secondary recon-
struction with bone paste was performed with-
out further problems.
Matic and Phillips described seven patients in
whom hydroxyapatite reconstruction was per-
formed with exposed sinuses.28 Three of these
seven patients (43 percent) developed late infec-
tion. The authors concluded that hydroxyapatite
cement was contraindicated in the presence of
exposed sinuses in the pediatric population.
Matic and Manson reviewed their patients who
had undergone cranioplasty with bone cements
and noted a 40 percent rate of infection.11 At
reoperation, the implants were loose and frag-
mented. The authors suggest that minor trauma
may be the inciting factor leading to fragmenta-
tion or fracture. Conversely, Greenberg and
Schneider recently reported 85 patients, 45 of
whom were adults who underwent repair of large,
full-thickness defects.8 The authors relate an over-
all 8 percent complication rate, although the spe-
cific complication rate for the large, full-thickness
defects (⬎25 cm2) in the adult group was unclear.
In reviewing our reconstructions of large full-
thickness cranial defects, 10 of 16 patients devel-
oped complications. These complications could
not be related to the initial reason for reconstruc-
tion, as complications occurred in all three etio-
logic groups. Each etiologic group had such small
numbers and complication rates were so high in
each group that further comparison or analysis
was not possible. Our complications were then
arbitrarily divided into minor and major ones.
Major complications were defined as those requir-
ing total removal of hydroxyapatite or requiring
another operation of similar magnitude as the
initial reconstructive effort. Eight of these com-
plications were major and resulted in total re-
moval of the bone cement. Of these eight major
complications, four patients underwent recon-
struction secondarily an average of 28 months af-
ter alloplast removal. Three underwent recon-
struction with autogenous cranial bone and one
with bone cement. Four patients have yet to un-
dergo reconstruction. In analyzing these patients
further, failure was arbitrarily divided into judg-
ment errors (three patients), technical errors
(one patient), and material-related errors (four
patients).
With respect to judgment errors, three of eight
major complications occurred in patients who had
undergone previous irradiation. In one of these
patients, the cement became exposed, whereas in
the other two, particulation, foreign body reac-
tion, and an effusion developed. These problems
developed at 4 months and 1 and 6 years after
reconstruction, respectively (Fig. 2). Our compli-
cation rate with bone cement in patients who had
undergone previous irradiation was therefore 100
percent (three of three).
One of the eight patients developed compli-
cations, including an effusion and particulation of
the bone cement with negative cultures within 3
weeks of surgery. This was early in our experience
(when BoneSource was mixed with water rather
than sodium phosphate) and probably resulted
from failure of the hydroxyapatite to harden (i.e.,
technical error).
The four other bone cement full-thickness
skull reconstruction complications were related to
neither judgment nor technical errors. Further-
more, these complications occurred relatively late
in the postoperative period (mean, 2.5 years). One
of these patients developed a significant contour
irregularity 2 years postoperatively, and on explo-
ration, resorption and fracture of the cement was
found (Figs. 3 and 4). In a second patient, the
complication presented with wound breakdown
and erythema. A third presented with wound
breakdown and infection (Figs. 5 through 7). A
fourth patient presented with a sterile fluid col-
lection. In two of the above four patients, a history
of trauma was elicited.
With regard to these material-related compli-
cations, cement setting time appears to be a major
factor leading to particulation. This particulation
occurred in our cases despite meticulous tech-
nique, including great care in keeping the mate-
rial dry and prolonged waiting time intraopera-
tively to ensure adequate setting before closure.
Others have reported the failure of hydroxyapatite
and resulting particulation despite efforts to keep
the field dry.29,30 It should be noted that the ex-
perience in this report has been based predomi-
nantly on the first generation of calcium-phos-
phate cements. A new form of Norian (fast-set
putty) is currently available and sets significantly
faster. Similarly, BoneSource is now routinely
mixed with a phosphate buffer rather than water,
1339
 Plastic and Reconstructive Surgery • October 2007
significantly reducing the setting time.4,5,27,31,32 Al-
though BoneSource was mixed with water in our
earlier cases, it was mixed with phosphate buffer
in our later cases, and fragmentation still occurred
in two patients. Future studies will be needed to
answer the question of whether the newer forms
of quick-setting pastes will reduce fragmentation
and thus complication rates.
In our experience, particulation is quite dif-
ferent from fracture. Particulation generally oc-
curs earlier in the postoperative period and is the
result of inadequate setting of the bone paste. In
contrast, we believe that fracture is the result of
biomechanical failure as discussed below.
Although the literature documents a high
incidence of infection with the calcium-based
bone cements, we believe that it is important to
differentiate true infection from sterile effu-
sions associated with foreign body reaction. In
five of our eight patients, effusions were sterile
and probably the result of particulation of the
material. In only three of the eight patients were
cultures positive.
Another material-related problem appears to
relate to the biomechanical strength of the large
full-thickness cement-skull constructs. In two of
our reconstructions, fracture clearly occurred and
was documented at the time of exploration (Figs.
3 through 7). In a third patient who developed
complications of the material 6 years postopera-
tively, repeated minor trauma was elicited by his-
tory. It is presumed that this minor trauma may
have led to particulation and/or fracture. In a
recent biomechanical study, Matic and Manson
showed that bone cements can fracture even after
low-velocity trauma, in a pattern similar to what we
observed clinically in our patients.11 A recent in
vitro study compared the strength of commercial
calcium-based bone cement formulations to full-
thickness cranial bone.33 All bone cements were
significantly weaker than full-thickness cranial
bone. However, the study failed to demonstrate
that this difference in strength was physiologically
important (i.e., how much of this difference in
strength represents added, unnecessary strength
of the skull).
We had the opportunity to reoperate on nine
of these patients. In none of these patients was
significant revascularization present beyond the
periphery of the skull constructs. We therefore
presume, as mentioned earlier, that the small pore
size seen with bone cements prevents revascular-
ization and thus new bone formation in these
large skull defects.
1340
The use of calcium phosphate cements for
full-thickness defects in the child during the
period of rapid skull growth is probably ill con-
ceived. At the time of introduction of the cal-
cium phosphate cements, the manufacturer and
others suggested that the construct was largely
resorbed over several years.34 –36 This was the
basis of our rationale for using resorbable plates
in the rapidly growing skull in our early expe-
rience. Resorbable rather than titanium plates
were used to dampen dural pulsations with the
added hope that plate resorption would mini-
mize cranial growth abnormalities. On the basis
of our findings in large skull defects and that of
others that these calcium-phosphate constructs
largely do not resorb, the advantage of resorb-
able plates becomes a moot point.37 Therefore,
our high complication rate combined with the
fact that the calcium-phosphate construct is
largely nonresorbable and thus has a potentially
deleterious effect on the rapidly growing skull
brings us to the conclusion that this material
should not be used for large, full-thickness skull
defects in the pediatric population.
Finally, it should be restated that the bone
cements were used off label in these large skull
defects. That is, the product was being used in a
fashion not recommended by either the U.S. Food
and Drug Administration or the manufacturer.
This off-label use was fully discussed with the pa-
tient and their families preoperatively, as were all
potential complications. The authors felt that the
avoidance of the potential morbidity of large cra-
nial bone harvest made this a reasonable ap-
proach. Based on the above, we make the follow-
ing suggestions:
1. Calcium-based bone cement should be used
with caution in patients who have had pre-
vious irradiation to the scalp.
2. The overall complication rate when bone
cements are used for large skull defects is
unacceptably high.
3. The ultimate strength of the cement repair
in large skull defects is suspect and may be
prone to fracture.
4. Little cement in these large skull defects is
revascularized or replaced by bone.
On the basis of the above, we have returned to
the use of split cranial bone reconstruction for
these large skull defects.
CONCLUSIONS
Because of the high complication rate seen
with calcium-based bone cements when they are
Volume 120, Number 5 • Calcium-Based Bone Cements
used for large skull defects, we have returned to
the use of autogenous split-skull cranial bone for
reconstruction in these patients. The use of
bone cements in large skull defects should be
approached with caution.
James E. Zins, M.D.
Department of Plastic Surgery
Cleveland Clinic Foundation
9500 Euclid Avenue
Crile Building A60
Cleveland, Ohio 44195
zinsj@ccf.org
ACKNOWLEDGMENT
This project was supported by a $100,000 stipend
from Synthes Maxillofacial.
DISCLOSURE
None of the authors has a financial interest in any
of the products, devices, or drugs mentioned in this
article.
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niques: VI. The splitting of a parietal bone “flap.” Plast.
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13. Tessier, P., Kawamoto, H., Posnick, J., Raulo, Y., Tulasne, J.
F., and Wolfe, S. A. Taking calvarial grafts, either split in situ
or splitting of the parietal bone flap ex vivo—Tools and
techniques: V. A 9650-case experience in craniofacial and
maxillofacial surgery. Plast. Reconstr. Surg. 116: 54S, 2005.
14. Jackson, I. T., Adham, M., Bite, U., and Marx, R. Update on
cranial bone grafts in craniofacial surgery. Ann. Plast. Surg.
18: 37, 1987.
15. Jackson, I. T., Pellett, C., and Smith, J. M. The skull as a bone
graft donor site. Ann. Plast. Surg. 11: 527, 1983.
16. Tessier, P., Kawamoto, H., Posnick, J., Raulo, Y., Tulasne, J.
F., and Wolfe, S. A. Complications of harvesting autogenous
bone grafts: A group experience of 20,000 cases. Plast. Re-
constr. Surg. 116 (5 Suppl.): 72S, 2005.
17. Kline, R. M., Jr., and Wolfe, S. A. Complications associated
with the harvesting of cranial bone grafts. Plast. Reconstr. Surg.
95: 5, 1995.
18. Wilkinson, H. A. Autogeneic skull bone grafts (Letter). Neu-
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19. Manson, P. N., Crawley, W. A., and Hoopes, J. E. Frontal
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22. Byrd, H. S., Hobar, P. C., and Shewmake, K. Augmentation
of the craniofacial skeleton with porous hydroxyapatite gran-
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23. Grenga, T. E., Zins, J. E., and Bauer, T. W. The rate of
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osteoinduction in hydroxyapatite-derived biomaterials in an
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26. Burstein, F. D., Cohen, S. R., Hudgins, R., Boydston, W., and
Simms, C. The use of hydroxyapatite cement in secondary
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27. Eppley, B. L., Hollier, L., and Stal, S. Hydroxyapatite cra-
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of hydroxyapatite cement in the pediatric population. Plast.
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29. Friedman, C. D., and Costantino, P. D. Failure of hydroxy-
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30. Maniker, A., Cantrell, S., and Vaicys, C. Failure of hydroxy-
apatite cement to set in repair of a cranial defect: Case report.
Neurosurgery 43: 953, 1998.
31. Rupprecht, S., Merten, H. A., Kessler, P., and Wiltfang, J.
Hydroxyapatite cement (BoneSource) for repair of critical
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illofac. Surg. 31: 149, 2003.
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32. Eppley, B. L. Hydroxyapatite cranioplasty: I. Experimental
results from a new quick-setting material. J. Craniofac. Surg.
14: 85, 2003.
33. Miller, L., Guerra, A. B., Bidros, R. S., Trahan, C., Baratta,
R., and Metzinger, S. E. A comparison of resistance to
fracture among four commercially available forms of hy-
droxyapatite cement. Ann. Plast. Surg. 55: 87, 2005.
34. Friedman, C. D., Costantino, P. D., Takagi, S., and Chow,
L. C. BoneSource hydroxyapatite cement: A novel bioma-
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35. Kveton, J. F., Friedman, C. D., and Costantino, P. D. Indi-
cations for hydroxyapatite cement reconstruction in lateral
skull base surgery. Am. J. Otol. 16: 465, 1995.
36. Kveton, J. F., Friedman, C. D., Piepmeier, J. M., and Costan-
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37. Tuncer, S., Yavuzer, R., Isik, I., Basterzi, Y., and Latifoglu, O.
The fate of hydroxyapatite cement used for cranial contour-
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243, 2004.

Online CME Collections

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

1342
 PEDIATRIC/CRANIOFACIAL

Location of the Infraorbital and Mental

Foramen with Reference to the
Soft-Tissue Landmarks
Wu-Chul Song, M.D.
Sun-Heum Kim, M.D., Ph.D.
Doo-Jin Paik, M.D., Ph.D.
Seung-Ho Han, M.D., Ph.D.
Kyung-Seok Hu, D.D.S.
Hee-Jin Kim, D.D.S., Ph.D.
Ki-Seok Koh, Ph.D.
Chungju and Seoul, Korea
Background: The purpose of the present study was to determine the loca-
tions of the infraorbital foramen and mental foramen based on soft-tissue
landmarks to facilitate prediction of the locations of these structures during
facial surgery.
Methods: Fifty embalmed cadavers (100 sides) of Koreans were dissected to
expose the infraorbital foramen and mental foramen. The distances between
the bilateral infraorbital foramina and between the mental foramina and the
distances between the alae of the nose and between the corners of the mouth
(cheilions) were measured directly on the cadavers, and the vertical and hor-
izontal distances between the infraorbital foramen and mental foramen and the ala
of the nose and cheilions, respectively, were measured indirectly on photographs.
Results: The distance between the bilateral infraorbital foramina (54.9 ⫾ 3.4 mm)
was greater than that between the bilateral mental foramina (47.2 ⫾ 5.5 mm). The
infraorbital foramen was located 1.6 ⫾ 2.7 mm lateral and 14.1 ⫾ 2.8 mm superior
to the ala of the nose. The distance between the ala of the nose and the infraorbital
foramen was 15.9 ⫾ 2.8 mm, and the horizontal angle between these structures was
64.1 ⫾ 9.9 degrees laterosuperiorly. The mental foramen was located 20.4 ⫾ 3.9
mm inferior and 3.3 ⫾ 2.9 mm medial to the cheilions. The distance between
the cheilions and mental foramen was 20.9 ⫾ 3.8 mm, and the vertical angle
between these structures was 9.2 ⫾ 8.1 degrees inferomedially.
Conclusions: This study provides data that will be useful in predicting the
locations of the infraorbital foramen and mental foramen when used together
with hard-tissue landmarks. These data may be particularly helpful for facial
surgery in patients with missing teeth. (Plast. Reconstr. Surg. 120: 1343, 2007.)

T
he infraorbital nerve emerges from the in-
fraorbital foramen and branches to inner-
vate the middle region of the face. The
mental nerve exits the mental foramen and
branches to innervate the lower region of the
face.1,2 The infraorbital and mental nerves are
blocked at the foramen to induce local anesthe-
From the Departments of Anatomy and Plastic and Recon-
structive Surgery, College of Medicine, Konkuk University;
Department of Anatomy and Cell Biology, College of Medi-
cine, Hanyang University; Department of Anatomy, Catholic
Institution for Applied Anatomy, College of Medicine, The
Catholic University of Korea; and Division of Anatomy and
Developmental Biology, Department of Oral Biology, College
of Dentistry, Oral Science Research Center, Human Identi-
fication Research Center, Yonsei University.
Received for publication January 23, 2006; accepted April
25, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279558.86727.5a
sia during dental, plastic, and oromaxillofacial
surgery.3–5 However, sometimes it is necessary to
avoid neurovascular injury to these foramina
during surgery.6 Therefore, it is very important
to be able to predict the locations of the infraor-
bital foramen and mental foramen (and the
branches of the nerves that emerge from these
foramina) before initiating surgery.
The locations of the infraorbital foramen
and mental foramen have been determined in
numerous studies, mostly from measurements
on dry bones,7–9 photographs of dry bones,10 or
radiographs11; studies of cadavers are compar-
atively rare.12 In the aforementioned studies,
the locations of the infraorbital foramina were
determined using bony landmarks, 6 , 8 , 1 2
whereas the locations of the mental foramina
have been determined primarily according to
their relationship to the dentition.6,7,11 Data
from such studies have made it possible to

www.PRSJournal.com 1343
 Plastic and Reconstructive Surgery • October 2007

predict the locations of the infraorbital fora-

men and mental foramen with a reasonable
degree of accuracy. However, bony landmarks
and teeth are not readily accessible in living
subjects, and the precise relationship between
the infraorbital foramen and mental foramen
and reference landmarks can vary between pa-
tients and with the skill of the inspector.
Therefore, in addition to the hard-tissue land-
marks such as bone and teeth, soft-tissue land-
marks are required to predict the locations of
the infraorbital foramen and mental foramen
precisely. The purpose of the present study was
to determine the locations of the infraorbital fo-
ramen and mental foramen using soft-tissue land-
marks to facilitate the prediction of the locations of
these foramina during facial surgery.

MATERIALS AND METHODS

Fifty embalmed cadavers (100 sides; 28 male
and 22 female cadavers) were investigated. The Fig. 1. The direct measurement items used on the faces in this
ages of the subjects at death ranged from 32 to 101 study. IOF, infraorbital foramen; MF, mental foramen; AL, alare
years, with a mean of 67.7 years. Subjects with an (ala of the nose); CH, cheilion (mouth corner).
open mouth or pressed nose were excluded from
the analysis. The locations of the mental foramina
in elderly subjects with edentulous mandibles
were not analyzed. Laterality, sex, and age differ-
ences were not considered in the present study.
All soft tissues around the infraorbital fora-
men and mental foramen (including the perios-
teum) were excised. After obtaining initial mea-
surements, all faces were photographed from the
front using a digital camera (E-10; Olympus, To-
kyo, Japan) with a scale bar included in each pho-
tograph. The digital images were aligned vertically
using computer software (Adobe Photoshop 7.0;
Adobe Systems, Mountain View, Calif.). The loca-
tions of the infraorbital foramen and mental fo-
ramen were determined by marking these struc-
tures in each photograph, with the subsequent
measurements obtained using an image analyzer
(Image-Pro Plus 5.0; MediaCybernetics, Silver
Spring, Md.).
We used the ala of the nose and the mouth
corners (cheilions) as soft-tissue landmarks that
are clearly visible and palpable on the face. The
width (distance) between the same structures bi-
laterally and the longest diameters of the infraor- Fig. 2. The indirect measurement items used on the digitalized
bital foramen and mental foramen were measured photographs in this study. IOF, infraorbital foramen; MF, mental
directly on the face of each cadaver (Fig. 1). The foramen; AL, alare (ala of the nose); CH, cheilion (mouth corner);
locations of the infraorbital foramen and mental P1, cross point between alare horizontal line and infraorbital fo-
foramen relative to the ala of the nose and chei- ramen vertical line; P2, cross point between mental foramen hor-
lions were measured indirectly on the digital pho- izontal line and cheilion vertical line; Angle 1, horizontal angle
tographs (Fig. 2). These measurements were then from ala of the nose to infraorbital foramen; Angle 2, vertical angle
used to calculate the distance and angle between from cheilion to mental foramen.

1344
Volume 120, Number 5 • Infraorbital and Mental Foramen

the ala of the nose and infraorbital foramen and Table 2. Measurement of the Location of the
the cheilions and mental foramen. All direct and Foramina
indirect measurements were made relative to the Items No. Mean SD
center of each foramen. The calculations and sta- AL-P1 100 6.9 mm 2.7 mm
tistical analyses were performed using standard P1-IOF 100 14.1 mm 2.8 mm
computer software (SPSS for Windows, v12.0; AL-IOF 100 15.9 mm 2.8 mm
SPSS, Inc., Chicago, Ill.). Angle 1 100 64.1 degrees 9.9 degrees

CH-P2 72 20.4 mm 3.9 mm

RESULTS
The values of the parameters that were mea-
sured directly are listed in Table 1. These values
were divided by 2 (i.e., halved) to calculate the
distance from the midline. The distance between
the bilateral infraorbital foramina (54.9 ⫾ 3.4
mm, mean ⫾ SD) was greater than that between
the bilateral mental foramina (47.2 ⫾ 5.5 mm).
The longest diameters of the infraorbital foramen
and mental foramen were 5.0 ⫾ 1.0 and 3.0 ⫾ 0.7
mm, respectively. The infraorbital foramen
opened inferomedially and had a long oval shape,
whereas the mental foramen opened posterosu-
periorly and was almost circular. Interestingly, the
distance between the bilateral infraorbital foram-
ina was almost identical to that between the bilat-
eral cheilions (54.3 ⫾ 3.4 mm), indicating that the
infraorbital foramen and cheilions appear to lie in
the same vertical plane.
The infraorbital foramina were located 1.6 ⫾
2.7 mm lateral and 14.1 ⫾ 2.8 mm superior to the
alae of the nose. The distance between the ala of
the nose and the infraorbital foramen was 15.9 ⫾
2.8 mm, and the horizontal angle between these
structures was 64.1 ⫾ 9.9 degrees laterosuperiorly.
The mental foramen was located 20.4 ⫾ 3.9 mm
inferior and 3.3 ⫾ 2.9 mm medial to the cheilions.
The distance between the cheilions and mental
foramen was 20.9 ⫾ 3.8 mm, and the vertical angle
between these structures was 9.2 ⫾ 8.1 degrees
inferomedially (Table 2).
P2-MF 72 3.3 mm 2.9 mm
CH-MF 72 20.9 mm 3.8 mm
Angle 2 72 9.2 degrees 8.1 degrees
IOF, infraorbital foramen; MF, mental foramen; AL, alare (ala of the
nose); CH, cheilion (mouth corner); P1, cross point between alare
horizontal line and infraorbital foramen vertical line; P2, cross point
between mental foramen horizontal line and cheilions vertical line;
Angle 1, horizontal angle from ala of nose to infraorbital foramen;
Angle 2, vertical angle from cheilions to mental foramen.
The individual distributions and mean values
of the infraorbital foramen and mental foramen
locations are presented in Figure 3. The distribu-
tion of the mental foramen was more scattered
than that of the infraorbital foramen, as indicated
by a higher coefficient of variation for the mental
foramen. The mental foramina were located
mainly medial to the vertical line of the cheilions
(81.7 percent of cases), with them being on this
vertical line and lateral to it in 12.7 percent and 5.6
percent of cases, respectively (data not shown).
DISCUSSION
The results of the present study complement
those of previous studies that have analyzed the lo-
cations of the infraorbital foramen and mental
foramen.6,10,12,13 Based on the frequencies of partic-
ular spatial relationships of the facial foramen in
Koreans, the laterally located position of the infraor-

Table 1. Distances between the Contralateral

Foramen and Soft-Tissue Landmarks
Original
Value Mean
(mean ⴞ SD) Half Value
Items No. (mm) (mm)
IOF-IOF 74 54.9 ⫾ 3.4 27.4
AL-AL 74 39.9 ⫾ 4.8 19.9
MF-MF 56 47.2 ⫾ 3.4 23.6
CH-CH 56 54.3 ⫾ 5.5 27.1
IOF longest diameter 70 5.0 ⫾ 1.0
MF longest diameter 46 3.0 ⫾ 0.7 Fig. 3. Schematic drawing of the distribution of the foramen
IOF, infraorbital foramen; MF, mental foramen; AL, alare (ala of (left) and mean value of the foramen from the soft-tissue land-
nose); CH, cheilion (mouth corner). marks (right) (in millimeters).

1345
 Plastic and Reconstructive Surgery • October 2007

bital foramen relative to the supraorbital foramen

and/or the mental foramen might be related to the
lateral extension of the zygomatic arch, because the
position of the infraorbital foramen, which is part of
the maxilla, may be influenced by the development
of the zygomatic bone.10 Nevertheless, the values of
these parameters measured in several other studies
involving other races are similar to those reported
here,6,12,13 and thus it is reasonable to conclude that
our values are also applicable to races other than
Korean.
The inferior margin of the orbit has frequently
been used to predict the locations of the infraor-
bital foramen. The distance between the inferior
margin of the orbit and the infraorbital foramen
varies between studies and races.12 Nevertheless,
there is a consensus that the infraorbital foramina
lie sufficiently far (8 to 10 mm) below the infraor-
bital rim to allow the surgeon to palpate the small
depression at the inferior margin of the orbit to
predict the locations of the infraorbital foramina4; Fig. 4. Concise guide for locating the infraorbital and mental
this depression is called the infraorbital notch and foramina. ION, infraorbital notch; AL, alare (ala of nose); CH, chei-
is created by the zygomaticomaxillary suture. lion (mouth corner).
Combining the results of the present study with
those obtained using other methods, such as pal-
pation of the infraorbital notch, would facilitate
determining the locations of the infraorbital fo- inferior to the lower second premolar, but the
ramina. We consider that a more precise guide for frequency is still less than 50 percent.14 Moreover,
the locations of the infraorbital foramina is the the locations of the mental foramina differ be-
upper one-third point (8:14.1 mm, about 1:2) on tween races.6 Because the locations of the mental
the vertical line from the infraorbital notch to a foramina also vary between individuals, it is diffi-
horizontal line drawn between the alae of the nose cult to predict the locations of these structures
(Fig. 4). In addition, we found that the infraorbital using intraoral landmarks, especially in edentu-
foramina and cheilions lie in the same sagittal lous patients and those with mutilated dentition.4
plane by numerical values of the mean. Actually, Therefore, the elucidation in the present study of
the locations of the infraorbital foramina were the soft-tissue landmarks that can be used to de-
variable, being in the same plane, medial to, or termine the locations of the mental foramina may
lateral to that of the cheilions, with the structures be extremely useful. Specifically, the mental fo-
being in the same plane in approximately 50 per- ramina could be regarded as being located about
cent of cases. However, because the cheilions lie 2 cm inferior and slightly medial (up to one fin-
far from the infraorbital foramina and thus do not gertip) to the cheilions (Fig. 3).
constitute better landmarks than the alae of the The results of the present study, when com-
nose, we did not measure the vertical distance bined with the hard-tissue landmarks, facilitate
between the cheilions and the infraorbital foram- prediction of the locations of the infraorbital and
ina. Nevertheless, our novel elucidation of the mental foramina. Our data should be particularly
spatial relationships among these structures could useful in cases in which the hard-tissue landmarks
facilitate predicting the locations of the infraor- cannot be used, such as patients with missing teeth
bital foramina. (especially the first or second premolar).
Numerous studies have investigated the spatial
relationship between the mental foramen and Ki-Seok Koh, Ph.D.
mandibular dentition in various races,6,7,11,14,15 be- Department of Anatomy
College of Medicine
cause of the difficulty of clinically visualizing or pal- Konkuk University
pating the mental foramen and there being no ab- 322 Danwol-dong
solute anatomical landmarks for this structure.14 Chungju, Chungbuk 380-701, Korea
The mental foramina are most frequently located kskoh@kku.ac.kr

1346
Volume 120, Number 5 • Infraorbital and Mental Foramen

ACKNOWLEDGMENTS
This study was supported by Konkuk University in
2004. The authors thank Catholic Institution for Ap-
plied Anatomy, College of Medicine, The Catholic Uni-
versity of Korea for allowing us to use the cadavers.
DISCLOSURE
None of the authors has a financial interest in any of
the products, devices, or drugs mentioned in this article.
REFERENCES
1. Moore, K. L., and Dalley, A. F. Clinically Oriented Anatomy, 4th Ed.
Philadelphia: Lippincott Williams & Wilkins, 1999. P. 859.
2. Standring, S. Gray’s Anatomy, 39th Ed. Edinburgh: Churchill
Livingstone, 2005. P. 513.
3. Miller, R. D. Anesthesia, 5th Ed. Philadelphia: Churchill Liv-
ingstone, 2000. P. 1520.
4. Blanton, P. L., and Jeske, A. H. The key to profound local
anesthesia. J. Am. Dent. Assoc. 143: 753, 2003.
5. Salam, G. A. Regional anesthesia for office procedures: Part
I. Head and neck surgeries. Am. Fam. Physician 69: 585, 2004.
6. Cutright, B., Quillopa, N., and Schubert, W. An anthropo-
metric analysis of the key foramen for maxillofacial surgery.
J. Oral Maxillofac. Surg. 61: 354, 2003.
7. Yoon, K. W., Kim, K. R., Woo, J. H., et al. Anatomical study
on the location of the mental foramen in adult Korean
mandibles. Korean J. Phys. Anthropol. 2: 11, 1989.
8. Kazkayasi, M., Ergin, A., Ersoy, M., et al. Certain anatomical
relations and the precise morphometry of the infra-orbital
foramen-canal and groove: An anatomical and cephalomet-
ric study. Laryngoscope 111: 609, 2001.
9. Igbigbi, P. S., and Lebona, S. The position and dimensions
of the mental foramen in adult Malawian mandibles. West Afr.
J. Med. 24: 184, 2005.
10. Chung, M. S., Kim, H. J., Kang, H. S., et al. Locational rela-
tionship of the supraorbital notch or foramen and infra-orbital
and mental foramen in Koreans. Acta Anat. 154: 162, 1995.
11. Ngeow, W. C., and Yuzawati, Y. The location of the mental
foramen in a selected Malay population. J. Oral Sci. 45: 171,
2003.
12. Aziz, S. R., Marchena, J. M., and Puran, A. Anatomic char-
acteristics of the infra-orbital foramen: A cadaver study.
J. Oral Maxillofac. Surg. 58: 992, 2000.
13. Agthong, S., Huanmanop, T., and Chentanez, V. Anatomical
variations of the supraorbital, infra-orbital, and mental foramen
related to gender and side. J. Oral Maxillofac. Surg. 63: 800, 2005.
14. Phillips, J. L., Weller, R. N., and Kulild, J. C. The mental fora-
men: Part I. Size, orientation, and positional relationship to the
mandibular second premolar. J. Endodont. 16: 221, 1990.
15. Aktekin, M., Celik, H. M., Celik, H. H., et al. Studies on the
location of the mental foramen in Turkish mandibles. Mor-
phologie 87: 17, 2003.

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1347
SPECIAL TOPIC

Definitive Repair of the Unilateral Cleft Lip

Nasal Deformity
H. Steve Byrd, M.D.
Kusai A. El-Musa, M.D.
Arjang Yazdani, M.D.
Dallas, Texas
Summary: The majority of patients with a unilateral cleft nasal deformity still
benefit from additional nasal surgery in their teenage years, despite having
undergone a primary nasal repair. However, the secondary nasal deformity of
these patients stands in sharp contrast to those of children who have not
benefited from primary repair. The authors’ algorithm for the definitive cor-
rection of these secondary deformities considers the differences in these two
patient groups and defines their indications for rib cartilage grafts and their
method of using septal and ear cartilage in the repair. Balancing the muscle
forces on the septum and alar cartilage is emphasized in both the primary and
secondary repair. Both cartilage malposition and hypoplasia of the lower lateral
cartilage complex have been identified as factors contributing to the
deformity. (Plast. Reconstr. Surg. 120: 1348, 2007.)

D
espite the current trend toward nasal re-
construction at the time of primary lip
repair, the prevalence of the historic
dogma against primary cleft nasal correction re-
sults in two classes of patients with secondary
cleft nasal deformities: those with primary repair
and those with no primary correction. In gen-
eral, patients who have had primary nasal cor-
rection are less severely deformed and can be
managed following standard rhinoplasty tech-
niques. Early repair has a major role in balanc-
ing the muscle forces on the septum and alar
cartilage. As a result, the algorithm for secondary
cleft rhinoplasty varies widely between groups
with and without primary nasal correction.
CLEFT NOSE ANATOMY
Primary Cleft Nasal Deformity
The primary cleft nasal deformity is charac-
terized by the following features: malposition and
hypoplasia of the lower lateral cartilage, interrup-
tion of the muscle ring across the nasal sill, fixation
of the accessory chain of the lateral crus through
fibrous connections to the pyriform, soft-tissue de-
ficiency to the nasal floor, septal deviation, and
abnormal muscle insertions at the alar base to the
cheek and lip. Controversy persists as to whether
From the Children’s Medical Center and The University of
Texas Southwestern Medical Center at Dallas.
Received for publication September 18, 2006; accepted Feb-
ruary 12, 2007.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279497.95331.1e
the cleft nasal deformity is secondary to tissue
malposition or is associated with tissue deficien-
cies. McComb1,2 has shown from his dissections in
stillborn fetuses with clefts that tissue distortion
and malposition is the primary factor in the de-
formity. This opinion was reinforced by Huffman
and Lierle.2,3 Despite these published results, our
experience in the dissection of stillborn clefts and
in open rhinoplasties suggests that hypoplasia of
the lower lateral cartilage complex may be found
in association with malposition (Fig. 1).
Malposition is felt to be secondary to an im-
balance of muscle forces across the cleft. This
would explain the deviation of the septum away
from the cleft and the lateralization of the cleft
dome and lateral crus. Equally significant is the
abnormal fixation of the lateral crus to the peri-
osteum of the pyriform through a continuation of
cartilaginous and fibrous structures.
Secondary Cleft Nasal Deformity
The secondary cleft nasal deformity may be
characterized by the features of the primary de-
formity complicated by the influence of facial
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1348 www.PRSJournal.com
Volume 120, Number 5 • Unilateral Cleft Lip Nasal Deformity

Fig. 1. Dissection of the lower lateral cartilages in a stillborn in- Fig. 2. The cleft side maxilla is underdeveloped, accounting for
fant with a unilateral cleft lip shows hypoplasia of the cleft side alar base lowering.
(right).

growth. Lesser degrees of the primary deformity

are seen, depending on what was done at the time
of lip repair. The surgical steps at primary repair
that most influence the outcome of the nasal de-
formity are (1) adequate release of the lateral crus
from its attachments to the pyriform and reattach-
ment to the cheek muscles, (2) reconstruction of
the muscle ring across the nasal sill, and (3) re-
position of the caudally rotated lateral crus and
dome.

Cleft Ala and Tip
The major defect of an unrepaired or inade-
quately repaired cleft nasal deformity concerns
the position of the ala. The ala lies caudal and
lateral to the contralateral side, tethered by a
pathologic attachment of the accessory chain to
the pyriform aperture. It rests on an underdevel-
oped maxilla, which partly accounts for alar base
lowering and horizontal nostril seating (Fig. 2).
The ala may be underdeveloped and weak and
exhibit a convoluted shape (Fig. 3). This contrib-
utes further to dome lowering on the cleft side.
The clefted orbicularis muscle ring across the na-
sal sill adds to the nasal deformity by placing un-
equal pull on the cleft and noncleft sides. Mal-
function of the cleft ala external valve is caused by
alar base malposition, imbalanced muscular pull,
and abnormal attachment of the cheek muscles
to the lateral crus. Tip projection is further com-
promised by a foreshortened columella that lies
obliquely with its base directed away from the
cleft side.
Fig. 3. The unrepaired alar cartilage is weak and contributes to
collapse of the ala.
Septum
The septum may be displaced from the
vomerine groove and the cartilaginous portion
may be buckled. The caudal septum is displaced
away from the cleft, and dorsal septal curvature
is present.
Skeletal Framework
The nasal bones are frequently widened both
at the dorsum and at the frontal process of the
maxilla. The dorsum may be low, normal, or over-
projecting. Deviation may affect the bony and the
cartilaginous segments. Generally, midvault cur-
vature is present with collapse on the concave side
and fullness on the convex side (Fig. 4).
Obstruction of the Airway
Besides the narrowing expected from the de-
viated septum and bony obstruction, nasal rhi-

1349
 Plastic and Reconstructive Surgery • October 2007
Fig. 4. Midvault curvature can be seen with concavity on the
cleft side and convexity on the noncleft side.
nometry has demonstrated statistically significant
findings of smaller airways in patients with cleft
deformity. Furthermore, external valve malfunc-
tion may add to the airway problem.
PATIENTS AND METHODS
We retrospectively reviewed 50 secondary rhi-
noplasties. Half had primary correction of the cleft
nasal deformity and the other half had no prior
nasal correction. The rhinoplasty maneuvers used
in these two groups were reviewed to establish an
algorithm for repair. Complications or undesir-
able outcomes were categorized where possible
against the underlying deformity and the maneu-
ver used to correct it.
Timing of Secondary Surgical Procedure
We plan the secondary cleft lip nose repair
after the age of 14 years in female patients and
after the age of 16 years in male patients. The goal
is to allow the completion of the postpubertal
growth spurt in the anterior septum and in the
bony dorsum. Occasionally, a failed primary repair
will result in such a severe nasal stigmata that nasal
tip-plasty is performed. Such occurrences are al-
most always in association with severe hypoplasia
of the lower lateral cartilage complex, require ear
cartilage augmentation, and are generally repaired
before the second grade. These repairs are not con-
sidered definitive but temporizing. We do not favor
repetitive rhinoplasty procedures throughout the
course of childhood, as we believe the final long-
term result is greatly compromised.
1350
Analysis of Cleft Nose Deformities
The key points of our analysis that influence
the algorithm of repair are as follows:
1. Was primary cleft nasal repair performed?
a. Was the lateral crus released from the pyri-
form?
b. Is the nasal lining deficient?
c. Was muscle reconstruction across the nasal
sill accomplished?
d. Is the external valve patent and functional?
e. Was malposition of the lateral crus and
dome corrected?
2. Is tip projection adequate?
3. Is the cleft lateral crus deformed by persisting
alar crease or buckle?
4. Is the alar base recessed and tethered to the
pyriform?
5. Are the pyriform and maxilla hypoplastic?
6. Is projection of the bony dorsum deficient, nor-
mal, or overprojecting?
Surgical Algorithm
In those children who have had successful pri-
mary correction of the nasal deformity, surgical
treatment ranges from the management of airway
obstruction to traditional rhinoplasty procedures
to balance the tip and dorsum. Unfortunately, a
few of these patients have enough residual defor-
mity to place them into the category of unrepaired
cleft noses. Hypoplasia of the septum, the maxilla,
and the lower lateral cartilage complex is frequently
found in association with these patients and may be
more responsible for the poor outcome than inad-
equacy of the primary repair per se. Clefts with cen-
tral facial dysplasia (approximately 5 percent) are
unique to this group and have practically no septal
development and support.
In patients with no nasal repair or failed pri-
mary repair, the presence of dorsal deficiency or
inadequate tip projection in association with a
deformed ala is the driving force in rib graft re-
construction. The great majority of these patients
are approached with an open rhinoplasty. A dorsal
approach to the septum is carried out, detaching
the upper lateral cartilages submucoperichondri-
ally from the septum. A wide vomerian-septal-eth-
moid resection is carried out under direct vision
leaving an 8- to 10-mm dorsal and caudal L-strut.
The base of the caudal septum is mobilized and
repositioned to the aesthetic midline with suture
anchorage.
If the dorsum is deficient or the nose is short,
reconstruction of the dorsum with rib graft is used.
Generally, the free floating tenth rib cartilage
Volume 120, Number 5 • Unilateral Cleft Lip Nasal Deformity
Fig. 5. The tenth or eleventh rib can be used as a graft. If the
tenth rib is used, the convexity of the graft is placed cephalad and
the medial crus is joined in front of the graft. This prevents wid-
ening of the columella.
Fig. 6. The dorsal excess of the upper lateral cartilage is hinged
on the nasal side and used as a spreader flap.
taken in its entirety from the osseocartilaginous
junction to the tip will provide a 33-mm columella
strut and a 40-mm segment of cartilage for the
dorsal graft. Alternatively, the free floating elev-
enth rib can be used as an osseocartilaginous dor-
Fig. 7. Septal grafts are used on both sides of the alar cartilage to
provide support and shape to the abnormal alar cartilage.
sal graft. The columella strut projects beyond the
junction of the dorsal graft for a distance of 8 to
12 mm, depending on the thickness of the soft
tissues4 (Fig. 5).
If the dorsum is overprojecting, the septum
and bony dorsum are reduced and lateral percu-
taneous J-osteotomies made. The excess of the
upper lateral cartilages is turned in as alar
spreader flaps (Fig. 6) and nasal bone in-fracture
is carried out. A traditional spreader graft is fre-
quently added to the concave side of the septal
curvature.
If the dorsal projection is normal, medial
oblique osteotomies with lateral percutaneous os-
teotomies are carried out to narrow the bony
width. A spreader graft is used on the concave side
and clocking sutures between the upper lateral
cartilage and septum are adjusted to bring the
septum to midline.
The algorithm now turns to the tip and the
deformed ala. If tip projection is inadequate, the
lateral crus collapsed, or the columella labial angle
1351
 Plastic and Reconstructive Surgery • October 2007

Fig. 8. A 17-year-old girl with inadequate primary nasal correction. Her secondary rhinoplasty
consisted of dorsal hump reduction and osteotomies, right spreader graft, columellar strut
graft,andreleaseoflowerlateralcartilagewithleftalarstrutandcontourgraft.(Above)Preoperative
and postoperative frontal views. (Below) Preoperative and postoperative lateral views.

acute and recessed, tip support is provided by a
columellar strut taken from the cartilage of the
tenth rib. We preferentially use rib for the colu-
mellar strut because its strength will overcome the
soft-tissue shortage in the columella and lateral
sidewall (see Video, Supplemental Digital Content
1, which demonstrates the definitive rhinoplasty
of a 15-year-old girl with left unilateral cleft lip and
cleft palate and associated cleft nasal deformity,
http://links.lww.com/A92). In the area of the nasal
spine, the bulk of the rib graft lifts the base of the
lip and achieves a more obtuse columella-lip an-
gle. This creates an aesthetic fullness and restores
a youthful curve to the central lip. Notably, by

1352
Volume 120, Number 5 • Unilateral Cleft Lip Nasal Deformity
Fig. 9. Preoperative and postoperative submental views of the patient shown in Figure 8.
using rib for the columellar strut, all of the har-
vested septal cartilage can be used in tip and alar
reconstruction.
The convexity of this rib graft is placed ceph-
alad and secured to the caudal septum. This allows
the medial crus to be joined in front of the graft
and avoids widening of the columella.
The algorithm expands at this point depend-
ing on the characteristics of the alar base and
lateral crus. If the accessory chain in the lateral
crus remains attached to the periosteum of the
pyriform, perialar dissection is carried out mobi-
lizing the muscle beneath the base and freeing it
from the lateral cheek and lip musculature. This
release goes up to the nasal lining, ensuring that
all the attachments between the lateral crus and
the pyriform periosteum have been lysed. The
mobilization extends across the cleft and the sill of
the nose to the midline dissection of the colu-
mella. The muscle of the alar base is then sutured
to the contralateral medial footplate, rotating it
toward midline and bringing the muscle across the
floor and sill. The divided fibrinous attachments
between the accessory chain and the pyriform are
then sutured to the muscles of the cheek to float
the external valve and alar base and free them
from their points of anchorage along the pyri-
form (see Video, Supplemental Digital Content
1). The dead space from the release of the base
is filled by the muscle that is rotated in and
toward the midline.
Further release of the ala may be achieved by
detaching the lateral crus from the upper lateral
cartilage along the scroll. If the nasal lining re-
stricts the movement and relocation of the lateral
crus, a V-Y advancement of the lining and cartilage
along the nasal vestibularis is performed. An alar
strut graft 3 to 4 mm in width and 28 to 30 mm in
length is placed beneath the cleft lateral crus in a
pocket created by elevation of the lining on the
underside of the cartilage. The strut graft serves to
stabilize external valve incompetence that can be
produced by the lateral release4 (see Video, Sup-
plemental Digital Content 1). An alar contour
graft of residual septum is then fashioned to
span from the dome out beyond the alar crease.5
These grafts essentially sandwich the abnormal
alar cartilage (Fig. 7). Domal mattress sutures
are then added to further define the domes. The
domes are sutured over the projecting rib col-
umellar strut. A slight overprojection of the cleft
lateral crus and domal segment is allowed to
compensate for the tight soft-tissue envelope on
the cleft side.
With normal soft-tissue thickness, the domal
tip projection is carried approximately 7 to 8 mm
above the plane of the dorsum. In thick-skinned
patients, the domal projection is increased to 10 to
12 mm above the plane of the dorsum.
When a Le Fort I maxillary advancement is
required, the same algorithm may be applied, but
a rib graft is always used as columellar support. It
is imperative that a stable maxillary segment (rigid
fixation and normal dental relation) is achieved if
rhinoplasty is to be combined; otherwise, malpo-
sition or displacement of the caudal columellar
strut is a possible complication. Even when ad-
vancements are in the range of 6 to 8 mm, the
advantage of the columella rib graft for control
and shaping of the columella labial angle cannot
be overemphasized.
The algorithm takes a different direction if
primary reconstruction accomplishes four keys:
(1) adequate lining, (2) release of the lateral ala
from the pyriform, (3) muscle reconstruction of
the sill, and (4) dome repositioning. When these
1353
 Plastic and Reconstructive Surgery • October 2007

Fig. 10. (Above) Preoperative and postoperative frontal views of a 17-year-old girl. Note
the maxillary advancement combined with a columellar strut using rib graft. Right alar
contour and strut grafts were also used. (Below) Preoperative and postoperative lateral
views.

surgical steps are accomplished in the primary
repair, the secondary surgical correction is fre-
quently limited to alar contour grafting of the
lateral crus, caudal septal repositioning, and other
routine steps in rhinoplasty. The augmentation
can frequently be performed with the combina-
tion of septal and ear cartilage. Augmentation of
the deficient pyriform aperture on the cleft side
may be necessary (Figs. 8 through 11).
RESULTS
We have found that the greatest risk for a
compromised outcome is when rhinoplasty is
combined with Le Fort I osteotomies. The com-

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Volume 120, Number 5 • Unilateral Cleft Lip Nasal Deformity

Fig. 11. Preoperative and postoperative submental views of the patient shown in Figure 10.

Over- Dorsal reduction, closing

osteotomies, & spreader flap/grafts
projecting

Osteotomies to narrow nasal bones,

Dorsum Normal spreader graft to concave side of
dorsum septal curvature

Under- Dorsal and columellar graft using rib

projecting cartilage

Inadequate Columellar graft with rib cartilage

No or Tip
projection
Inadequate
Release of lateral crus from
Primary Nasal
Lateral pyriform, release of nasal lining or
Repair V-Y advancement of nasal lining,
displacement medial rotation of alar base

Caudal Inter-domal sutures, complete

Ala release of lateral crus from pyriform
rotation and upper lateral cartilage

Hypoplastic
Alar strut graft, alar contour graft
cartilage
Fig. 12. Our proposed algorithm for rhinoplasty techniques in the definitive rhinoplasty of a patient with inadequate primary nasal
repair.

plications have included columellar strut displace-
ment and failure to achieve adequate tip projec-
tion. The one case in which the columellar strut
was displaced occurred immediately postopera-
tively and necessitated reoperation. Failure to
achieve adequate tip projection and nostril shape
may relate to relapse of the maxillary platform or
a failure to recognize the degree of soft-tissue con-
tracture that occurs following the wide dissection
of the nasal floor and pyriform.
Patients requiring dorsal rib grafts are more
prone to dorsal irregularities and have a 15 to 20
percent occurrence of revisional surgery. The
most common finding in all groups is a slight

1355
 Plastic and Reconstructive Surgery • October 2007

undercorrection of cleft domal projection and a
failure to achieve the desired convexity across the
alar crease.
DISCUSSION
In the pursuit of a normal lip/nose relation-
ship, there is a move from delayed cleft nasal re-
pair to primary nasal correction. The results we
achieve at the primary operation remain amaz-
ingly consistent with subsequent growth.6,7 The
primary operation eliminates alar buckling and
achieves normal or near-normal nasal tip projec-
tion and alar base symmetry. Nevertheless, virtu-
ally all these patients still benefit from a defin-
itive rhinoplasty procedure in adolescence.
These secondary procedures are performed
both open and closed depending on the tip
morphology. Generally, septal and ear cartilages
suffice in the reconstruction and most fre-
quently are combined as alar strut grafts and alar
contour grafts.
CONCLUSIONS
Despite these shortcomings in treatment out-
comes, the proposed algorithm for selecting and
using a structure in the correction of the second-
ary unilateral cleft nasal deformity has provided
greater consistency and symmetry than other tech-
niques we have attempted (Fig. 12).
Arjang Yazdani, M.D.
Department of Plastic Surgery
The University of Texas Southwestern
Medical Center at Dallas
5323 Harry Hines Boulevard
Dallas, Texas 75390
arjang_yazdani@yahoo.com
DISCLOSURE
The authors have no financial interests related to
this study.
REFERENCES
1. McComb, H. Primary correction of unilateral cleft lip nasal
deformity: A 10-year review. Plast. Reconstr. Surg. 75: 791, 1985.
2. McComb, H. Primary repair of unilateral cleft lip nasal de-
formity. Oper. Tech. Plast. Reconstr. Surg. 2: 200, 1995.
3. Wolfe, S. A. A pastiche for the cleft lip nose. Plast. Reconstr.
Surg. 114: 1, 2004.
4. Gunter, J. P., and Friedman, R. M. Lateral crural strut graft:
Technique and clinical application in rhinoplasty. Plast. Re-
constr. Surg. 99: 943, 1997.
5. Rohrich, R. J., Raniere, J., and Ha, R. Y. The alar contour graft:
Correction and prevention of alar rim deformities in rhino-
plasty. Plast. Reconstr. Surg. 109: 2495, 2002.
6. Byrd, H. S. Cleft lips I: Primary deformities (overview). Select.
Read. Plast. Surg. 8: 1, 1997.
7. Byrd, H. S., and Salomon, J. Primary correction of the
unilateral cleft nasal deformity. Plast. Reconstr. Surg. 106:
1276, 2000.

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1356
 IDEAS AND INNOVATIONS
Correction of the Unilateral Cleft Lip
Nasal Deformity with a Composite
Cartilage–Vestibular Lining Flap
Michael B. Lewis, M.D.
Andrew A. Winkler, M.D.
Ronald P. Silverman, M.D.
Boston, Mass.; and Baltimore, Md.
A
dvances in cleft lip repair have vastly im-
proved cosmetic outcomes after primary
repair. Attempts to repair the associated
nasal deformity, however, have had less success.
The intricate cartilaginous support of the nose
complicates even the description of the cleft na-
sal anatomy. Over the past several decades, a
movement toward nasal repair at the time of
cheiloplasty has gradually led to improved cos-
metic results. Despite this trend, a nasal defor-
mity often persists in these children.
Nasal tip deformities associated with a unilat-
eral cleft lip are problematic and numerous (Ta-
ble 1). The distortion of the alar cartilage is
caused mainly by extrinsic forces exerted by im-
proper muscular insertions.1 The orbicularis oris
muscle is interrupted by the cleft and abnor-
mally inserts into the columella on the noncleft
side. The resultant unopposed pull causes devi-
ation of the columella and caudal nasal septum
to the noncleft side. The contralateral orbicu-
laris oris muscle inserts on the lateral aspect of
the ala, contributing to the lateral and inferior
position of the alar base. Also, the absent nasal
floor causes further displacement of the ala lat-
erally, posteriorly, and inferiorly.2
Many procedures have been developed to cor-
rect the stereotyped anatomy of the secondary
cleft lip nose. Sadao Tajima wrote that “it may be
assumed that the use of so many methods is
proof none is satisfactory.”3 We present a novel
tip rhinoplasty technique in patients with this
deformity. We describe the use of a composite
chondrovestibular lining flap to advance both
the medial and lateral crura of the alar cartilage.
From Boston Shriners Hospital and the University of Mary-
land Medical Center.
Received for publication November 8, 2005; accepted June 1,
2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279556.11710.45
www.PRSJournal.com
The senior author has had very satisfactory re-
sults over the past 20 years using this technique
and finds it to be relatively easy to perform.
ANATOMY OF THE CLEFT LIP NOSE
In 1925, Blair was one of the first surgeons to
discuss the cleft lip nasal deformities in the scien-
tific literature.4 With extreme accuracy and based
only on his clinical experiences, Blair described
many of the abnormalities that we still appreciate
today. He discussed the deformity as one of lateral
spreading of the ala, which results in “changes in
the direction of the long axis of the nostril, flat-
tening of the tip on the affected side, and flatten-
ing or even an infolding of the affected ala.” Blair
also acknowledged the role of the deviated carti-
laginous septum on the shape of the nose, writing
that it can lead to divergence of the entire nose at
birth.
Huffman and Lierle contributed to our knowl-
edge of the cleft lip nose with the first scientific
attempt to describe the anatomy.5 They found that
the malformation was not attributable to any in-
herent abnormality of the size of the nasal skele-
ton, but rather to abnormal attachment and po-
sitioning within the skin envelope. As a tribute to
the complexity of the cleft nose anatomy, Huff-
man and Lierle conceded that “it is very possible
that the conclusions we have reached are entirely
erroneous.”
Today, the concept put forth by Huffman and
Lierle is largely accepted. The cleft-side alar car-
tilage is essentially normal in size and simply mal-
positioned, with the exception of the medial crus,
which is somewhat diminutive. The most signifi-
cant and consistent cleft lip nasal deformity is the
malpositioning of the genu of the alar cartilage on
the cleft side. The genu is displaced in both a
caudal and posterior position, carrying with it all
of the medial crus and a good portion of the
adjacent lateral crus. The reduced projection of
the cleft side nasal tip causes the nose to take on
1357
 Plastic and Reconstructive Surgery • October 2007
Table 1. Nasal Deformities Associated with
Unilateral Cleft Lip
● Caudal and posterior displacement of the alar cartilage genu
● Shortened cleft-side columella
● Introversion of the lateral crus
● Lateral bowing of the medial crus
● Cutaneous webbing between the ala and columella
● Alar base displacement (lateral, inferior, and posterior)
● Decreased cleft-side projection
● Deviation of the nasal septum to the noncleft side
● Asymmetric maxillary base
a flat appearance and gives the nostril a horizontal
orientation. The posterior and inferior rotation of
the cephalic edge of the lateral crus of the alar
cartilage, known as introversion, is also a common
feature in the cleft lip nose.2,6 Introversion of the
lateral crus into the vestibule causes “hooding”
internally and an external dimpling at the scroll
region of the nasal cartilages. These distinctive
nasal deformities are listed in Table 1. Each de-
formity may exist in an individual patient to vary-
ing degrees. It is evident to any cleft surgeon,
however, that every cleft lip nose is unique and
requires individual consideration.
TECHNIQUE
An open rhinoplasty technique is used, as ma-
nipulation and balancing of the alar cartilages are
greatly facilitated. A V-columellar incision is used,
with the remaining incisions being intranasal, at
the caudal border of the alar cartilages (Fig. 1,
above, left). The nasal skin flap is developed well
beyond the alar cartilages onto the nasal dorsum
to allow tension-free redraping of the nasal skin
(Fig. 1, above, right, also demonstrates the posi-
tional asymmetry of the alar cartilages).
A composite flap of alar cartilage and vestib-
ular lining is outlined on the cleft side extending
from the footplate on up to or beyond the genu.
The cephalad border of this flap is in the mem-
branous septum (Fig. 1, second row, left). An ex-
tension of vestibular lining and mucosa is in-
cluded at the distal end (footplate) in a pennant
shape. This extension is oriented vertically and will
be used to cover the footplate and provide the
necessary lining as the medial crus and genu are
advanced forward (ventrally) and cephalad. The
donor defect from the pennant-shaped extension
will be closed directly in V-Y fashion.
The composite flap is then mobilized suffi-
ciently to allow tension-free movement of the genu
to a position symmetrical to the uninvolved op-
posite cartilage (Fig. 1, second row, right). Not
infrequently, once the mobilization has been
1358
done, the cartilage “springs” into this appropri-
ate incision.
If the cephalic border of the lateral alar crus
is posteriorly and inferiorly displaced (introver-
sion), it is dissected free from the upper lateral
cartilage, keeping intact the lining (Fig. 1, third
row, left). This will allow the upper border of the
lateral crus to slide anterior and cephalad to the
lower edge of the upper lateral cartilage.
Once the mobilization is complete, the pen-
nant-shaped extension is closed in V-Y fashion.
The upper border of the composite flap vestibular
lining is closed to the septal mucosal border, an-
ticipating its anterior (ventral) advancement.
Insetting this flap is very simple, as the flap
automatically springs into the appropriate ana-
tomical position once it is released. The alar car-
tilages are simply fixed together in a balanced
fashion with several sutures of slowly absorbing
suture (Fig. 1, third row, right). Permanent sutures
are not required and we feel should be avoided so
close to the internal surfaces of the nasal lining.
The cephalic border of the lateral crus is fixed to
the upper lateral cartilage, if necessary, in the
fashion described by Fomon et al.7 Care should
be taken in placing this suture so as not to in-
hibit the anterior (ventral) position of this por-
tion of the alar cartilage.
If a cartilage columellar strut is used, it is
placed at this time (Fig. 1, below, left). This is per-
formed in almost all adult corrections, and septal
cartilage is preferred.
Finally, the skin is brought back into position
and the incision closed (Fig. 1, below, right). Nasal
packing and splinting are routinely used.
DISCUSSION
Credit for recognizing which part of the alar
cartilage has to be freed and moved belongs to
Millard.8 This article describes a technique of mov-
ing the medial portion of the alar cartilage that we
feel offers several advantages over what Millard
described.
First, it eliminates the need to tediously dissect
the vestibular lining off the underside of the alar
cartilage yet provides tension-free movement and
positioning of the alar cartilage. Because the ves-
tibular lining–alar cartilage plane is not disturbed,
the delicate anatomical relationship of the two
structures will not be disturbed by the buildup
of scar tissue. This technique also avoids the
need for special bolstering in an attempt to re-
apply the vestibular lining to the underside of
the alar cartilage.
Volume 120, Number 5 • Cleft Lip Nasal Deformity

Fig. 1. (Above,left)Placementofthecolumellarincision.(Above,right)Thedeglovedalarcartilages.(Secondrow,left)Markingsofthe
pennant-shaped composite cartilage–vestibular lining flap. (Second row, right) The mobilized composite flap. (Third row, left) Dis-
section of the cephalic border of the lateral alar crus for cases where there is introversion at the junction of the upper lateral cartilage.
(Third row, right) The alar cartilages sutured together in a balanced position. (Below, left) A columellar strut using a septal cartilage
graft in an adult patient. (Below, right) The closed incision at the conclusion of the procedure.

1359
 Plastic and Reconstructive Surgery • October 2007

Fig. 2. Preoperative (left) and 6-year postoperative (right) views of a child who underwent correction of a left unilateral cleft
lip nasal deformity.

Fig. 3. Additional views of the child shown in Figure 2.

1360
Volume 120, Number 5 • Cleft Lip Nasal Deformity

Fig. 4. Preoperative (left) and 1-year postoperative (right) views of an adult who underwent
correction of a left unilateral cleft lip nasal deformity.

1361
 Plastic and Reconstructive Surgery • October 2007
Because both the alar cartilage and vestibular
lining are freed as a unit, the repositioning is
completely tension free, and permanent sutures
and complicated bolstering to “hold” the cartilage
in its proper position are unnecessary. We have
not found that corrective or sculpting incisions at
the alar rim to obtain proper nostril shape are
necessary either. In fact, if anything, there is prob-
ably a deficiency of skin, and none should be ex-
cised or moved internally.
We have found that once the alar cartilage is
freed as described here, it assumes a very normal
shape and merely has to be fixed in a balanced
position to its opposite alar cartilage and possibly
to the upper lateral cartilage with slowly absorb-
able sutures. This technique has provided as per-
manent a correction of the tip deformity as any
method attempted, especially in adults.
The senior author (M.B.L.) has not performed
this procedure in infants at the time of primary lip
repair. The alar cartilage is too weak and delicate
to be manipulated safely. An extensive soft-tissue
release and repositioning without touching the
alar cartilage is used at the time of initial lip
repair.9
If required, this procedure can be performed
safely and adequately in patients 5 years of age or
older (Figs. 2 and 3). Those patients who are re-
ferred as infants generally have the procedure
scheduled at age 5, but the procedure can be
performed anytime thereafter for those patients
referred later in life. In adults, the tip correction
is combined with full septorhinoplasty as required.
Almost always, an autogenous cartilage columellar
strut to support the tip unit is used in the adult
cases (Fig. 4).
1362
CONCLUSIONS
The senior author (M.L.B.) has performed
this technique over the past 20 years and has found
it easy to perform. Advantages of this technique
are its simplicity and durable results. The vestib-
ular lining–alar cartilage plane is not disturbed,
which preserves the delicate anatomical relation-
ship between these structures. The chondroves-
tibular pennant flap provides as permanent a cor-
rection of the tip deformity as any method
attempted.
Michael B. Lewis, M.D.
Boston Shriners Hospital
51 Blossom Street
Boston, Mass. 02114
rsilverman@smail.umaryland.edu
REFERENCES
1. Park, B. Y., Lew, D. H., and Lee, Y. H. A comparative study of
the lateral crus of alar cartilage in unilateral cleft lip nasal
deformity. Plast. Reconstr. Surg. 101: 915, 1998.
2. Shih, C. W., and Sykes, J. M. Correction of the cleft-lip nasal
deformity. Facial Plast. Surg. 18: 253, 2002.
3. Tajima, S., and Maruyama, M. Reverse-U incision for second-
ary repair of cleft lip nose. Plast. Reconstr. Surg. 60: 256, 1977.
4. Blair, V. P. Nasal deformities associated with congenital cleft
of the lip. J.A.M.A. 84: 185, 1925.
5. Huffman, W. C., and Lierle, D. M. Studies on the pathologic
anatomy of the unilateral hare-lip nose. Plast. Reconstr. Surg. 4:
225, 1949.
6. Madorsky, S. J., and Wang, T. D. Unilateral cleft rhinoplasty:
A review. Otolaryngol. Clin. North Am. 32: 669, 1999.
7. Fomon, S., Bell, J. W., Schattner, A., and Syracuse, V. R..
Harelip-nose revision. Arch. Otolaryngol. 64: 14, 1956.
8. Millard, R. D., Jr. Earlier correction of the unilateral cleft lip.
Plast. Reconstr. Surg. 70: 64, 1982.
9. Lewis, M. B. Unilateral cleft lip repair: Z-plasty. Clin. Plast.
Surg. 20: 647, 1993.
 IDEAS AND INNOVATIONS
Microdialysis: Use in the Assessment of a
Buried Bone-Only Fibular Free Flap
Constantinos Mourouzis,
Ph.D., M.D., D.D.S.
Rajiv Anand, F.D.S.R.C.S.,
F.R.C.S.
John R. Bowden, M.Sc.,
F.D.S.R.C.S., F.R.C.S.
Peter A. Brennan, F.R.C.S.,
F.R.C.S.I., F.D.S.
Portsmouth, United Kingdom
M
onitoring of free tissue flaps is difficult,
especially when the flap is inaccessible
or buried. It has been suggested that
flap monitoring should be simple and harmless
to both patient and flap, and be rapid, repeat-
able, reliable, recordable, accurate, and ideally
undertaken by any member of the microvascular
team.1 Clinical measures such as skin color, skin
turgor, surface temperature, and capillary refill
time remain the favored method in nonburied
flaps.2 Other measures described in buried free
flap monitoring include use of an externalized
skin paddle, Doppler probes, spectrophotometry,
laser Doppler flow, oxygen tension probes, indo-
cyanine green, plethysmography, hydrogen clear-
ance, and power Doppler with microbubble con-
trast perfusion. With the exception of power
Doppler microbubble contrast perfusion and the
use of an externalized skin paddle, one can com-
ment on inflow and outflow, but there is no mea-
sure of the microcirculation and tissue perfusion
dynamics. The failure to recognize early a compro-
mised buried flap is clearly demonstrated in stud-
ies that have found no flap salvage in these cases.3
Metabolic activity in free flaps has been mon-
itored by microdialysis previously,4 –7 although to
our knowledge there are no studies of flaps used
for head and neck reconstruction. Microdialysis
is a sampling technique that studies the biochem-
istry of organs or tissues. It has been used in free
tissue transfer (mainly for rectus flaps in breast
reconstruction), transplant, and neurosurgery.
From the Department of Oral and Maxillofacial Surgery,
Queen Alexandra Hospital.
Received for publication November 16, 2005; accepted Jan-
uary 12, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279555.75241.4c
www.PRSJournal.com
A double-lumen microdialysis catheter or probe
similar in size to an 18-gauge venous cannula is
placed (using an open needle) under direct vision
into the subcutaneous tissues, muscles, or viscera
(depending on type of flap).
It is then connected to a small micropump,
which perfuses physiologic fluid across a dialysis
membrane in the catheter at a rate of 0.3 ␮l/
minute. This fluid equilibrates with the intersti-
tial fluid surrounding the catheter, and there-
fore care is taken to ensure that it is not inserted
into a blood vessel. To date, we have not expe-
rienced any problems with inserting the cathe-
ters. The catheter itself can remain in the tissue
for as long as is clinically required although, as
with any indwelling catheter, the risk of infection
rises after a few days in situ. A microvial port
forms part of the double-lumen catheter, and
microvials are easily inserted and removed from
this. The minimal time taken to fill a microvial
sufficiently for analysis is 20 minutes. This is
therefore the shortest interval between readings,
and this frequency can be used if required in the
early postoperative period.
Once the microvial has been filled, it is easily
inserted into an analyzer/monitor (CMA Iscus
Microdialysis Monitor; CMA Microdialysis, Stock-
holm, Sweden) for analysis of glucose, lactate,
pyruvate, and glycerol metabolite concentrations.
The machine does this automatically and an on-
screen graphical display shows values for these me-
tabolites and their respective ratios (if required),
reflecting viability of the tissue being monitored.
The time delay from inserting the vial into the
analyzer and subsequent readings is approximately
10 minutes. The results can be copied to a remov-
able disk for subsequent downloading. A falling
glucose and rising lactate-to-pyruvate ratio indi-
cates anaerobic metabolism and thus indicates po-
1363
 Plastic and Reconstructive Surgery • October 2007

Fig. 1. Graph showing stable metabolites throughout the monitoring period, which followed re-
anastomosis at time 7 hours.

tential arterial compromise.6 A rising glycerol re-

flects cell membrane damage and is seen in
both venous congestion and arterial compro-
mise. Metabolites change rapidly with the pre-
vailing conditions in the tissue, with glucose
often paralleling tissue oxygen concentrations.8
It is therefore very sensitive to changes in perfu-
sion and would predict vascular compromise
early. The cost for each patient including cathe-
ters, reagents, and consumables is approximately
US$400. The greatest expense is the analyzer/
monitor itself (approximately US$50,000), al-
though these can be rented from CMA for ap-
proximately US$1500 per month).
As part of our prospective study, this tech-
nique is also being used in nonburied flaps as
part of validation. An example is shown in Figure
1, in which a change in the above parameters
clearly indicates radial forearm flap compromise
that was successfully salvaged. There is also an
increase in glycerol concentrations indicating tis-
sue damage. After reanastomosis, the parame-
ters return to their normal range.

CASE REPORT
Fig. 2. Microdialysis catheter in situ (above) with attached pump An 81-year-old woman with a T4N0 squamous cell carcinoma
(below). was treated with a segmental resection of the mandible, level 1

1364
Volume 120, Number 5 • Microdialysis to Monitor a Buried Flap
to 3 neck dissection, and reconstruction with an osseous fibula
free flap. The CMA 60 microdialysis catheter was inserted into
a muscular cuff of flexor hallucis longus at the end of insetting
the flap. The dialysate was pumped through the catheter using
a micropump (Fig. 2). Regular samples (using microvials) were
taken at 2-hour intervals for 36 hours postoperatively. The
microvials were sampled using an ISCUS Clinical Microdialysis
Analyser (CMA Microdialysis) and analyzed for glucose, glyc-
erol, pyruvate, and lactate. An on-screen graphic display showed
values for these metabolites (Fig. 3). All the parameters re-
mained stable after the anastomosis and initial reperfusion
subsequent to a short period of ischemia during flap inset
(unlike that of the salvaged radial forearm flap).
DISCUSSION
Postoperative transplant monitoring plays an
important role in detecting flap ischemia at the
earliest time point. Free tissue flap monitoring
with a bone-only fibula flap is difficult and cur-
rently is only possible with the use of indirect
methods, such as Doppler monitoring of the ar-
terial pedicle. This has the difficulty of not only
delineating vasculature but correctly identifying it
as the anastomosed pedicle. Furthermore, it does
not give any idea of bone perfusion and micro-
circulation. The use of microdialysis monitoring
allows the insertion of the microdialysis cannula
into a muscular cuff of flexor hallucis longus, with
the catheter tubing being led out through the skin
Fig. 3. Graph showing change in metabolites with arterial compromise, which returned to their
normal range following successful reanastomosis.
after the flap has been inset as the neomandible.
The catheters cannot be inserted directly into
bone, as the technique relies on the equilibration
of the pumped physiologic microdialysis fluid with
interstitial fluid. However, bone viability can be
assessed, as in this case, by inserting the catheter
as close to the bone as possible, in a cuff of muscle.
It is readily inserted into other soft-tissue flaps
including fasciocutaneous, myocutaneous, and je-
junal flaps.
This technique has successfully demonstrated
metabolism in the residual fragments of flexor
hallucis longus, reflecting viability of the flap and
integrity of the anastomoses. Microdialysis can be
used to facilitate early detection of ischemia. The
technique was easy to use and gives an indication
of potential flap compromise.
The microdialysis technique is well established
for metabolic events in the brain and musculocu-
taneous tissues, although it needs further investi-
gation in head and neck reconstruction. The sen-
sitivity and specificity for the microdialysis technique
in other areas (such as intensive care and brain mon-
itoring) is close to 100 percent.9 Although this is a
preliminary report, it would appear to be the first use
of microdialysis in the monitoring of a buried bone
free flap. A prospective clinical study is currently in
1365
 Plastic and Reconstructive Surgery • October 2007

progress, and animal studies are being planned to REFERENCES

provide further data for this type of monitoring in
microvascular free tissue transfer surgery.
CONCLUSIONS
The technique was easy to use and provides an
indication of potential flap compromise, particu-
larly in the buried flap. Although this is a prelim-
inary report, it would appear to be the first use of
microdialysis in the monitoring of a buried bone
flap. A prospective study is currently in progress.
Peter A. Brennan, F.R.C.S., F.R.C.S.I., F.D.S.
Department of Oral and Maxillofacial Surgery
Queen Alexandra Hospital
Portsmouth PO6 3LY, United Kingdom
peter.brennan@porthosp.nhs.uk
ACKNOWLEDGMENTS
The authors are grateful to CMA Microdialysis for
supplying the analyzer and materials in this report. No
funding was given by this company for this project.
DISCLOSURE
The authors have no commercial interests in CMA
Microdialysis, the manufacturer of the equipment used
in this study.
1. Creech, B., and Miller, S. Evaluation of circulation in skin
flaps. In W. C. Grabb and M. B. Myers (Eds.), Skin Flaps.
Boston: Little, Brown, 1975.
2. Devine, J. C., Potter, L. A., Magennis, P., et al. Flap monitoring
after head and neck reconstruction: Evaluating an observation
protocol. J. Wound Care 10: 525, 2001.
3. Disa, J. J., Cordeiro, P. G., and Hidalgo, D. A. Efficacy of
conventional monitoring techniques in free tissue transfer: An
11-year experience in 750 consecutive cases. Plast. Reconstr.
Surg. 104: 97, 1999.
4. Udesen, A., Lontoft, E., and Kristensen, S. R. Monitoring of
free TRAM flaps with microdialysis. J. Reconstr. Microsurg. 16:
101, 2000.
5. Rojdmark, J., Blomqvist, L., Malm, M., et al. Metabolism in
myocutaneous flaps studied by in situ microdialysis. Scand.
J. Plast. Reconstr. Surg. Hand Surg. 32: 27, 1998.
6. Setala, L. P., Korvenoja, E. M., Harma, M. A., et al. Glucose,
lactate, and pyruvate response in an experimental model of
microvascular flap ischemia and reperfusion: A microdialysis
study. Microsurgery 24: 223, 2004.
7. Edsander-Nord, A., Rojdmark, J., and Wickman, M. Metabo-
lism in pedicled and free TRAM flaps: A comparison using the
microdialysis technique. Plast. Reconstr. Surg. 109: 664, 2002.
8. Goodman, J. C., Valadka, A. B., Gopinath, S. P., et al. Extra-
cellular lactate and glucose alterations in the brain after head
injury measured by microdialysis. Crit. Care Med. 27: 1965,
1999.
9. Klaus, S., and Bahlmann, L. Microdialysis: Monitoring Tissue
Chemistry in Intensive Care Medicine. Lengerich, Germany: Pabst
Science Publishers, 2004. Pp. 8 – 44 and 71– 89.

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1366
 COSMETIC

Observations on Periorbital and Midface Aging

Val Lambros, M.D.
Background: Many of the anatomical changes of facial aging are still poorly
Newport Beach, Calif. understood. This study looked at the aging process in individuals linearly over
time, focusing on aspects of periorbital aging and the upper midface.
Methods: The author compared photographs of patients’ friends and relatives
taken 10 to 50 years before with closely matched recent follow-up pictures. The
best-matching old and recent pictures were equally sized and superimposed in
the computer. The images were then assembled into GIF animations, which
automate the fading of one image into the other and back again indefinitely.
Results: The following findings were new to the author: (1) the border of the
pigmented lid skin and thicker cheek skin (the lid-cheek junction) is re-
markably stable in position over time, becoming more visible by contrast, not
by vertical descent as is commonly assumed. (2) Orbicularis wrinkles on the
cheek and moles and other markers on the upper midface were also stable
over decades. (3) With aging, there can be a distinct change in the shape of
the upper eyelid. The young upper lid frequently has a medially biased peak.
The upper lid peak becomes more central in the older lid. This article
addresses these three issues. No evidence was seen here for descent of the
globe in the orbit.
Conclusions: There seems to be very little ptosis (inferior descent) of the
lid-cheek junction or of the upper midface. These findings suggest that
vertical descent of skin, and by association, subcutaneous tissue, is not
necessarily a major component of aging in those areas. In addition, the arc
of the upper lid changes shape in a characteristic way in some patients. Other
known changes of the periorbital area are visualized. (Plast. Reconstr. Surg.
120: 1367, 2007.)

S
ince 1989, it has been my practice to have
patients bring old photographs of them-
selves to their initial consultation. In 2000,
I thought to try to match these photographs with
recent follow-up images and compare them by
overlaying one on the other. The interpupillary
distance1 and the inter–medial canthal tendon
From the Department of Plastic Surgery, University of Cal-
ifornia, Irvine.
Received for publication October 24, 2006; accepted Decem-
ber 12, 2006.
Presented at the 2002 Annual Meeting of the Society for Aes-
thetic Plastic Surgery, in Las Vegas, Nevada, April 27 through
May 3, 2002; 2003 Annual Meeting of the Society for Aesthetic
Plastic Surgery, in Boston, Massachusetts, May 16 through 21,
2003; 2004 Annual Meeting of the Society for Aesthetic Plastic
Surgery, in Vancouver, British Columbia, Canada, April 15
through 21, 2004; 70th Annual Scientific Meeting of the Amer-
ican Society of Plastic Surgeons, in Orlando, Florida, November
3 through 7, 2001; and 74th Annual Meeting of the American
Society of Plastic Surgeons, in Chicago, Illinois, September 24
through 28, 2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279348.09156.c3
distances are constant in the adult face. These
landmarks and others, the base of the columella
and the sublabial crease, were used to equally
size and to align the images.2
This method of analysis was originally con-
ceived as an “animated” format of direct, not
numerical, comparison. The very closely
matched images are superimposed and fade
from one to the other in the computer showing
motion of landmarks or changes in shape of
various structures. Because the eye is very sensi-
tive to motion, comparing images in this way is
more discriminating than comparing side-by-
Supplemental digital content is available for
this article. Direct URL citations appear in
Appendix 1; simply type the URL address into
any web browser to access this content. Click-
able links to the material are provided in the
HTML text and PDF of this article on the
Journal’s Web site (www.PRSJournal.com).

www.PRSJournal.com 1367
 Plastic and Reconstructive Surgery • October 2007
side pictures. Some very subtle changes in the
shape of facial structures (e.g., the changing arc
of the upper lid) are hardly noticeable except
with overlay techniques.
Photographic comparisons of the face are very
difficult. It is easy to draw false conclusions about
positions of facial structures based on what are
actually differences in expression, camera posi-
tion, or head position. Drawing valid photo-
graphic conclusions about the face ideally re-
quires that the images be perfectly aligned, or at
least within several degrees of each other. Con-
sequently, the biggest challenge is obtaining a
recent picture that accurately matches the old
one. I take my best guess as to where the camera
was relative to the subject in the old picture and
take a grid of photographs. The periorbital area
in the anteroposterior view is easiest and usually
can be matched with 10 to 15 photographs.
Oblique views are more difficult, especially if
they are off a level axis. Lateral views are the
most difficult because of the lack of landmarks.
Sometimes, despite numerous attempts, I cannot
find a suitable match.
The digital images were opened in Adobe
Photoshop (Adobe Systems, Inc., San Jose,
Calif.). Color and contrast were adjusted, but no
morphogenic pixels were altered. After appro-
priately sizing and rotating the old and recent
images, one image was superimposed on the
other using the Layers function. Rapid cover-
ing and uncovering of the bottom image by
the top one will show the slightest relative
motion between the two. The final images
were then assembled into a GIF animation,
which automates the process of fading from
one image to the other. A useful ruler for
estimating sizes in these images is the trans-
verse iris diameter, which averages 10.5 to 11
mm in diameter. The print images presented
here are the source images used to prepare the
animated views and are within several degrees of
alignment. Of necessity, the animated images are
in the online Journal, and the reader is encouraged
to look there for additional clinical subjects.
Some practice is necessary to look at the ani-
mated images. It is nearly impossible to obtain
exact alignment; there almost always is some
relative motion of the subject in the photo-
graphs from young to old for which the eye of
the viewer compensates. With well-aligned im-
ages, millimeter precision is possible.
In these images, as in life, low-contrast skin
borders are best viewed from a distance. These
1368
are all nonsmiling images. A smile distorts the
face and offers little help in understanding facial
aging except how the skin reacts to underlying
muscle shortening and perhaps the constancy of
the nasolabial folds.3
RESULTS
There were 130 patients in the study and most
of them were Caucasian. Fifteen were male pa-
tients. The youngest subject was 10 years old and
the oldest was 89 years old. The average time be-
tween images was 25 years (range, 10 to 56 years).
There were 123 patients whose brows could be
evaluated. Of those, the brows were visibly ele-
vated in 35 (28 percent), the brows were seen to
be stable in 51 (41 percent), and the brows were
seen to descend in 36 (29 percent). Of the 87
patients whose brows stayed in place or fell, the
brows fell in 41 percent.
There were 83 patients whose lid-cheek junc-
tions could be seen and evaluated. Of those, three
(3.6 percent) were seen to descend.
Fifteen patients were noted to have visible up-
per lid ptosis of 1 to 2 mm. There was descent of
the lower lid in eight patients. The lower lid pos-
ture was the same or rose in the rest.
Fifty of 130 patients (38 percent) exhibited the
upper lid arc shift (see Discussion). Of 108 pa-
tients whose lateral canthal angles could be iden-
tified, 80 exhibited medial drift of the lateral can-
thal angle and 28 did not.
DISCUSSION
Studying the Aging Face
Greater understanding of the face may alter
surgical thought and provide better clinical treat-
ment. In addition, facial aging is among the most
universal of human experiences and is intrinsically
interesting to understand. Unlike the bony dom-
inated issues of facial growth, the story of facial
aging is overwhelmingly one of soft-tissue changes
and is visual rather than statistical.4
When looking at a face at one point in time,
one might draw a certain set of conclusions as to
how it got to its current state. Looking at several
points in time, one might draw an entirely differ-
ent set of conclusions. The observation that facial
skin might appear better when elevated does not
answer the question of where it was originally.
Studying a process, by definition, requires
information at several points in time, and in the
face the easiest way to do so is the matching of
old photographs. Although old photographs are
useful for studying aging, I do not think that they
Volume 120, Number 5 • Periorbital and Midface Aging

should be a literal blueprint for surgery of the aging
face: far from it. What looks good on a young face
does not necessarily look good on an older one.
Though long a proponent of volume addition in
some faces, I did not set out to support or detract
from any particular form of treatment; it was curi-
osity that led to this study. Actually, only curiosity
would be a sufficient driving force to persist through
the difficulties and frustrations of this particular
method of analysis.
been higher. The descent is minor in most cases.
The clinician will recognize that the brows do not
drop as much as a brow lift typically elevates them.
The periorbital areas of a large group of patients
had very little geographic change at all (Figs. 1 and
2). This group of patients tended to have slow der-
mal changes and usually minor subcutaneous thin-
ning. (See Animations, Supplemental Digital Con-
tent 1 through 8; hyperlinks to view animations and
descriptions available in Appendix 1.)

The Brow The Upper Lid Arc Changes Shape

Resting brow position is a clinical rather than
anatomical concept, as some patients may use mus-
cle tone to maintain the brows in position. Early in
this study, I did not tell patients to relax their fore-
heads while being photographed and, consequently,
a number of patients are elevating their brows. Of
the patients whose brows were stable or fell, 41 per-
cent fell. If the patients’ foreheads had been per-
fectly relaxed, this number would probably have
The upper lid can change shape in a fascinat-
ing way. In younger people, the arc of the upper
lid often peaks medially, forming a true almond-
shaped eyelid aperture (Fig. 3). This is not to be
confused with the almond-shaped eyelid skin and
epicanthal fold seen in Asians (Fig. 4).
In some art and cartoons, one can see this shape
correctly depicted, but it is not stressed in the med-
ical literature. The medial peak of the young upper

Fig. 1. Views of the patient at 22 years (left) and 43 years (right). Note the immobility of the lid-cheek junction. Various moles on the
skin are stable. She had a rhinoplasty and upper lid surgery at age 22. It looks as if the lid-cheek junction has dropped on her right,
which is illusory. The actual border is the inferior edge of the lid-cheek shadow, and that remains stationary. The animation of this
figure is Supplemental Digital Content 1A.

Fig. 2. Views of the patient at 36 years (left) and 54 years (right). She has had an upper lid blepharoplasty. There is remarkable stability
in skin position. There is the slightest change of the lid aperture seen more on her right. Patients like those in Figures 1 and 2 are not
uncommon; the dermal changes are slight and there is very little net change in skin.

1369
 Plastic and Reconstructive Surgery • October 2007

Fig. 3. View of the subject at age 10 years (left) and 57 years (right). An almond-shaped eye can originate from the shape of the upper
eyelid itself. The peak of the upper lid arc becomes more lateral with time. This is a real change in lid shape and not simply from lid
ptosis. Note the relative position of the tail of the brow and the apparent elongation of the medial canthal tendons. I do not know
whether the finding is real, but the globe seems to retreat from the medial canthal tendon. The animation of this figure is Supple-
mental Digital Content 9.

eyelid moves laterally with age, making the lid
appear more fusiform. This “arc shift” seems to be
primarily a phenomenon of youth, but one can see
remnants of it over time (Figs. 3, 5, and 6). (See
Animations, Supplemental Digital Content 7 and 9
through 14; hyperlinks available in Appendix 1.)
The bulge of the cornea itself can make a small
elevation of the upper lid margin, but the described
arc shift is independent of direction of gaze.
The medial peak configuration is common but
by no means universal in childhood. I do not know
its true incidence. When the eyelid peak is medial
in youth, it moves laterally with time. No cases were
identified where a lateral peak becomes medial.
The lateralizing of the eyelid peak means that
the medial lid curve flattens or even reverses cur-
vature (Figs. 3, 5, and 6; see Animations, Supple-
mental Digital Content 9, 10, and 15; hyperlinks
available in Appendix 1) and seems unrelated to
the lacrimal papilla, which can also enlarge with
time. The cause of the arc shift is not obvious.
Fig. 4. An almond-shaped eye can have several causes. In Asians,
it arises from the configuration of the upper lid skin and epican-
thal fold.
Shore and McCord observed that the medial
levator aponeurosis attenuates with age and that
the aging tarsus moves laterally.5 It may be that
the high medial arc represents a normal variant
of the levator aponeurosis, although looking at
the images it is hard to imagine that changes in
intraorbital volume do not play a role. I saw no
evidence of the globe descending within the
orbit in any of the subjects studied.
Apparent Eye Size Diminishes
I have always wondered how a young doe-like
eye becomes a small beady one. The change is
small by measurement but perceptually huge in
the gestalt of facial aging. The globe itself does not
change size in adulthood,6 so the explanation
must be in the lids. It seems obvious in these
images that medial drift of the lateral canthal an-
gle is the primary explanation, making the visible
area of conjunctiva smaller and diminishing ap-
parent eye size7–9 (Figs. 7 and 8; see Animations,
Supplemental Digital Content 7, 9, 13, and 15
through 19; hyperlinks available in Appendix 1).
In this series, unlike in others that found more
lower lid descent,10 –12 most patients’ lower lids
were stable or they were seen to rise slightly, which
would also participate in the apparent shrinking of
the eye.
Contributory also are the commonly seen mil-
limeter or two of upper lid ptosis and the upper
lid arc shift. I wonder whether an age-related en-
ophthalmos could contribute to apparent lateral
canthal tendon laxity and the rise in lower lid
position depending on the interaction of tone and
eyelid length. Interestingly, the medial canthal
angle in this group did not move laterally as might
be expected. Either it stayed immobile or it moved
slightly medially (Figs. 5 and 9).

1370
Volume 120, Number 5 • Periorbital and Midface Aging

Fig. 5. Views of the patient at ages 16 years (left) and 57 years (right). She has had a rhinoplasty. She exhibits the upper lid arc change
as well. There is also some apparent shortening of the lid aperture and loss of volume in the upper lids responsible for the “extra” skin.
The shape of the bony orbit becomes visible. She is one of the patients who showed descent of the lid-cheek junction. The animation
is available online, as is a detail of the lid (Supplemental Digital Content 10 and 15).

Fig. 6. Views of the patient at ages 27 years (left) and 61 years (right). The upper lid arc changes. The lid-cheek junction is stable. The
lower lid posture rises slightly. The lid aperture shortens and there may be a millimeter of ptosis. The brow deflates and descends
minimally (Supplemental Digital Content 13).

Fig. 7. Polaroid photographs obtained before rhinoplasty at age 31 (left) and at age 67 (right). She raises the brows slightly and turns
slightly to her left. These are the classic signs of periorbital aging. The eye appears smaller because the aperture is constricted laterally
and superiorly. The lower lid posture rises slightly. The lid-cheek junction is stable. She does not exhibit the arc shift (Supplemental
Digital Content 16).

The Lid-Cheek Junction Is Stable tiple names for the same borders, and the borders
What is the lid-cheek junction? There is a dis- themselves have not been well defined.
tinct problem with nomenclature in this area. The I define the lid-cheek junction as the junction
lower lid and cheek are notorious for having mul- of the thin pigmented lower lid skin with the

1371
 Plastic and Reconstructive Surgery • October 2007
Fig. 8. Views of patient at ages 40 (above), 49 (center), and 60
(below) years. He has undergone lower lid blepharoplasty at age
49. There are multiple wrinkles and moles that can be identified
in the same position in all three images in addition to the criss-
crossing of orbicularis wrinkles. The lid-cheek junction has not
changed. There is slight sag in lower lid posture (Supplemental
Digital Content 21 and 23).
Fig. 9. Views of the change in the patient from ages 21 to 54. She is not smiling. Note the mole on the right cheek (arrow). Her lateral
canthal angle has moved slightly medially. Her medial canthal angle has done the same. Her lid-cheek junction is unchanged. An
animated view of this patient is available in Supplemental Digital Content 7.
1372
thicker cheek skin at and medial to the midpu-
pillary line (the site of the V deformity). This is a
distinct border and visible from infancy. It is easy
to see clinically and represents reproducible an-
atomical landmarks. Clearly, there are borders
that proceed farther across the lid (the border
demarcating the lateral eyelid from the cheek)
and down the cheek (the various borders collec-
tively known as the nasojugal crease) and, regard-
less, they were all equally stable in this study. The
lid-cheek junction at the midpupillary line lies well
below the level of the bony orbital rim. In these
images, the lid-cheek junction is seen at the infe-
rior border of the lid-cheek shadow.
In all but three of the patients studied, the
lid-cheek junction was positionally stable over long
periods, although in several patients I noted that
the medial lid-cheek junction seemed to round
out slightly (see Animation, Supplemental Digital
Content 20; hyperlink available in Appendix 1).
Within the lid itself, wrinkles generally persist, al-
though they may splay and descend somewhat. In
those with particularly bad sun damage, the lower
lid skin can lose its wrinkle structure and seem-
ingly collapse along the stable lower lid border
(see Animations, Supplemental Digital Content 21
and 22; hyperlinks available in Appendix 1).
When visible, moles and wrinkles and other
skin markers did not show signs of descent in the
periorbital and upper midface (Figs. 6, 8, and
9). (See Animations, Supplemental Digital Content
3 through 8, 14, 19, 21, and 23 through 27; hyperlinks
available in Appendix 1.) This finding of stability of
the lid-cheek junction was unexpected, as the visual
impression one gets with age is that the lower lid
Volume 120, Number 5 • Periorbital and Midface Aging
border drops and becomes closer to the nasolabial
fold.
If the lid-cheek junction does not drop, then
why does it become more visible? With age, the
shadow from the enlarging fat pads increases the
apparent height of the lid. The shadow from fat
protrusion exaggerates the growing indentation at
the tear trough just above the lid-cheek junction.
The pigmented lower lid becomes thinner and the
skin darker, increasing the contrast between lid
and cheek.
Note that there seems to be a net downward
transposition of the lower lid border that is created
solely from anteroposterior enlargements and
diminutions of tissue. The addition that this study
makes is to suggest that these events occur beneath
essentially static skin. The finding of skin immo-
bility in the upper midface suggests that midface
curvatures change for a similar reason, anteropos-
terior shifts in volume (thin meets thick) rather
than descent.
It is odd that the lid-cheek junction should be
so constant because of the mobility of the lower lid
area to finger distraction. The upper cheek is very
firmly suspended by the medial zygomatic part of
the orbicularis retaining ligaments as described by
Muzaffar et al.11 (though these are simply exten-
sions of the ligament systems described previ-
ously by Furnas14 and Stuzin et al.15). It is rea-
sonable to suppose that the preosseous lower lid
sits on the stable upper midface and simply has
no place to go.
Implications for the Midface and Nasolabial
Fold
The curvatures of the face clearly change over
time. In popular concept, the midface behaves like
a tectonic plate sliding down the face to form the
nasolabial fold, leaving in its wake the nasojugal
crease and the exposed and diminished malar em-
inence.
If the skin of the cheek descends with age, one
would expect to see orbicularis oculi skin wrinkles
rotating down the face and motion of other mark-
ers on the face. The evidence from these obser-
vations is that orbicularis wrinkles and midfacial
scars and moles do not appear to move an amount
sufficient to explain these changes in shape, at
least in the upper midface.
Perhaps the cheek fat descends independently
of skin.16 When looking at the upper midface dur-
ing a dissection or a face lift, one finds a fibrous
network that is mobile in every direction except
inferior (caudal) at the skin and becomes pro-
gressively less mobile the deeper one goes. Fat is
interspersed throughout this fibrous structure in
globules of varying size. It seems illogical to me
and at odds with experience that this fat should
travel through the fibrous network like waves
through a pier to create ptosis (i.e., to desert the
malar prominence and flow down the cheek).
I would observe again that the lower lid area and
other parts of the face show a type of relativity be-
tween areas that enlarge and areas that indent. This
configuration can look like descent when seen at
one point in time. As noted above, the lower lid
seems to lengthen vertically with age. This is true
perceptually but is illusory in fact. The smooth
blending of the lid and cheek in the young person
leaves the lower lid without a strong inferior visual
border. The border appears from changes in tissue
projection (thin meets thick), color, and contrast
without actual geographic motion of soft tissues.
A similar process is visible in other parts of the
face. In many patients, the jowl expands but be-
comes still more visible by loss of adjoining soft
tissue at its anterior and posterior border. As
shown here, the loss of fullness over the malar
eminence and the appearance of fullness at the
medial nasojugal crease do not seem to be accom-
panied by skin migration. When looking at the
malar area over time, even in the presence of some
facial weight gain, one gets the impression of a
“deflation wave” paralleling the nasolabial fold
and moving obliquely from lateral to medial. In all
of these examples, the configurations formed by
tissue thickness changes are made smoother by
vertical finger traction, reinforcing the impression
of tissue descent and dominating surgical thought
of treatment.
If descent is not the dominant factor in chang-
ing upper midface curvatures, then what is? It
seems clear that there are relative losses and gains
of volume in these areas. Regional differences in
fat metabolism are well known in the face. Even
with weight gain, loss of upper periorbital fat is
commonplace; temple fat commonly and visibly
melts away without any obvious physical stresses on
it. The malar bony prominence or the repetitive
action of muscles may influence local longevity
of fat.
There is much yet to be learned about the
mechanics of the face, the way that it ages, and
which visual cues are most powerful in generating
the perception of age.
FUTURE PATHS
New technology will dominate this type of re-
search. The use of three-dimensional cameras will
1373
 Plastic and Reconstructive Surgery • October 2007
allow capture of the entire surface of a face and
will allow rotations, true skin measurements in
three axes, and the ability to measure volumes.
Faces can be compared over time and three-di-
mensional images can be more precisely matched
with two-dimensional images. Prospective studies
of facial aging with this technology will not supply
immediate answers but probably definitive ones.
Val Lambros, M.D.
Department of Plastic Surgery
University California, Irvine
360 San Miguel, Suite 406
Newport Beach, Calif. 92660
mrmondo@cox.net
ACKNOWLEDGMENTS
The author thanks Garrett Wirth, M.D., for help
with the bibliography; Bahman Guyron, M.D., and
Michelle Mauser for supplying many patient images
for the study; Howard Conn, M.D., for reviewing the
images; and David Furnas, M.D., for support and
advice over the years that this study took to mature.
DISCLOSURE
There are no financial conflicts of interest.
REFERENCES
1. Ortiz-Monasterio, F. Personal communication, 2006.
2. Lambros, V. Aligned image transformations and facial aging.
Presented at the Annual Meeting of the American Society for
Aesthetic Plastic Surgery, in Los Angeles, California, 2001.
3. Yousif, N. J., Gosain, A., Sanger, J. R., Larson, D. L., and
Matloub, H. S. The nasolabial fold: A photogrammetric anal-
ysis. Plast. Reconstr. Surg. 93: 70, 1994.
4. Farkas, L. G. Anthropometry of the Head and Face. New York:
Raven Press, 1994.
5. Shore, J. W., and McCord, C. D. Involutional changes in
involutional blepharoptosis. Am. J. Ophthalmol. 98: 21,
1984.
6. Duke-Elder, S., and Wybar, K. C. The anatomy of the visual
system. In S. Duke-Elder (Ed.), System of Ophthalmology, Vol.
II. St. Louis: Mosby, 1961.
7. McCord, C. M., Boswell, C. B., and Hester, T. R. Lateral
canthal anchoring. Plast. Reconstr. Surg. 112: 222, 2003.
8. Van den Bosch, W., Leenders, I., and Mulder, P. Topo-
graphic anatomy of the eyelids, and the effect of sex and age.
Br. J. Ophthalmol. 83: 347, 1999.
9. Hill, J. Analysis of senile changes in the palpebral fissure.
Trans. Ophthalmol. Soc. U.K. 95: 49, 1975.
10. Shore, J. W. Changes in lower eyelid resting position, move-
ment, and tone with age. Am. J. Ophthalmol. 99: 415, 1985.
11. Hill, J. C. An analysis of senile changes in the palpebral
fissure. Can. J. Ophthalmol. 10: 32, 1975.
12. Hill, J. C. Analysis of senile changes in the palpebral fissure.
Trans. Ophthalmol. Soc. U.K. 95: 49, 1975.
13. Muzaffar, A. R., Mendelson, B. C., and Adams, W. P., Jr. Surgical
anatomy of the ligamentous attachments of the lower lid and
lateral canthus. Plast. Reconstr. Surg. 110: 873, 2002.
14. Furnas, D. W. The retaining ligaments of the cheek. Plast.
Reconstr. Surg. 83: 11, 1989.
1374
15. Stuzin, J. M., Baker, T. J., and Gordon, H. L. The relationship
of the superficial and deep fascias: Relevance to rhytidectomy
and aging. Plast. Reconstr. Surg. 89: 441, 1992.
16. Owsley, J. Commentary to Lambros, V., “facial aging” pre-
sentation at ASPS. 2005, Philadelphia.
APPENDIX 1
Supplemental Digital Content 1, http://links.lww.
com/A65. Animation demonstrates facial aging from
ages 16 to 55. She tilts slightly back and to her right.
The lid-cheek junction is not visible. There is very
little change of the periorbital area; nonetheless, she
would be a candidate for “rejuvenative” surgery
of the lids, with essentially the same anatomy as
at age 16.
Supplemental Digital Content 1A, http://links.lww.
com/A113. Animation of Figure 1, with the patient at
22 years and 43 years. Note the immobility of the
lid-cheek junction. Various moles on the skin are
stable. She had a rhinoplasty and upper lid surgery
at age 22. It looks as if the lid-cheek junction has
dropped on her right, which is illusory. The actual
border is the inferior edge of the lid-cheek shadow,
and that remains stationary. Notice that the lid-
cheek junction appears higher on the right in Figure
1, but one can see that is actually at the same level.
Supplemental Digital Content 2, http://links.lww.
com/A66. Animation demonstrates facial aging from
ages 21 to 42. She exhibits almost pure dermal aging,
with no change of the lid-cheek junction.
Supplemental Digital Content 3, http://links.lww.
com/A67. Animation demonstrates facial aging
from ages 35 to 53. He tilts forward slightly in the
older image. The lid-cheek junction is stable and
at almost every other point on his face. The brows
have thinned. The subject is a Boston-based art
photographer who has photographed his face
daily since 1987. In many people, the appearance
of aging is subtle, complex, and defies simple ex-
planation.
Supplemental Digital Content 4, http://links.lww.
com/A68. Animation demonstrates facial aging
from ages 26 to 44. The camera is very slightly
higher in the young image, and he rotates very
slightly to his left in the older image. There is very
minor descent of the brow. The lid-cheek junction
is stable and his orbicularis wrinkles are stable. A
vertical wrinkle just lateral to the orbicularis wrin-
kle moves slightly medially. This may be positional.
Supplemental Digital Content 5, http://links.lww.
com/A69. Animation demonstrates facial aging
from ages 33 to 55. There is very slight descent
of the brows that accentuates her eyelid hood-
ing. Patients such as this develop a small amount
of upper lid retraction that disappears with up-
Volume 120, Number 5 • Periorbital and Midface Aging
per lid blepharoplasty. The lid-cheek junctions
are stable.
Supplemental Digital Content 6, http://links.lww.
com/A70. Animation demonstrates facial aging
from ages 27 to 51. The lid-cheek junction is sta-
ble, as are moles on her right upper cheek and left
paranasal area. The eyelid aperture seems to
shorten on her left.
Supplemental Digital Content 7, http://links.lww.
com/A71. Animation of Figure 9. The brows are el-
evated. The lid-cheek junction and an orbicularis
wrinkle are visible and stable (arrows).
Supplemental Digital Content 8, http://links.lww.
com/A72. Animation in which the patient tilts slightly
upward to her right and elevates her brow. The
lid-cheek junctions are stable. There is a mole on her
right cheek that has not moved. She loses some
upper lid volume.
Supplemental Digital Content 9, http://links.lww.
com/A73. Animation of the images in Figure 3. The
young picture was obtained at age 10 and the older
picture at age 57. They have been sized to the
interpupillary distance. Note the very distinct
change in the shape of the upper lid curve. The
peak is medial in the young image and moves
laterally with age. The relative size of the lid ap-
erture shortens. Note that the medial canthal an-
gle seems to elongate and that the globe seems to
recede medially.
Supplemental Digital Content 10, http://links.lww.
com/A74. Animation of Figure 5, with images com-
bined from ages 16 and 55. Her eyes were off to her
right in the young image and she turns slightly to her
right. Note the upper lid arc shift and the “break
points” of the medial upper lid curves (arrows). As
the globe gives the shape of the lid arc, this finding
might be an indirect sign of enophthalmos. Note the
loss of volume of the lids and brow and how the
globes seem to recede medially.
Supplemental Digital Content 11, http://links.lww.
com/A75. Animation demonstrates facial aging
from ages 17 to 55. She has had a rhinoplasty. She
turns slightly to her right. The change in lid shape
is obvious, going from a medial dominant, al-
mond-shaped upper lid curve to a laterally peaked
curve. She loses orbital volume and may be hold-
ing her brows up slightly. The curve of the orbit
becomes more visible with time. The arrow points
to the break point between curve-out and curve-in.
The lid-cheek junction is visible on the right. The
elongation of the medial canthal tendon seen on
the left is occasionally seen. It is probably not
related to her rhinoplasty.
Supplemental Digital Content 12, http://links.lww.
com/A76. Animation demonstrates facial aging from
ages 10 to 59. The upper lid arc change is well seen.
She has had an upper lid blepharoplasty.
Supplemental Digital Content 13, http://links.lww.
com/A77. Animation of the patient in Figure 6, at
ages 27 and 61. The upper lid arc shift is apparent,
as is the stability of the lid-cheek junctions. The brow
descends slightly and visibly thins and loses volume.
The lateral canthal angle moves medially.
Supplemental Digital Content 14, http://links.lww.
com/A78. Animation demonstrates facial aging from
36 to 54 years. Note the small arc shift on his right.
The brow descends very slightly. The lid-cheek junc-
tion is stable, as are numerous moles on the face.
The medial canthal tendon seems to elongate on the
right. There is a millimeter of lid ptosis.
Supplemental Digital Content 15, http://links.lww.
com/A79. Animation detail of Supplemental Digital
Content 10. The usual size of the iris is 10.5 to 11
mm. Placing a cursor on the medial iris, one can see
that the apparent large motion is approximately 1 to
2 mm. Note how the medial upper lid curve reverses,
implying to us a loss of soft-tissue and/or globe sup-
port.
Supplemental Digital Content 16, http://links.lww.
com/A80. Animation demonstrates facial aging. She
is 33 in the younger image taken just before a rhi-
noplasty and 67 in the older. There has been im-
pressive loss of volume in the upper lids and brow,
which on multiple images remained at that height.
The loss of length of the eyelid and stability of the
lid-cheek junction are clearly seen. She has a few
millimeters of lid ptosis. It is easy to see why the eye
seems to become smaller in patients such as this one.
Supplemental Digital Content 17, http://links.lww.
com/A81 . Animation demonstrates facial aging from
ages 21 to 67. He has had a brow lift and upper lid
blepharoplasty. Note the stability of the lid-cheek
junction and the shortening of the lid aperture.
Supplemental Digital Content 18, http://links.lww.
com/A82. Animation demonstrates facial aging
from ages 54 to 74. There has been a profound
change in her skin. There has been some brow
descent and loss of volume of the upper lid and
brow. The lid-cheek junction is stable (patient im-
ages courtesy of Bahman Guyuron, M.D.).
Supplemental Digital Content 19, http://links.lww.
com/A83. Animation demonstrates facial aging from
ages 30 to 47. She rocks backward slightly. The lid
apertures shorten dramatically. The lid-cheek junc-
tions are stable, as are a cluster of five moles on her
left cheek (arrow) (photographs courtesy of Bahman
Guyuron, M.D.).
Supplemental Digital Content 20, http://links.lww.
com/A84. Animation demonstrates facial aging
from ages 21 to 49. She tilts forward slightly in the
1375
 Plastic and Reconstructive Surgery • October 2007
older picture. The lid-cheek junction (arrow) is
stable considering the relative head motion. The
brows drop slightly. The horizontal eyelid aper-
ture is clearly smaller. The lid-cheek junction
rounds out slightly medially.
Supplemental Digital Content 21, http://links.lww.
com/A85. Animation shows the same subject as
shown in Supplemental Digital Content 23 but
from ages 49 to 61. In the interim, his skin has
acquired substantial mobility to finger traction.
The same wrinkles and moles visible at age 40 are
visible and in the same places. It is possible to have
skin that has not had shifted become more lax to
superior displacement.
Supplemental Digital Content 22, http://links.lww.
com/A86. Animation demonstrates facial aging from
the mid-20s to 65 years. This is one of the few patients
whose lid-cheek junctions descend in this series. Eye-
lid wrinkles collapse. The arc effect is visible on her
right.
Supplemental Digital Content 23, http://links.lww.
com/A87. Animation demonstrates facial aging from
ages 40 to 49 years (animation of Fig. 8). He tilts
back slightly in the older image. The lid-cheek
junction orbicularis wrinkles and several moles
on the face are stable. Brow and lid positions are
unchanged.
1376
Supplemental Digital Content 24, http://links.lww.
com/A88. Animation demonstrates facial aging from
ages 22 to 55. She turns slightly to her right. The
pictures were taken because of the mole of the right
cheek, which is stable. She has a small arc shift of the
upper lid. She is not smiling and her lower lid pos-
ture can be seen to rise slightly. The medial canthal
angles seem to elongate slightly.
Supplemental Digital Content 25, http://links.lww.
com/A89. Animation demonstrates facial aging from
ages 45 to 73. The lid-cheek junctions are stable.
There are two moles on the cheek (arrows) that
have not moved. The deflation of the cheek is
visible, and it is easy to see how this pattern
could be confused with descent. On the oppo-
site side, the indentation of the nasojugal fold is
visible.
Supplemental Digital Content 26, http://links.lww.
com/A90. Animation demonstrates facial aging from
ages 25 to 53. The prominent mole of her left cheek
has not descended.
Supplemental Digital Content 27, http://links.lww.
com/A91. Animation demonstrates facial aging from
the mid-30s to 57 years. The lid-cheek junctions are
stable. A bump on her right cheek is seen in both
images and is immobile.

Observations on Periorbital and Midface Aging
Joel E. Pessa, M.D.
Dallas, Texas
I n this study, Dr. Lambros presents some
thoughts and observations on facial aging.
Many novel ideas are suggested; the common
thread that links all of these observations is the
concept that descent of skin plays a secondary
role in periorbital aging.
Without stating it as such, this is a highly so-
phisticated study of facial growth and aging. The
study method is a longitudinal analysis (the same
individual studied at different ages). Photo-
graphs at the time of surgery were taken to most
accurately match the photographs from a
younger age. The scaling and rotation of these
photographs is similar to the Procrustes transpo-
sition used in geometric morphometrics, a statis-
tically valid methodology. The interpretation is a
subjective analysis of periorbital changes.
Three findings are addressed in the present
study, as follows: (1) the position of the lid-cheek
junction was stable over time in the majority of
individuals (96 percent); (2) orbicularis wrinkles
and other skin markers were likewise stable in
position; and (3) there appeared to be a change
in the shape of the upper eyelid in a subset of
individuals (38 percent). Each of these observa-
tions is novel, and each refutes the classic teach-
ing that skin ptosis is the major component of
facial aging. The author summarizes his findings
in the statement that “these events occur be-
neath essentially static skin.”
It is Lambros who first described volume
changes as a major component of facial aging.
In these days, when fat injections and fillers
are routine, it is important to remember that
the concept was a major breakthrough when
first presented. As one well-known clinician
stated to this discussant after one of Dr. Lam-
bros’ lectures, “now I see fat and dermal
changes everywhere.” It took Lambros’ percep-
Received for publication January 10, 2007.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279330.84227.12
www.PRSJournal.com
DISCUSSION
tive eye to bring this contribution to the spe-
cialty.
The present study suggests that anteroposte-
rior changes in volume can lead to the appear-
ance and illusion of skin descent. The finding
of a stable lid-cheek junction and orbicularis
wrinkles is in agreement with this conclusion.
The author points out that the prominence of
the nasojugal fold does not appear to be ac-
companied by skin migration and may repre-
sent a similar phenomenon. Why facial fat
changes in different regions is unknown, al-
though variation in metabolic demands is sug-
gested as a possible factor.
The shape change of the upper eyelid, noted
in approximately one-third of individuals, is
certainly an interesting finding. Several possi-
ble causes are noted, including possible atten-
uation of the medial aponeurosis of the levator
muscle. That the shape of the upper eyelid
may change with age is certainly a new finding
that will require further investigation.
There are many other fascinating and new
observations included in this article, any one of
which could be the topic for a major thesis. Dr.
Lambros has certainly earned a place as a major
contributor in the field of cosmetic surgery.
However, despite all of his observations, perhaps
the greatest contribution has been his curiosity
and the ability to look at the data with a fresh,
new perspective. This article will almost certainly
lead to a number of studies in the future and a
better understanding of how the human face
changes with age.
Joel E. Pessa, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard
Dallas, Texas 75390-9132
joel.pessa@utsouthwestern.edu
DISCLOSURE
The author has no financial interest in any of the
products, devices, or drugs mentioned in this article.
1377
COSMETIC

Chin Surgery VII: The Textured Secured

Implant—A Recipe for Success
Stephen M. Warren, M.D.
Jason A. Spector, M.D.
Barry M. Zide, D.M.D., M.D.
New York, N.Y.
Background: Silicone chin augmentation remains a popular treatment for mi-
crogenia because its placement appears deceptively simple. However, when
extrusion, displacement, capsular contracture following implant removal, over-
augmentation, or malposition occurs, a revision operation may be required.
Secondary chin surgery is challenging because (1) implant removal alone may
produce a disfigured chin; and (2) placement of a new implant in an oversized
misshapen pocket demands precision, control, and reliability.
Methods: The textured implant may be placed by means of an intraoral or
extraoral route. The extraoral route is usually chosen except when transoral
procedures (e.g., mentalis suspension) are required. The superior 30 to 50
percent of a standard textured implant is always removed and then tapered
anteriorly at a 45-degree angle to reduce its sharp front edge. The lateral wings
are also reduced and tapered. Two pilot holes are drilled in each half of the
implant and then it is divided in the midline. Each half is inserted and secured
individually. The medial screw is placed first and nearly fully tightened. Then,
holding the implant exactly along the inferior border of the mandible, the distal
screw is placed and both screws are tightened completely. The lower border of
the implant should be exactly along the lower border of the mandible. The soft
tissues are closed in three layers over a drain.
Results: This technique has been used to treat more than 100 patients. Selected
photographs illustrate this technique.
Conclusion: This article explains how to place a textured implant efficiently and
effectively under light premedication and local anesthesia. (Plast. Reconstr.
Surg. 120: 1378, 2007.)

T
he senior author has evaluated and treated
well over 300 patients with chin problems
following genioplasty. Some of these pa-
tients had been treated with osseous genioplas-
ties, but more than 80 percent had Silastic im-
plants. In treating these patients, certain points
have become apparent: (1) silicone chin im-
plants placed by means of an intraoral route
have a much higher malposition rate than those
placed by means of a submental route; (2) most
off-the-shelf implants are too tall and too wide
(an unmodified implant will rarely fit a patient);
(3) removal of a chin implant by any route with-
out implant replacement or bony advancement
tends to cause unsightly dimpling and muscle
contraction or chin ptosis; and (4) replacement
From the Institute of Reconstructive Plastic Surgery, New
York University School of Medicine.
Received for publication February 17, 2006; accepted May
12, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279331.65910.75
of a malpositioned Silastic implant requires im-
plant fixation to prevent the new implant from
moving unpredictably in the old pocket. We dis-
cuss the indications, perioperative protocols, ra-
tionale, and operative technique using a fixed
textured chin implant.
PATIENTS AND METHODS
Indications for textured secured implants in-
clude the following:
1. Replacing a malpositioned silicone implant
requires fixation to prevent the new implant
from moving unpredictably.1
2. Replacing an implant that has caused bony
erosions (note that bony contouring to allow
even seating of the textured implant is often
required).2,3
3. The patient who is anxious about implant
movement, fearful of a less than excellent
result, or refuses a silicone implant.
4. Augmenting an insufficient osseous genio-
plasty when the patient refuses a second os-

1378 www.PRSJournal.com
Volume 120, Number 5 • Textured Secured Implant
teotomy or when a repeated osseous genio-
plasty would supply an unsatisfactory partially
resorbed genial segment.4
5. The primary patient with a tension chin (fas-
ciculations with closure of lips) and wide
interlabial gap (3 mm) tends to do better
with a textured implant.
Preoperative Evaluation
The patient is examined for chin balance and
facial relationships using the Quick Analysis of the
Chin.5 The lower third of the face (approximately
55 percent of total anterior facial height) is as-
sessed point by point for the following: (1) lip
eversion; (2) occlusion; (3) static chin pad thick-
ness; (4) labiomental fold depth and height; and
(5) dynamic chin pad motion while smiling.5 Pho-
tographs of frontal and side views, both in repose
and in smiling, are obtained. Cephalograms are
not routinely ordered.
Mentalis Repositioning
In some cases, mentalis resuspension was nec-
essary. This procedure was usually performed first,
and then 6 months later the implant was placed
through a submental incision as described below.
The two-stage approach allows for better judg-
ment regarding chin projection after the chin pad
has been properly repositioned. In certain cases,
when circumstances were extenuating (e.g., travel
or finances), mentalis resuspension and implant
placement were performed in the same stage.
Preoperative Protocol
The patient is given nothing by mouth for 4
hours before coming to the office with an escort.
The patient takes 20 mg of diazepam and 3 mg of
alprazolam (lorazepam works better in males) by
mouth and then reclines in a holding area for 30
to 45 minutes (doses are for the average otherwise
healthy young 60- to 80-kg adult). Bilateral infe-
rior alveolar nerve blocks are performed with 1%
lidocaine with 1:100,000 epinephrine. Ten min-
utes later, the mental plus jawline and submenton
injections are performed with approximately 15 cc
of a 50:50 mixture of 1% lidocaine/0.5% bupiv-
acaine with 1:100,000 epinephrine to anesthetize
the preperiosteal area on the anterior surface,
menton, and inferior borders of the mandible.6
This injection can be performed in the preoperative
area or after the patient is transferred to the oper-
ating room. The patient lies supine on the operating
room table with a pillow under the shoulders to allow
the head to extend into a Silastic gel head rest. A
pulse oximeter can be used, although respiratory
depression from oral medications is very rare. An
intravenous line is optional.
Operative Technique
In most cases, mentalis resuspension was per-
formed first through a gingivobuccal incision.
Then, after 6 months, the implant was placed
through a submental incision. In some cases, when
circumstances were extenuating (e.g., travel or
finances), mentalis resuspension and implant
placement were performed in the same stage;
however, this was not our preference.
The facial midline, from the labiomental fold
to the hyoid, and the intended incision are
marked (Fig. 1, above, left). During the first 10
minutes, while the last injection of local anesthesia
is taking effect, we perform the following steps: (1)
carve down the upper portion (superior 30 to 50
percent) of the textured implant with a burr or
knife (Fig. 1, above, right); (2) reduce and taper the
lateral wings as necessary (Fig. 1, center, left); (3)
taper the upper edge anteriorly at a 45-degree
angle with a burr Fig. 1, center, right); and (4) drill
two pilot holes in each half of the implant. The
first pilot hole is drilled approximately 3 to 5 mm
from the midline and the second pilot hole is
drilled halfway between the first and the end of the
implant. Then, the implant is divided in the mid-
line (Fig. 1, below).
A submental incision is made and electrocau-
tery dissection is carried down through the sub-
cutaneous tissues to the periosteum. Electrocau-
tery is used to clear the mandibular border from
canine to canine and then a periosteal elevator is
used to complete the lateral pockets (Fig. 2, above,
left). At the most lateral extent of the dissection,
the elevator is levered up to gain additional room
in the lateral pockets Fig. 2, above, right). Next, the
midline of the mandible at the menton is marked
with an electrocautery, a burr, or a drill (Fig. 2,
center, left).
The left half of the divided implant is custom-
arily inserted into the pocket first. The central
portion of the implant is aligned with the midline
menton mark and a screw is placed through the
medial predrilled pilot hole. This screw is partially
tightened. Then, the lateral segment of the im-
plant is exposed and held exactly along the inferior
border (Fig. 2, center, right). The second screw
(distal) is placed through the predrilled implant
pilot hole and then both screws are tightened
completely and countersunk, so that the screw
heads are below the implant surface to allow for
1379
 Plastic and Reconstructive Surgery • October 2007

Fig. 1. The surgeon should customize the commercially available textured implant to reduce the vertical height and
shorten the horizontal length. (Above, left) Marking the facial midline, from labiomental fold to hyoid, and the intended
incision. (Above, right) The upper 30 to 50 percent of the textured implant is removed so that the implant will only
provide projection at the pogonion. (Center, left) The lateral projection of the textured implant is trimmed and then
tapered. (Center, right) Returning to the upper portion of the implant, a burr is used to taper the upper edge at a
45-degree angle. (Below) The implant is divided in the midline and two drill holes are placed in each half of the implant.
The first drill hole is approximately 3 mm from the midline and the second drill hole is halfway between the first hole
and the end of the implant.

1380
Volume 120, Number 5 • Textured Secured Implant

Fig. 2. Placement of the customized textured implant. (Above, left) Electrocautery is used to clear the mandibular
border from canine to canine and then a periosteal elevator is used to complete the distal pocket. (Above, right) At the
most distal extent of the dissection, the elevator is levered up to complete the pocket. (Center, left) The midline of the
mandible at the menton is marked with electrocautery, drill, or burr. (Center, right) The central portion of the implant
is aligned with the midline menton mark and a screw is drilled and sunk through the medial pilot hole. This screw is
partially tightened. Then, the lateral segment of the implant is exposed and held exactly along the inferior border.
The second screw (lateral) is placed through the predrilled implant pilot hole. (Below) Both screws are tightened
completely and countersunk so that the screw heads are below the implant surface to allow for further reduction
of the anterior surface of the implant, if necessary (note that neither screw has yet to be satisfactorily countersunk
in this image).

1381
 Plastic and Reconstructive Surgery • October 2007

further reduction of the anterior surface of the
implant, if necessary (Fig. 2, below). The same pro-
cedure is performed on the right side of the man-
dible.
A small drain is passed from the implant to exit
the skin caudal to the submental incision. A 4-0
polypropylene suture is passed through the drain and
skin and then tied.7 The incision is then closed in
three layers: muscle, subcutaneous tissues, and skin.
The procedure takes approximately 40 minutes.
Postoperative Protocol
The patient wears an elastic chin support for
3 days. The Axiom drain is removed on postop-
erative days 1 to 2.
Postoperative Evaluation
The patient is examined for chin balance and
facial relationships with the same Quick Analysis
of the Chin used in the preoperative evaluation.5
Because validated standardized instruments to
measure chin aesthetics do not exist, outcomes are
subjective.
RESULTS
More than 100 patients have been treated with
a two-piece, custom-carved, rigidly fixed, textured
chin implant. We have observed two infections. One
infection was due to a stitch abscess and one infec-
tion was due to an unrecognized rent in a low gin-
givobuccal sulcus. Only one implant required ad-
justment because the lower edge of the implant
could be palpated along the inferior mandibular
border. Average primary and secondary results are
presented (Figs. 3 and 4).
DISCUSSION
Silicone implantation and osseous genioplasty
are two excellent choices for chin augmentation;
however, neither can satisfy all chin needs. Even

Fig. 3. (Above) Preoperative views of the primary patient, a 22-year-old man with minimal lip eversion, an Angle class I occlusion, and
microgenia. His chin pad soft-tissue thickness was normal (approximately 8 mm). The patient refused a silicone chin implant and
underwent placement of a textured secured implant through a submental incision. (Below) Postoperatively, his chin projection was
normal and his labiomental fold was more defined. (Note that the patient also had supraplatsymal and subplatysmal lipectomy and
a corset platysmaplasty.)

1382
Volume 120, Number 5 • Textured Secured Implant

Fig. 4. (Above) Preoperative dynamic views of the secondary patient, a 31-year-old woman who had previously undergone allo-
plastic genioplasty with a silicone implant, show the high-riding implant on the right and chin pad ptosis. The patient had right-sided
chin paresthesias and periodontal erosion. The silicone implant was removed and a textured secured implant was inserted through
a submental incision. (Center) Postoperative dynamic views. (Below) Axial computed tomographic scan (obtained by referring phy-
sician) shows the high-riding silicone implant. The implant has caused erosion of the anterior surface of the mandible and weakened
the periodontal ligaments.

the soft wings of the Gore-Tex implant (W. L. Gore
& Associates, Flagstaff, Ariz.) can fold in a small
pocket or the implant can move unpredictably in
a larger pocket.8,9 A secured textured implant
helps solve many difficult primary and secondary
chin problems. Some surgeons are reluctant to use
a textured implant, believing that placement re-
quires expensive equipment (e.g., air drills), more
time, and a deeper level of anesthesia. We have
overcome all of these impediments.

1383
 Plastic and Reconstructive Surgery • October 2007
Clinical examination of the chin enables the
surgeon to see and feel the problem.5,10,11 Dis-
placement/malposition of the chin implant can
result in excessive or inadequate chin projection,
irregular mandibular contour, changes in the cer-
vicomental angle (e.g., double chin) or labiomen-
tal angle, erosion of the mandible or alveolar
bone, and an irregular smile.2,3,12–14 Functionally,
the displaced/malpositioned implant may cause
labial ectropion and impair oral competence or
cause mental nerve paresthesias.15,16 We have ob-
served that silicone chin implants placed through
an intraoral route have the highest malposition
rate. When reoperating on a malpositioned sili-
cone implant, we disregard the previous gingivo-
buccal incision and approach the chin through a
submental incision unless a concomitant mentalis
repositioning is required. When mentalis reposi-
tioning is required, we prefer to perform the re-
suspension at least 6 months before placement of
the implant. Then, we use the submental access
incision; a well-placed submental incision rarely
produces a problematic scar. In no instance, when
patients had mentalis repositioning and implant
placement during the same operation, were in-
traoral and extraoral incisions used simultaneously.
One of the more common complications ob-
served in our referred patient population was a
high-riding implant (above the inferior border of
the mandible). A high-riding implant produces
excessively high projection with smile and a blunted
labiomental fold. These patients commonly com-
plain of unilateral numbness caused by implant roll
and impingement of the high-riding side of the im-
plant on the mental nerve. It is extremely difficult to
correctly replace a high-riding silicone implant with
another silicone implant. The fixed textured im-
plant along the inferior mandibular border corrects
the problem.
We also routinely observed alloplastic over-
augmentation of the female chin with a high la-
biomental fold. This error may result from choos-
ing an off-the-shelf implant without customizing it
for the patient. We find that removing an over-
sized chin implant without replacing it tends to
cause unsightly dimpling, muscle contraction, and
chin ptosis.2 By customizing the implant to reduce
its vertical height and lateral dimension, we can
correctly augment the chin only at the pogonion
(Fig. 1). Fixing a textured implant to avoid un-
predictable movement can also be used for pa-
tients who are undergoing multiple simultaneous
procedures in the head and neck (e.g., alloplastic
genioplasty plus rhytidectomy and/or platysma-
plasty) or for patients who have had a previously
1384
insufficient osseous genioplasty and now require
additional augmentation. Screws fix the textured
implant to the mandible, and the textured im-
plant may also fix the soft tissues and reduce re-
current chin pad ptosis. Textured implants have a
large (50 to 200 ␮m) interconnecting open pore
structure.17,18 This porous framework is rapidly
populated with fibroblasts that deposit collagen
and attract a vascular supply. The dense network
of collagen may extend from the rigidly fixed im-
plant into the soft tissues of the chin and reduce
chin ptosis.
Using a step-wise protocol, with oral premed-
ication, local and field block anesthesia, custom
implant carving during the postinjection period,
and fixation of a predrilled split implant, can rou-
tinely limit operative times to 40 minutes. More-
over, in one procedure, we can correct complica-
tions of secondary and tertiary operations with
precision.
SUMMARY
Chin surgery is challenging, but by recogniz-
ing and analyzing certain implant-related prob-
lems, a method to solve some of these issues has
evolved. A safe, reliable method of placing a pre-
split, predrilled, precarved, textured, secured im-
plant can save the day.
SURGICAL ADDENDUM
1. Porous implants should not, as a rule, be
used directly off the shelf. The implants
tend to be designed too large (i.e., too long
and too high). Since pogonion projection is
required only at the bottom 1 cm of the
chin, there is rarely a reason to use an
unmodified, full-height implant. Use the
time during field block set-up to get 90
percent of the implant contouring finished.
2. The top 30 to 40 percent of an implant can
usually be removed. The lateral wings can
also be shortened and flattened to improve
the taper. Sometimes the inferior part of
the implant must be reduced laterally, so it
does not hand below the inferior border of
the mandible.
3. If the bony take-off below the labiomental
fold is prominent, the upper part of the
implant will make the labiomental fold too
acute.
4. After marking, field blocking, draping, and
carving the implant, the pogonial and im-
plant midlines are scored. The implant is
predrilled (three holes if the implant is left
Volume 120, Number 5 • Textured Secured Implant
whole and four lateral holes if the implant
is split). The lateral holes should not be too
far from the midline for simple screw place-
ment.
5. Place the central screw in the in mesial hole
first. Then insert the lateral screw so that
the implant is exactly along the mandibular
border in order to avoid palpability.
6. If the vertical height of the mandible is
short, you must see the mental foramina
because they may be very low. In a vertically
challenged mandible, the implant can eas-
ily pinch the mental nerves as they exit their
foramina.
7. In secondary surgery, if you are replacing a
silicone implant, consider suturing the cen-
tral portion of the soft-tissue capsule to the
anterosuperior surface of the new porous
implant in order to eliminate dead space.
This may require one to two sutures to ef-
fectively eliminate the dead space.
8. Place and countersink all screws in the
lower third of the implant, so that final
implant contouring can be done without
encountering the screws.
Barry M. Zide, D.M.D., M.D.
420 East 55th Street, 1D
New York, N.Y. 10022
barry.zide@med.nyu.edu
DISCLOSURES
The authors hereby certify that, to the best of their
knowledge, no financial support or benefits have been
received by any coauthor, by any member of their imme-
diate families, or by any individual or entity with whom
or with which they have a significant relationship from
any commercial source that is related directly or indirectly
to the scientific work that is reported on in the article.
REFERENCES
1. Yaremchuk, M. J. Improving aesthetic outcomes after allo-
plastic chin augmentation. Plast. Reconstr. Surg. 112: 1422,
2003.
2. Cohen, S. R., Mardach, O. L., and Kawamoto, H. K., Jr. Chin
disfigurement following removal of alloplastic chin implants.
Plast. Reconstr. Surg. 88: 62, 1991.
3. Jobe, R., Iverson, R., and Vistnes, L. Bone deformation be-
neath alloplastic implants. Plast. Reconstr. Surg. 51: 169, 1973.
4. Sclaroff, A., and Williams, C. Augmentation genioplasty:
When bone is not enough. Am. J. Otolaryngol. 13: 105, 1992.
5. Zide, B. M., Pfeifer, T. M., and Longaker, M. T. Chin surgery:
I. Augmentation—The allures and the alerts. Plast. Reconstr.
Surg. 104: 1843, 1999.
6. Zide, B. M., and Swift, R. How to block and tackle the face.
Plast. Reconstr. Surg. 101: 840, 1998.
7. Zide, B. M. Seven more tips for the operating room. Plast.
Reconstr. Surg. 115: 973, 2005.
8. Godin, M., Costa, L., Romo, T., et al. Gore-Tex chin implants:
A review of 324 cases. Arch. Facial Plast. Surg. 5: 224, 2003.
9. Mole, B. The use of Gore-Tex implants in aesthetic surgery
of the face. Plast. Reconstr. Surg. 90: 200, 1992.
10. Zide, B. M., and Longaker, M. T. Chin surgery: II. Submental
ostectomy and soft-tissue excision. Plast. Reconstr. Surg. 104:
1854, 1999.
11. Zide, B. M., and Boutros, S. Chin surgery III: Revelations.
Plast. Reconstr. Surg. 111: 1542, 2003.
12. Flowers, R. S. Alloplastic augmentation of the anterior man-
dible. Clin. Plast. Surg. 18: 107, 1991.
13. McCarthy, J. G., and Ruff, G. L. The chin. Clin. Plast. Surg.
15: 125, 1988.
14. Spear, S. L., and Kassan, M. Genioplasty. Clin. Plast. Surg. 16:
695, 1989.
15. Matarasso, A., Elias, A. C., and Elias, R. L. Labial incompe-
tence: A marker for progressive bone resorption in silastic
chin augmentation. Plast. Reconstr. Surg. 98: 1007, 1996.
16. Matarasso, A., Elias, A. C., and Elias, R. L. Labial incompe-
tence: A marker for progressive bone resorption in silastic
chin augmentation. An update. Plast. Reconstr. Surg. 112: 676,
2003.
17. Yaremchuk, M. J. Mandibular augmentation. Plast. Reconstr.
Surg. 106: 697, 2000.
18. Seare, W. J., Jr. Alloplasts and biointegration. J. Endourol. 14:
9, 2000.
1385
COSMETIC

Patient-Reported Benefit and Satisfaction with

Botulinum Toxin Type A Treatment of
Moderate to Severe Glabellar Rhytides: Results
from a Prospective Open-Label Study
Mitchell A. Stotland, M.D.
Jonathan W. Kowalski,
Pharm.D., M.S.
Belinda B. Ray, M.A.
Hanover and Lebanon, N.H.; and
Irvine, Calif.
Background: Patient satisfaction is a key measure of success when using botu-
linum toxin type A to treat glabellar rhytides. However, lack of a standardized
method of assessing satisfaction has limited its evaluation.
Methods: In this open-label study, 58 women with moderate or severe glabellar
rhytides at maximum frown were treated with 20 units of botulinum toxin type
A (divided injections in corrugator and procerus muscles). Patients’ self-per-
ceptions were assessed at baseline and the following were assessed at days 30 and
120: investigator- and patient-rated global assessment of change in glabellar line
severity, patient self-perception of age, and patient satisfaction with the effects
of treatment and the procedure itself (using the Facial Lines Treatment Satis-
faction Questionnaire).
Results: Overall, patients had a positive self-image at baseline. At day 30, the
investigator reported that all patients had 50 percent or greater improvement
in glabellar line severity. At days 30 and 120, 95 percent and 86 percent of
patients, respectively, reported satisfaction with treatment overall and 82 per-
cent or more reported satisfaction with various aspects of the effects of treatment
(time to onset of action, improvement in facial lines and appearance, and
appearing better and relaxed) and the procedure itself (absence of downtime
and side effects). More than one-third of patients considered that they looked
younger than they did before treatment (by a median of 5 years at both time
points).
Conclusions: Botulinum toxin type A treatment of glabellar rhytides resulted in
high levels of patient satisfaction, and more than one-third of patients thought
they appeared younger than they did before treatment. (Plast. Reconstr. Surg.
120: 1386, 2007.)

F
acial rhytides are often unwelcome either
because they are a sign of aging or because
they can be misinterpreted and mistakenly
perceived to signify stress, anxiety, annoyance,
disapproval, or anger.1,2 The presence of facial
rhytides can have a negative impact on patients’
perception of themselves and also on other
From Dartmouth Medical School, Dartmouth-Hitchcock
Medical Center, and Global Health Outcomes Research, Al-
lergan, Inc.
Received for publication November 29, 2005; accepted April
20, 2006.
Poster presented at the Academy ’05 Meeting of the American
Academy of Dermatology, in Chicago, Illinois, July 20 through
24, 2005.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279377.86280.8d
people’s impressions of them and, as a result,
they may seek treatment to achieve a more
youthful appearance, to help them appear their
best, to help prevent miscues of facial commu-
nication, or simply to feel better about their
appearance.2,3
The use of botulinum toxin type A for the
treatment of glabellar lines was approved by the
U.S. Food and Drug Administration in 2002.4
The durable efficacy and good safety profile of
botulinum toxin type A therapy are well estab-
lished in the literature.4 – 6 Nevertheless, in the
field of facial aesthetic therapy, a key measure of
the success of treatment is actually patient satis-
faction—as one goal of any cosmetic treatment is
not to eliminate imperfections but to increase
the patient’s happiness.2 Although the level of

1386 www.PRSJournal.com
Volume 120, Number 5 • Botox and Glabellar Rhytides
clinical improvement remains an important out-
come measure, particularly in research studies,
ultimately it is the patient’s impression of the
treatment that is of most importance to them
and a key determinant of whether the effects of
treatment translate into benefits in their well-
being. Furthermore, patient satisfaction is partic-
ularly important for therapies such as botulinum
toxin type A that require repeated treatments for
the maintenance of efficacy.
Although patient satisfaction associated with
botulinum toxin type A therapy has not been
evaluated as extensively as efficacy and safety,
reports do indicate that levels of satisfaction are
high.7,8 However, the assessment of patient satis-
faction has not been standardized. In previous
reports, satisfaction was assessed using either a
simple nonstandardized questionnaire7 or an in-
strument designed for a general cosmetic der-
matology setting8 and not specifically for facial
rhytides.
Patient satisfaction is multidimensional and a
difficult concept to define and assess accurately
and reliably. It can be influenced by many fac-
tors, including efficacy, perceptions of efficacy
(the patient’s and other people’s), durability of
efficacy, tolerability, safety, convenience, and
cost, with the relative importance of each of
these differing between patients. Given the im-
portance of patient satisfaction in the field of
facial aesthetic enhancement, the challenge of
standardizing its assessment needs to be ad-
dressed. Because of the many subjective factors
that may be involved, it should ideally be an
assessment made by the patient.
The Facial Lines Treatment Satisfaction Ques-
tionnaire was developed to evaluate patient sat-
isfaction specifically in patients receiving mini-
mally invasive treatment for hyperfunctional
facial rhytides.9,10 In the case of botulinum toxin
type A therapy, patient satisfaction can be influ-
enced both by the effects of treatment and by the
patient’s impression of the procedure itself, and
this questionnaire takes account of both of
these. The questionnaire evaluates 14 parame-
ters that have been found to be important in
influencing patient satisfaction—11 that can in-
fluence satisfaction with the effects of treatment
and three that can influence satisfaction with the
procedure. The relative importance of the pa-
rameters varies between individual patients.
We report here the results from the first pro-
spective study to use this instrument to evaluate
patient satisfaction with botulinum toxin type A
treatment for glabellar rhytides. In addition to
assessing patient satisfaction prospectively, this
study also assessed patients’ perceptions of their
age after treatment, which has not to our knowl-
edge been reported in the literature previously.
PATIENTS AND METHODS
Patients were eligible for enrollment into the
study if they were female and between 35 and 60
years of age, with glabellar rhytides of at least
moderate severity at maximum frown (glabellar
line severity was graded as none, mild, moderate,
or severe using a photonumeric guide). Patients
were recruited through advertisements in local
newspapers.
Exclusion Criteria
Patients were excluded from the study if they
had previously been treated with botulinum toxin
type A; had received facial rejuvenation treatment
or undergone facial aesthetic surgery in the pre-
ceding year or were planning such treatment dur-
ing the study period; had a significant facial move-
ment disorder; had preexisting brow or eyelid
ptosis; had a history of cerebrovascular accident,
head injury, or other cerebral damage affecting
the recognition or expression of emotion; had any
psychiatric illness that might interfere with the
ability to produce facial expressions or experience
emotion normally; had any disorder or were using
any agent that might interfere with neuromuscu-
lar function; or were pregnant, breastfeeding, or
of childbearing potential and not using reliable
contraception.
Treatment Regimen
A total dose of 20 units of botulinum toxin type
A (Botox Cosmetic; Allergan, Inc., Irvine, Calif.)
was injected (five injections of 4 units, two in each
corrugator muscle and one in the procerus mus-
cle) using a 30-gauge needle.4 Reconstitution of
botulinum toxin type A (4 units/0.1 ml) was per-
formed immediately before injection using non-
preserved injectable saline. All injections were ad-
ministered by a single investigator. The study was
approved by the institutional review board for the
Dartmouth-Hitchcock Medical Center, and all pa-
tients were required to sign informed consent.
Baseline Assessments
Glabellar Line Severity
The investigator used a photonumeric guide
to grade the severity of the patient’s glabellar lines
at baseline (as none, mild, moderate, or severe),
both at rest and at maximum frown.
1387
 Plastic and Reconstructive Surgery • October 2007
Patients’ Self-Perceptions
Patients were asked to rate their level of agree-
ment with nine possible self-perceptions related to
either self-confidence (confidence in their own
attractiveness, feeling good, appearing their best,
and appearing young) or other self-perceptions
(self-consciousness, attractiveness, appearing tired,
appearing stressed, and worrying about facial
lines) on a seven-point scale (where 1 ⫽ strongly
disagree, 2 ⫽ disagree, 3 ⫽ slightly disagree, 4 ⫽
neutral, 5 ⫽ slightly agree, 6 ⫽ agree, and 7 ⫽
strongly agree).
Efficacy Outcome Measures
Global Assessment of Change in Glabellar
Line Severity
At days 30 and 120, the investigator and pa-
tients reported their global assessment of change
in glabellar line severity on a nine-point scale
[where ⫹4 ⫽ 100 percent better (complete im-
provement), ⫹3 ⫽ 75 percent better, ⫹2 ⫽ 50
percent better, ⫹1 ⫽ 25 percent better, 0 ⫽ un-
changed, ⫺1 ⫽ 25 percent worse, ⫺2 ⫽ 50 percent
worse, ⫺3 ⫽ 75 percent worse, and ⫺4 ⫽ 100
percent worse]. The investigator considered the
change in glabellar line severity at both rest and
maximum frown when determining the global
level of improvement and used preinjection base-
line photography (at both rest and maximum
frown) to assist in the evaluation.
Patients’ Self-Perception of Age
At days 30 and 120, patients were asked to
report whether they thought they appeared
younger, the same age, or older compared with
before treatment. If they thought they appeared
younger or older, they were asked to report how
many years younger or older they thought they
appeared compared with before treatment.
Patient Satisfaction
At days 30 and 120, patients were asked to rate
their satisfaction using the validated and reliable
Facial Lines Treatment Satisfaction Questionnaire, a
14-item measure in which patients rate their satis-
faction on a seven-point scale (where 1 ⫽ very dis-
satisfied, 2 ⫽ dissatisfied, 3 ⫽ somewhat dissatisfied,
4 ⫽ neutral, 5 ⫽ somewhat satisfied, 6 ⫽ satisfied,
and 7 ⫽ very satisfied).9,10 The Facial Lines Treat-
ment Satisfaction Questionnaire consists of a Satis-
faction with Effects of Treatment domain (11 items)
and a Satisfaction with the Experience of the Pro-
cedure domain (three items). The domain scores
are calculated by taking the mean of all item scores
in that domain. Patients with a mean score of at least
5 were considered to have achieved satisfaction in
1388
that domain. For each patient, the total score and
the score for each of the domains were recorded.
Statistical Analyses
Patients’ demographic characteristics, glabel-
lar line severity assessments, and self-perceptions
were summarized as mean values or the percent-
age of patients in each category. The degree of
correlation between the investigator and patient
ratings of the global assessment of change in gla-
bellar line severity was evaluated by calculating the
Spearman correlation coefficient together with
the 95 percent upper and lower confidence limits.
For the Facial Lines Treatment Satisfaction Ques-
tionnaire data, the means of all patients’ total
scores and domain scores were calculated to give
the overall total and domain scores, respectively,
and their associated standard deviations for the
study population.
RESULTS
Patients
A total of 58 women received treatment and 56
(97 percent) completed the study. Two discontin-
ued because of adverse events considered possibly
related to treatment (headache, pulling sensation
in eye, and aching pressure across forehead).
Overall, the patients had a positive perception of
themselves (95 percent agreed with the statement
“I feel good about myself”) and had confidence in
their appearance (64 percent agreed with the
statement “I feel confident others find me attrac-
tive”) (Table 1). However, the majority also re-
ported that their facial lines made them appear
stressed (69 percent) or tired (69 percent) or
made them feel less attractive than when younger
(67 percent) (Table 1). In addition, 50 percent
were self-conscious about their facial lines and 45
percent worried that others noticed their facial
lines. Two-thirds of the patients (66 percent) did
not agree with the statement “I look as young on
the outside as I feel on the inside,” suggesting a
difference in how young they feel relative to how
old they perceive themselves to appear when look-
ing in the mirror.
Efficacy
Global Assessment of Change in Glabellar
Line Severity: Investigator Assessment
At day 30, the investigator considered 100 per-
cent of patients to have achieved greater than or
equal to 50 percent improvement from baseline,
Volume 120, Number 5 • Botox and Glabellar Rhytides

Table 1. Patient Details and Self-Perceptions at with 66 percent of patients still showing greater
Baseline than or equal to 50 percent improvement at day
Value (%) 120 (Fig. 1).
Demographics Global Assessment of Change in Glabellar
No. of patients (all female) 58 Line Severity: Patient Assessment
Age, years
Mean 49 At day 30, 88 percent of patients considered
Range 38–59 they had greater than or equal to 50 percent im-
Ethnicity, no. of patients (%) provement from baseline, with 57 percent consid-
Caucasian 57/58 (98)
Hispanic 1/58 (2) ering they still had greater than or equal to 50
Investigator rating of glabellar line severity percent improvement at day 120 (Fig. 1). The
At rest investigator and patient ratings of change in gla-
Mild 6/58 (10)
Moderate 37/58 (64) bellar line severity were moderately correlated
Severe 15/58 (26) with each other—the Spearman correlation coef-
At maximum frown ficient was 0.34 at day 30 (95 percent confidence
Moderate 25/58 (43)
Severe 33/58 (57) interval, 0.11 to 0.57; p ⫽ 0.009) and 0.53 at day
Patient self-perceptions (based on your 120 (95 percent confidence interval, 0.33 to 0.73;
appearance over the past week, how p ⫽ 0.00004).
much do you agree or disagree with
each statement below?)* Patients’ Self-Perception of Age
“I feel good about myself.” 55/58 (95) The percentage of patients reporting that
“I look tired because of my facial lines.” 40/58 (69)
“I look stressed because of my facial they appeared younger after treatment was 37
lines.” 40/58 (69) percent at day 30 and 34 percent at day 120. At
“I feel less attractive than I did when I both time points, these patients perceived that
was younger because of my facial they appeared younger by a median of 5 years
lines.” 39/58 (67)
“I feel confident others find me to be (Table 2). No patient thought they appeared
attractive.” 37/58 (64) older after treatment.
“I look the best I can.” 37/58 (64)
“I am self-conscious about my facial Patient Satisfaction
lines.” 29/58 (50) A high proportion of patients reported satis-
“I worry other people notice my facial faction (i.e., a mean total score on the Facial Lines
lines.” 26/58 (45)
“I look as young on the outside as I feel Treatment Satisfaction Questionnaire of ⱖ5) with
on the inside.” 20/58 (34) the treatment overall (95 percent at day 30 and 86
*Data are expressed as number of patients (with percentage in pa- percent at day 120), the effects of their treatment
rentheses) who slightly agree, agree, or strongly agree. (88 percent at day 30 and 82 percent at day 120),
and the experience of the botulinum toxin type A
injection procedure itself (93 percent at day 30
and 95 percent at day 120) (Fig. 2).

Fig. 1. Percentage of patients with improvement in the severity of glabellar lines 30 days and 120 days after
treatment with botulinum toxin type A.

1389
 Plastic and Reconstructive Surgery • October 2007

Table 2. Patients’ Self-Perception of Age

Day 30 Day 120

Perceived Change in Perceived Change in

Age (yr) Age (yr)
Patient’s Self-
Perception No. of Patients (%) Mean ⴞ SD Median No. of Patients (%) Mean ⴞ SD Median
Appear younger 21/57 (37) 4.9 ⫾ 2.59 5.0 19/56 (34) 4.8 ⫾ 2.12 5.0
Appear the same age 36/57 (63) — 37/56 (66) — —
Appear older 0/57 (0) — — 0/56 (0) — —

Fig. 2. Percentage of patients reporting satisfaction with the effects of their treatment, the experience
of the procedure, and the treatment overall (satisfaction is defined as a mean total score of at least 5 on
the seven-point scale of the Facial Lines Treatment Satisfaction Questionnaire).

At both day 30 and day 120, the majority of
patients reported satisfaction with various aspects
of their study treatment as indicated by individual
items on the Facial Lines Treatment Satisfaction
Questionnaire (Figs. 3 and 4).
Tolerability
Adverse events that were considered probably
or definitely related to treatment were limited to
headache (reported in 12 percent of patients),
soreness/itching at the injection site (5 percent),
and feeling pressure (2 percent). None was seri-
ous and all were mild except for a moderate head-
ache in one patient.
DISCUSSION
Data from this study confirm that botulinum
toxin type A treatment offers durable efficacy in
the treatment of glabellar lines. Importantly, the
results also revealed that more than one-third of
patients perceived themselves to appear younger
after treatment than before (by a median of 5 years
at both day 30 and day 120). Given that glabellar
lines are considered to be primarily lines of facial
expression and communication, the extent of
the effect of botulinum toxin type A therapy on
patients’ perception of their age is remarkable. We
believe this is the first report in the literature of
patients perceiving themselves to be younger after
treatment with botulinum toxin type A, and it is
especially noteworthy that this effect was achieved
with a single treatment modality even though com-
bination therapies are commonly used in the pur-
suit of facial rejuvenation.
Although not all patients considered that
they appeared younger (some did not perceive
any difference, but none thought they appeared
older), this may be related to the fact that the
goals of treatment are different in different pa-
tients—whereas some wish to appear younger,
others simply want to appear or feel their best,
and others wish to eradicate the lines of expres-
sion that cause facial miscues.2 One limitation of
this study was that the level of importance to

1390
Volume 120, Number 5 • Botox and Glabellar Rhytides

Fig. 3. Percentage of patients reporting satisfaction with items in the Effects of Treatment domain of the Facial Lines Treatment
Satisfaction Questionnaire (satisfaction is defined as a mean score of at least 5 on the seven-point scale).

Fig. 4. Percentage of patients reporting satisfaction with items in the Experience of Procedure domain
of the Facial Lines Treatment Satisfaction Questionnaire (satisfaction is defined as a mean score of at
least 5 on the seven-point scale).

each patient of each item on the Facial Lines
Treatment Satisfaction Questionnaire was not
assessed before treatment.
The percentage of patients who felt more con-
fident after botulinum toxin type A treatment of
facial rhytides has been assessed previously using
the Freiburg questionnaire on aesthetic derma-
tology and cosmetic surgery (an instrument that is
specific to cosmetic dermatology but not to the
treatment of facial lines).8 The incidence of these
improvements was comparable in the earlier as-
sessment and the present study. In the earlier
study, 45 percent of patients (at approximately
days 56 to 84) had more confidence in their ap-
pearance and, in the present study, 39 percent (at
day 30) and 45 percent (at day 120) were at least
somewhat satisfied with the ability of the treatment
to make them feel more confident. It should be
noted that, in the present study, confidence was
already high at baseline, with 64 percent of pa-

1391
 Plastic and Reconstructive Surgery • October 2007
tients reporting they were confident they were
attractive to others. Important differences be-
tween the two studies were the different methods
of assessment, different timings of assessment, and
the fact that nearly 50 percent of the patients in
the earlier study were being treated for nongla-
bellar facial rhytides. Furthermore, patients who
were being treated for glabellar rhytides received
a higher dose (24 to 30 units) than the 20 units
used in the present study and approved by the U.S.
Food and Drug Administration.
The study presented here is the first to eval-
uate patient satisfaction with botulinum toxin type
A using a validated and reliable instrument de-
signed for use in patients undergoing minimally
invasive treatment for facial rhytides. Patient sat-
isfaction was high, with 91 and 84 percent of pa-
tients at least somewhat satisfied with the improve-
ment in their facial appearance at days 30 and 120,
respectively (Fig. 3). In addition, 88 and 82 per-
cent of patients reported satisfaction with the ef-
fects of their treatment at days 30 and 120, re-
spectively, and 93 and 95 percent reported
satisfaction with the procedure. High levels of sat-
isfaction were reported for the procedure itself
(specifically, the absence of downtime, the ab-
sence of side effects, and the feeling that no one
knew they had received treatment for their facial
lines) and also for aspects related to the effects of
treatment (e.g., overall satisfaction, improvement
in facial lines, improvement in facial appearance,
time to onset of action, the ability to appear better,
and the ability to appear relaxed). The high pa-
tient satisfaction ratings are consistent with pre-
viously reported findings. In other studies, 91 per-
cent of patients considered their treatment
successful7 and 100 percent reported they would
recommend the treatment to others.8
The observed moderate correlations between
the investigator and patient ratings of improve-
ment in glabellar line severity are not unexpected.
However, the lack of strong correlations empha-
sizes the importance in clinical practice of obtain-
ing patient assessments, as investigator ratings can-
not be relied on as a surrogate or sole indicator of
patient satisfaction or perception of treatment
success. Thus, patient ratings are important even
though, in this study, they appeared to be less
sensitive than investigator ratings to changes oc-
curring between days 30 and 120.
Botulinum toxin type A treatment of glabellar
rhytides enhanced the self-image of the patients in
this study even though they already had a positive
perception of themselves at baseline. This con-
firms that it is an appropriate and valuable treat-
1392
ment in patients who are already self-confident
and feel good about themselves. It would be in-
teresting to evaluate whether the effects may be
even more marked in individuals with a lower self-
image before treatment. Future research could also
address other limitations of the present study by
including controls, men, non-Caucasians, and pa-
tients who had previously received botulinum
toxin type A treatment.
In the early days of botulinum toxin type A
treatment for facial lines, it was questioned
whether such therapy might result in a loss of
facial affect. However, Heckmann et al. have
shown that botulinum toxin type A enhances the
facial expression of positive emotions and reduces
the facial expression of negative emotions, result-
ing in a shift toward a more positive facial affect
(rather than a loss of facial affect).11 This likely
plays a role in improving patients’ perceptions of
themselves. It would be interesting to understand
whether the change in appearance resulting from
botulinum toxin type A treatment is the only factor
involved in improving patients’ self-perceptions or
whether the effect of inhibiting the contraction of
certain muscles, and thereby minimizing or prevent-
ing certain expressions such as frowning, has a di-
rect physiologic role in influencing emotions. An-
ger, fear, and sadness are the emotions most
closely associated with increased corrugator mus-
cle activity11 and so could be the most likely to be
affected. Research is currently underway to fur-
ther expand our knowledge in this area.
CONCLUSIONS
Botulinum toxin type A treatment of glabellar
rhytides was highly effective—at day 30, the inves-
tigator considered that 100 percent of patients
had achieved greater than or equal to 50 percent
global improvement from baseline, and the pa-
tient evaluations showed that 88 percent consid-
ered they had achieved this level of improvement.
Patient satisfaction was assessed comprehensively
in terms of satisfaction with the treatment overall,
satisfaction with the effects of treatment, satisfac-
tion with the procedure, and patients’ self-percep-
tion of age. A high proportion of patients reported
satisfaction with the treatment overall (95 percent
at day 30 and 86 percent at day 120), the effects of
their treatment (88 percent at day 30 and 82 per-
cent at day 120), and the botulinum toxin type A
injection procedure itself (93 percent at day 30
and 95 percent at day 120). Furthermore, more
than one-third of patients considered that they
appeared younger than before treatment (by a
median of 5 years at both day 30 and day 120).
Volume 120, Number 5 • Botox and Glabellar Rhytides
Importantly, botulinum toxin type A treatment of
glabellar rhytides enhanced the self-image of the
patients in this study even though they already had
a positive perception of themselves at baseline.
Mitchell A. Stotland, M.D.
Section of Plastic Surgery
Dartmouth-Hitchcock Medical Center
One Medical Center Drive
Lebanon, N.H. 03755
mitchell.a.stotland@hitchcock.org
ACKNOWLEDGMENTS
This study was funded by an unrestricted educa-
tional grant from Allergan, Inc. The authors thank Inna
K. Zadorozhna, PhD., for statistical expertise, and Gill
Shears, Ph.D., for assistance in the development of the
article.
DISCLOSURES
Mitchell A. Stotland, M.D., and Belinda B. Ray are
not employed by Allergan, Inc., and have no financial
interest in the company. Jonathan W. Kowalski,
Pharm.D., M.S., is an employee of, and owns stock in,
Allergan, Inc. Dosing and results reported in this study
are specific to the Botox Cosmetic formulation of botuli-
num toxin type A manufactured by Allergan, Inc.
(Irvine, Calif.). Botox Cosmetic is not interchangeable
with other botulinum toxin products and cannot be
converted by using a dose ratio. The Facial Lines
Treatment Satisfaction Questionnaire is a copyright of
Allergan, Inc., 2002.
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clinical or laboratory research, operative procedures, comprehensive reviews, cosmetic surgery—as well as
selected ideas and innovations, letters, case reports, and announcements of educational courses, meetings,
and symposia are invited for publication.
REFERENCES
1. Song, K. H. Botulinum toxin type A injection for the treat-
ment of frown lines. Ann. Pharmacother. 32: 1365, 1998.
2. Finn, J. C., Cox, S. E., and Earl, M. L. Social implications of
hyperfunctional facial lines. Dermatol. Surg. 29: 450, 2003.
3. Khan, J. A. Aesthetic surgery: Diagnosing and healing the
miscues of human facial expression. Ophthal. Plast. Reconstr.
Surg. 17: 4, 2001.
4. Botox Cosmetic (botulinum toxin type A) prescribing infor-
mation. Irvine, Calif: Allergan, Inc., 2004.
5. Carruthers, J. D., and Carruthers, J. A. Treatment of glabellar
frown lines with C. botulinum-A exotoxin. J. Dermatol. Surg.
Oncol. 18: 17, 1992.
6. Carruthers, J. D., Lowe, N. J., Menter, M. A., et al. Double-
blind, placebo-controlled study of the safety and efficacy of
botulinum toxin type A for patients with glabellar lines. Plast.
Reconstr. Surg. 112: 1089, 2003.
7. Foster, J. A., Barnhorst, D., Papay, F., et al. The use of bot-
ulinum A toxin to ameliorate facial kinetic frown lines. Oph-
thalmology 103: 618, 1996.
8. Sommer, B., Zschocke, I., Bergfeld, D., et al. Satisfaction of
patients after treatment with botulinum toxin for dynamic
facial lines. Dermatol. Surg. 29: 456, 2003.
9. Cox, S. E., Finn, J. C., Stetler, L., et al. Development of the
Facial Lines Treatment Satisfaction Questionnaire and initial
results for botulinum toxin type A-treated patients. Dermatol.
Surg. 29: 444, 2003.
10. Kowalski, J. W., Cox, S. E., Finn, C., et al. Development,
validity, and reliability of the Facial Lines Treatment Satis-
faction (FTS) Questionnaire. Poster 293 presented at the 9th
Annual Meeting of the International Society for Quality of
Life Research (ISOQOL), Orlando, Florida, October 30
through November 2, 2002.
11. Heckmann, M., Teichmann, B., Schröder, U., et al. Phar-
macologic denervation of frown muscles enhances base-
line expression of happiness and decreases baseline ex-
pression of anger, sadness, and fear. J. Am. Acad. Dermatol.
49: 213, 2003.
1393
DISCUSSION
Patient-Reported Benefit and Satisfaction with Botulinum
Toxin Type A Treatment of Moderate to Severe Glabellar
Rhytides: Results from a Prospective Open-Label Study
Jean Carruthers, M.D.
Vancouver, British Columbia, Canada
M ost patient-involved clinical research trials
compare the ratings of the expert observer
with the ratings of the subjects using the same
validated visual clinical rating scale. In other
words, the subject is being made to function as
an expert observer too, but perhaps without the
same educational background and clinical expe-
rience of the expert physician observer.
The counterintuitive notion of actually asking
the subjects to respond using a completely dif-
ferent paradigm—“How does this treatment
make you feel?”—allows the subjects to respond
also as expert observers.
The authors chose to use a very conservative
dosing regimen, 20 units only for moderate to
severe glabellar rhytides in female subjects only.
The questions were weighted toward the outcome
of the cosmetic treatment at different time points,
but also added in three questions referring to the
actual injection experience itself. We all know that,
with respect to treatments that will need repetition,
subjects will go elsewhere if the treatment was not
viewed as comfortable and safe. Two subjects did
not complete the study because of their subjective
discomfort with the injection experience.
The Facial Lines Outcome Questionnaire was
carefully validated before its use in this study.
The correlations between the expert observer
analysis based on the standard glabellar furrow
rating scale and the subject’s perception of sat-
isfaction with the treatment trended together
but were not exactly correlated. For example, at
day 30, the investigators considered 100 percent
of subjects to have achieved 50 percent improve-
ment; at the same point, only 88 percent of
subjects felt they had achieved 50 percent im-
provement. The Spearman correlation coeffi-
cient was 0.34 at day 30.
When the subjects were asked how they felt about
the treatments, 95 percent were happy at day 30,
93 percent were comfortable with the injection
Received for publication September 10, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279372.47250.88
1394 www.PRSJournal.com
experience at day 30, and 37 percent felt they
appeared younger by a median of 5 years. The
drop-off in positive feeling about the experience at
day 120 may relate to the relatively conservative
Botox (Allergan, Inc., Irvine, Calif.) dosing.
This is an important article because it nicely
demonstrates that it is important to ask the sub-
jects the right subjective questions. One might
have felt they were relatively unhappy with the
actual objective results until one asked them how
they felt, rather than what they saw.
The methodology in this article has been ap-
plied in two subsequent studies— one about the
glabella1 and one about multiple upper facial
lines.2 In both of these studies, the subjective
questionnaire was able also to titrate a dose-
response curve that correlated with the objective
evaluations. This methodology will be extremely
valuable too in studying the effects over time of
many other facial enhancement procedures.
Jean Carruthers, M.D
University of British Columbia
943 West Broadway, Suite 740
Vancouver, British Columbia V5Z 4E1, Canada
drjean@carruthers.net
DISCLOSURE
Dr. Carruthers is a consultant and investigator for and
receives honoraria from Allergan, Inc.; a stockholder and
member of the advisory board for Artes Medical Inc; a
consultant and investigator for Bioform Medical, Inc.; an
investigator for BioPelle (formally Ferndale Laboratories,
Inc.); a consultant and investigator for and receives hon-
oraria from Medicis, Inc.; a consultant and investigator for
Merz Pharmaceuticals; an investigator for Organogenesis
Inc.; an investigator for Q-Med; and on the advisory board
for Solstice Neurosciences. In addition, Dr. Carruthers is on
the advisory board for Lumenis, Inc.
REFERENCES
1. Fagien, S., Cox, S., Finn, C., Werschler, P., and Kowalski, J. W.
Patient-reported outcomes with botulinum toxin type A treat-
ment of glabellar rhytids: A double-blind, randomized, pla-
cebo-controlled study. Dermatol. Surg. 33: S2, 2006.
2. Carruthers, A., and Carruthers, J. Botulinum toxin type A
treatment of multiple upper facial sites: Patient-reported out-
comes. Dermatol. Surg. 33: S10, 2006.
 COSMETIC

A Primary Protocol for the Management of

Ear Keloids: Results of Excision Combined
with Intraoperative and Postoperative
Steroid Injections
Daniel J. Rosen, M.D.
Mitesh K. Patel, M.D.
Katherine Freeman, Dr.P.H.
Paul R. Weiss, M.D.
Bronx and New York, N.Y.
Background: Keloids of the ear are a challenging problem, with many treatment
modalities advocated. The primary determinant in choosing a treatment pro-
tocol should be a low recurrence rate. Most reports in the literature suffer from
small numbers of patients and inadequate follow-up.
Methods: This study presents a retrospective analysis of 64 patients representing
92 ear keloids treated between 1982 and 1997. The treatment protocol consisted
of excision with an intraoperative and two postoperative steroid injections. All
patients were treated by a single physician. Long-term follow-up was obtained
at a minimum of 5 years.
Results: Protocol success was achieved in 74 of 92 keloids (80 percent) excised.
Prior excision of the keloid was significantly associated with protocol failure
(p ⫽ 0.0068). Keloid recurrence was seen in 10 of 43 (23 percent). Statistically
significant differences were noted in keloids that had undergone prior excision
as compared with those presenting for initial treatment. These differences
included growth rate (p ⫽ 0.0026), protocol failure (p ⫽ 0.0149), and total
postoperative steroid injections administered (p ⫽ 0.0104).
Conclusions: The primary protocol presented for the treatment of ear ke-
loids produces durable results, with an acceptably low recurrence rate. Strat-
ification of keloids based on an assessment of aggressiveness may allow for
a more informed choice in their optimal treatment. (Plast. Reconstr. Surg.
120: 1395, 2007.)

K
eloids arise from skin trauma and must
be removed through skin trauma. Therein
lies the challenge of resection, where re-
currence would seem inevitable. Indeed, exci-
sion of keloids without an adjuvant treatment to
minimize recurrence results in a failure rate of
45 to 100 percent.1,2 The exact cause and patho-
genesis of keloid development remain unclear,
although both environmental factors and genetic
disposition are contributory.3,4
Niessen et al. aptly quote, “the less that is known
about a disease, the more therapeutic modalities
seem to be available, with, in general, unsatisfying
From the Department of Plastic and Reconstructive Surgery,
Montefiore Medical Center–Albert Einstein College of Med-
icine, and the Department of General Surgery, St. Lukes–
Roosevelt Hospital Center.
Received for publication November 24, 2005; accepted April
20, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279373.25099.2a
results.”3 This universal medical truth certainly
applies to keloids. Surgical adjuncts such as
compression,5 corticosteroid injections, and radia-
tion are the most widely used methods to limit
recurrence, but everything from cryotherapy6 and
topical silicone-gel sheeting7 to intralesional
verapamil,8 intralesional interferon,9 and laser
ablation10 have been advocated. Unfortunately,
most reports in the literature suffer from small
numbers of patients and inadequate follow-up.
This hinders the development of a consensus and
standard of care among treating surgeons.
A frequently encountered problem, as pierc-
ing is a custom practiced around the world, ear
keloids can cause both cosmetic deformity and
psychological trauma to the patient, because of
their highly visible location.11,12 As these lesions
are excised, recurrences can be devastating. With
each recurrence, the keloid consumes more local
soft tissue, and can grow to compromise the un-
derlying cartilage. Eventually, the successive resec-
tions leave a tissue deficit, making an aesthetically

www.PRSJournal.com 1395
 Plastic and Reconstructive Surgery • October 2007
acceptable reconstruction difficult to achieve.
Therefore, the establishment of a reliable and safe
technique for keloid excision with a low recur-
rence rate is especially critical for ear keloids. In
this article, we present one surgeon’s case series of
92 ear keloids in 64 patients treated over a 15-year
period by means of a protocol of surgical excision
with intraoperative and postoperative corticoste-
roid injections.
PATIENTS AND METHODS
A retrospective review of all charts of pa-
tients with keloids of the external ear treated
between 1982 and 1997 was conducted. The
treatment protocol used was excision with one
intraoperative and two postoperative steroid in-
jections. The intraoperative steroid injection is
believed to be the most critical injection; thus,
the inclusion criteria were set to include all ear
keloids treated by means of excision with an
intraoperative injection and at least one post-
operative injection. All patients were examined
and treated by a single physician (Table 1).
Initial Operative Procedure
After extralesional excision of the keloid as a
whole, flaps were raised when necessary to mini-
mize tension on the closure. Hemostasis was
achieved, followed by primary closure with 6-0 ny-
lon sutures. The flaps and wound base were then
infiltrated with 0.1 to 0.3 cc of a triamcinolone
acetonide suspension, 40 mg/cc, with the volume
given proportional to incision length. The site was
covered with a lightly compressive dressing con-
sisting of bacitracin ointment, sterile gauze, and
1-inch foam tape (3M, St. Paul, Minn.). This dress-
ing was implemented to minimize hematoma for-
Table 1. Patient Demographics and Keloid Data
Value
No. of patients 64
Age, years
Average 28.3
Range 3–80
Sex
Female 50 (78%)
Male 14 (22%)
Race
African American 53 (83%)
Caucasian 6 (9%)
Hispanic 5 (8%)
Keloids (n ⫽ 92)
Size (range) 1.94 cm (0.5–5 cm)
Time present (range) 2.1 yr (0.5–10 yr)
Growth rate (range) 1.42 cm/yr (0.2–5 cm/yr)
Prior excision (range) 23/92 (25%)
1396
mation, worn for 48 hours postoperatively, and
then removed.
Follow-Up Procedures
All patients were seen at 7 days postoperatively
for suture removal and then again at approxi-
mately 1 month and 2 months postoperatively for
corticosteroid injections. If there was no evidence
of recurrence at the 2-month postoperative visit,
the injections were stopped. Patients were specif-
ically informed about the possibility of delayed
keloid formation and were told to return in 3 to
6 months or earlier if there was any evidence of
scar growth.
Endpoints
The first endpoint was protocol success, de-
fined by the absence of postoperative hypertrophy
in a well-healed scar following the standard post-
operative injections. Protocol failure was defined
as the presence of scar hypertrophy despite the
postoperative steroid injections. Hypertrophy was
defined as a raised scar above the level of the
adjacent skin but not extending beyond its orig-
inal borders. For those protocol failures that
showed hypertrophy either at completion of the
second injection or on subsequent return, the in-
jections were continued at regular intervals in an
attempt to arrest the inflammatory process. The
injections were stopped when the hypertrophy
worsened to the point of keloid formation or the
hypertrophic process subsided with eventual flat-
tening and resolution of the scar. This informa-
tion was determined through chart review.
The second endpoint was keloid recurrence at
any time within the postoperative period, with a
minimum follow-up of 5 years. Keloid recurrence
was defined as continued growth of the hypertro-
phic scar beyond its original confines. This in-
cluded keloids treated with continued steroid in-
jections above and beyond those of the primary
protocol. This endpoint served to assess the lasting
durability of keloid nonrecurrence. Information
for this endpoint was obtained through telephone
interview. Patients were asked whether they had
suffered a keloid recurrence or maintained a sta-
tus of keloid nonrecurrence over the intervening
years at any time since their final steroid injection.
Statistical Analysis
Considering multiple keloids per subject, de-
scriptive statistics were presented separately, with
keloids as the unit of analysis and again for subjects
as the unit of analysis. Continuous variables are
Volume 120, Number 5 • Management of Ear Keloids
presented as means and standard deviations, or
medians and ranges if not normally distributed.
Categorical variables are described using relative
frequencies. Bivariate analyses were performed us-
ing generalized estimating equations with the di-
chotomous outcome of protocol success versus
failure and keloid recurrence versus nonrecur-
rence. This analysis was chosen because of multi-
ple lesions per subject, with dichotomous end-
points. A value of p ⬍ 0.05 was considered to be
statistically significant.
RESULTS
A total of 64 patients met criteria for inclusion,
representing 92 keloids. After the primary proto-
col, five of 92 (5.4 percent) postoperative compli-
cations were noted; among them were three pa-
tients with mild depigmentation of the lobule, one
patient with scar widening postoperatively, and
one patient with a minor wound dehiscence that
healed secondarily without further sequelae.
Protocol success was achieved in 74 of 92 (80
percent) keloids excised. Keloid and patient vari-
ables were assessed to see whether any were asso-
ciated with protocol failure. Prior excision of the
keloid was significantly associated with protocol
failure (p ⫽ 0.0068). The association between a
rapid relative growth rate, as calculated by dividing
the size of the keloid with its duration of presence,
and protocol failure approached statistical signif-
icance (p ⫽ 0.0694).
Of the protocol successes, 26 of 74 keloids
were reached for follow-up interviews. The re-
maining 48 could not be reached because of out-
dated contact information. Of the protocol fail-
ures, 17 of 18 had updated contact information
and were reached for follow-up interviews. For
those 43 keloids on which long-term follow-up was
obtained, the average time from surgery was 10.38
years (range, 5 to 17.5 years). For protocol suc-
cesses reached, 26 of 26 maintained their keloid
nonrecurrence over the long term. This repre-
sents a 100 percent durability of protocol success.
The second endpoint showed keloid recur-
rence in 10 of 43 (23 percent). Protocol failure did
Table 2. Differences between Primary and Secondary Keloids*
Mean Relative
Growth
No. Rate (range)
Primary keloids 69 1.17 cm/yr (0.15–4 cm/yr)
Secondary keloids 23 2.16 cm/yr (0.30–5 cm/yr)
p 0.0026
*Generalized estimating equations, final multivariate analyses: keloid differences by prior excision.
not make keloid recurrence a certainty. In the 17
protocol failures reached, the hypertrophy even-
tually subsided in seven of 17 (41 percent). This
keloid nonrecurrence seems to be long-lasting,
with an average interval since final corticosteroid
injection of 7.3 years (range, 2.4 to 10.1 years).
The data collected were stratified by whether
the primary protocol was the first operative inter-
vention or the keloid being treated had under-
gone a prior excision with subsequent recurrence.
Those keloids that had no prior excision were
designated as primary keloids. Those keloids with
a prior excision and recurrence before presenta-
tion were designated as secondary keloids. Ana-
lyzed as separate groups, two strikingly different
pictures emerged.
Significant differences between these two
groups were seen in both baseline characteristics
and their response to the primary protocol. The
primary keloids presented with a relative growth
rate of 1.17 cm/yr compared with 2.16 cm/yr seen
in the secondary keloids. Protocol success was
achieved in 63 of 69 primary keloids (91 percent)
but only in 11 of 23 secondary keloids (48 per-
cent). Related to their increased protocol failure
rate, secondary keloids also required a mean of
3.39 postoperative steroid injections per keloid,
compared with 1.97 injections for the average pri-
mary keloid. The difference in keloid recurrence,
four of 28 in primary keloids (14 percent) and six
of 15 in secondary keloids (40 percent), did not
reach statistical significance. A summary of the
above along with relevant p values is presented in
Table 2.
DISCUSSION
The vast majority of the literature available
on decreasing recurrence in the treatment of
keloids deals with excision combined with com-
pression therapy, postoperative radiation, or
corticosteroid injections. Compression therapy
has a proven history,13 with recurrence rates as
low as 20 percent.14,15 However, it relies on pa-
tient adherence to a strict postoperative regi-
men of nearly continuous pressure application
Protocol Postoperative Keloid
Failure (%) Injections (range) Recurrence (%)
6/69 (9) 1.97 (1–7) 4/28 (14)
12/23 (52) 3.39 (1–9) 6/15 (40)
0.0149 0.0104 0.1565
1397
 Plastic and Reconstructive Surgery • October 2007

by means of splints or special clip-on earrings. mary keloids. However, this early success rate rep-
These devices must be worn for 18 to 24 hours resents a short follow-up of only 1 to 6 months. An
per day for a period of at least 4 to 6 months.16 effective keloid treatment must yield durable re-
Early release of pressure garments can result in sults without long-term recurrence. Treated scars
rebound hypertrophy, making patient noncom- following keloid excision can lie dormant for a
pliance a serious deterrent.17 number of years, only to respond to unknown
Radiation therapy, though effective,3 should not stimuli and subsequently enlarge. The durability
be the primary postexcisional adjunct because of its of our protocol was established by obtaining a rate
potentially severe side-effect profile.18,19 Many sur- of conversion from protocol success to keloid re-
geons are appropriately wary of exposing their pa- currence of 0 of 26. This suggests that a healed
tients to radiation to treat a benign lesion. The side wound at protocol completion is a durable result
effects can be severe, and include radiation derma- and no keloid recurrence can be expected for 5
titis, hyperpigmentation, hypopigmentation, telan- years and beyond. It is important to note that the
giectasia, localized pruritus, paresthesias, and pain.20 48 patients with keloids that were protocol suc-
The recent development of brachytherapy has cesses but could not be reached for follow-up rep-
helped to alleviate some of these drawbacks.21 How- resent a limitation of this study (Figs. 1 and 2).
ever, the risks of radiation and the significant in- The additional value in this large study is that
crease in cost associated with its use lead many phy- it allows an examination of characteristics of ke-
sicians to seek other options in treatment. loids that tended to recur, and why. The data
The use of corticosteroids as an adjunct to
excision has a low morbidity, is cost-effective, is
easy to administer, and provides reliable and
durable results. Corticosteroids work by decreas-
ing collagen synthesis and limiting fibroblast
proliferation.22–24 The adverse effects of skin at-
rophy, hypopigmentation, telangiectasia, necro-
sis, ulceration, wound dehiscence, and Cush-
ing’s disease are all significantly minimized by
local application of a low-dose depot preparation.25
The addition of an intraoperative dose of steroids
produced minimal side effects. The single wound
dehiscence seen in this series healed without recur-
rence of the keloid. This represents a low dehiscence
rate of 1 percent, which compares favorably with
dehiscence rates of surgical wounds in general. Pa-
tients who experienced depigmentation reported a
return to normal pigmentation over time. Fig. 1. Large keloid on the left lobule following a second
Despite an extensive search of the literature piercing.
regarding keloid excision and steroid injection,
only two articles were found that espoused deliv-
ering an intraoperative dose.26,27 Between them,
they included a total of six ear keloids. Cortico-
steroids can abort the inflammatory process. Thus,
installation into the wound should be carried out
at the time of the operation to arrest the initiation
of hypertrophy and keloid development. The in-
traoperative steroid dose is therefore the critical
dose. Understanding this, the keloids that re-
ceived only one postoperative injection were in-
cluded in the analysis despite the fact that their
treatment was suboptimal in not receiving the
second injection of the fully prescribed primary
protocol.
The primary protocol delivered acceptable Fig. 2. Appearance of the patient 10 years after primary proto-
success, with well-healed scars, especially in pri- col treatment.

1398
Volume 120, Number 5 • Management of Ear Keloids
Fig. 3. Characteristics and outcomes of primary versus second-
ary keloids.
indicate that secondary keloids seem to represent
a more aggressive variant than the vast majority of
primary keloids, having self-selected through prior
failure and recurrence. These keloids develop more
rapidly, and when treated in the same manner as
primary keloids, they necessitate a more compli-
cated postoperative course (Fig. 3). Although it was
not statistically significant, secondary keloids showed
a greater trend toward recurrence than primary ke-
loids over the long term.
Fig. 4. Ear keloid treatment algorithm.
Keloids that failed the primary protocol and
suffered a recurrence despite ongoing steroid in-
jections were mainly treated with reexcision and
postoperative radiation therapy. Recently, this sec-
ondary protocol has been modified, with postop-
erative external beam radiation replaced with
postoperative brachytherapy. More recently, we
have begun treating secondary keloids with this
alternate protocol on initial presentation. The risk
of side effects from radiation administration is
warranted in this aggressive keloid population to
obtain decreased recurrence rates. A treatment
algorithm is presented in Figure 4.
This study shows that prior excision with re-
currence or a rapid relative growth rate can be
valuable prognostic indicators in predicting fu-
ture recurrence. Keloids can be stratified into
groups based on aggressiveness, and the appro-
priate treatment can be properly administered.
CONCLUSIONS
Our algorithm for ear keloids involves a pri-
mary protocol of excision with intraoperative
and postoperative steroid injections. Results are
durable and recurrence rates are low. The pro-
tocol avoids the drawbacks, side effects, and
costs of other modalities. Stratification of ke-
1399
 Plastic and Reconstructive Surgery • October 2007
loids based on an assessment of aggressiveness
may allow for a more informed choice in their
optimal treatment.
Paul R. Weiss, M.D.
1049 Fifth Avenue, Suite 2D
New York, N.Y. 10028
weissclan@minspring.com
DISCLOSURE
None of the authors has a financial interest in any
of the products, devices, or drugs mentioned in this
article.
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586, 1997.
24. Griffith, B. H., Monroe, C. W., and McKinney, P. A follow-up
study on the treatment of keloids with triamcinolone ace-
tonide. Plast. Reconstr. Surg. 46: 145, 1970.
25. Boyadjiev, C., Popchristova, E., and Mazgalova, J. Histomor-
phologic changes in keloids treated with Kenacort. J. Trauma
38: 299, 1995.
26. Chowdri, N. A., Masarat, M., Mattoo, A., and Darzi, M. A.
Keloids and hypertrophic scars: Results with intra-operative
and serial post-operative corticosteroid injection therapy.
Aust. N. Z. J. Surg. 69: 655, 1999.
27. Tang, T. W. Intra- and postoperative steroid injections for ke-
loids and hypertrophic scars. Br. J. Plast. Surg. 45: 371, 1992.
 COSMETIC

Magnetic Resonance Imaging and Explantation

Investigation of Long-Term Silicone Gel
Implant Integrity
Nick Collis, M.Phil., B.Sc.,
F.R.C.S.Plast.(Ed.)
Janet Litherland, M.R.C.P.,
F.R.C.R.
David Enion, F.R.C.S.(G.),
F.R.C.R.
David T. Sharpe, M.A.,
F.R.C.S.
Newcastle Upon Tyne, Glasgow,
Blackburn, and Bradford,
United Kingdom
Background: Information about silicone gel implant longevity is sparse. Mag-
netic resonance imaging studies have superseded explantation studies in the
search for data on their long-term integrity. Unfortunately, the majority of
studies are based predominantly on second-generation implant cohorts. Al-
though magnetic resonance imaging is acknowledged to be the best imaging
modality, the results of any study are entirely dependent on its ability to dif-
ferentiate ruptured from intact implants.
Methods: A single, textured, third-generation implant type was chosen, to re-
duce the number of variables. The largest cohort of patients in our database had
subglandular Mentor Siltex gel implants (Mentor Medical Systems, Santa Bar-
bara, Calif.). They were contacted and offered a magnetic resonance imaging
scan. All patients with at least one radiologically ruptured implant were then
offered explantation.
Results: One hundred forty-nine patients with bilateral subglandular implants
(median ⫾ SD age, 8.9 ⫾ 2.3; range, 4.8 to 13.5 years) were imaged and reported
by two independent radiologists. Twenty-three patients were reported to have
33 radiologically ruptured implants. Twenty-one patients (30 radiologically rup-
tured implants) agreed to explantation. Statistical analysis using maximum
likelihood estimation of survival curve for cross-sectional data suggests that
implant rupture starts at 6 to 7 years and that by 13 years approximately 11.8
percent of implants will have ruptured.
Conclusion: Although these results cannot necessarily be extrapolated to other
implant types and manufacturers, they provide further information about the
natural history of implant integrity, better enabling us to counsel prospective
and current implant recipients. (Plast. Reconstr. Surg. 120: 1401, 2007.)

S
ilicone breast implants have now been in
use for over 40 years. For over a decade,
they have been the subject of considerable
controversy, brought about by misunderstanding
and poor supportive and often misleading scien-
tific evidence, and fueled by opportunistic litiga-
tion, the media, and pressure groups. Although
many of the silicone concerns have been allayed,
questions remain about the long-term integrity
of silicone breast implants. Rupture is a well-
recognized but poorly understood consequence
of long-term implantation. Evidence regarding
From the Royal Victoria Infirmary, Glasgow Royal Infir-
mary, Blackburn Royal Infirmary, and Bradford Royal In-
firmary.
Received for publication December 22, 2005; accepted June
30, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279374.99503.89
implant rupture has moved from explantation
cohorts and meta-analyses thereof to more re-
cent magnetic resonance imaging studies. How-
ever, given all the variables involved (implant age,
generation, position, and manufacturer), only
broad conclusions can be drawn. Furthermore, in
the majority of studies, the conclusions are based
on implants predominantly of the second genera-
tion, which cannot necessarily be extrapolated to
those currently used. Although magnetic reso-
nance imaging is currently acknowledged to be the
best implant imaging modality, accuracy for detect-
ing implant rupture can vary. The conclusions of
any magnetic resonance imaging study are entirely
dependent on the accuracy with which intact im-
plants can be differentiated from ruptured ones.
We therefore present the results of a magnetic
resonance imaging study, examining one manufac-
turer’s third-generation textured silicone gel
breast implants (Mentor Siltex Gel; Mentor Medi-

www.PRSJournal.com 1401
 Plastic and Reconstructive Surgery • October 2007

cal Systems, Santa Barbara, Calif.) placed in a sub-
glandular position. Patients with at least one radio-
logically ruptured implant were offered bilateral
explantation. Although the results cannot neces-
sarily be extrapolated to other implant types, posi-
tion, and manufacturers, they provide evidence for
the magnitude and time scale of third-generation
implant rupture, enabling us better able to counsel
prospective and current implant recipients.
PATIENTS AND METHODS
A database was compiled detailing all patients
who received, or were treated for complications
arising from the use of, silicone breast implants for
both cosmetic and reconstructive purposes. The
database was started in February of 1997 and up-
dated continuously so that by December of 1998
it contained the details of the 1140 patients who
had undergone surgery since 1986 and that were
related to the use of silicone breast implants since
1971. To reduce the number of variables for the
magnetic resonance imaging study, the single larg-
est cohort in the database consisted of those who
had received subglandular Mentor textured sili-
cone gel breast implants for cosmetic reasons.
This cohort contained 338 patients. To avoid the
possible effects of surgical trauma and to ensure
the cohort included those with the oldest implants,
patients were excluded who had undergone revi-
sional procedures. None of these excluded patients
had surgery because of suspected implant ruptures.
Three hundred ten patients remained who had un-
dergone no further interventions since their original
breast augmentation.
After ethical approval, the patients were in-
vited by confidential explanatory letter to partic-
ipate in the study. Patients were examined to ex-
clude contraindications to magnetic resonance
imaging and document any problems with their
breast implants. A Philips Gyroscan Intera 1.5-T
scanner (Philips Medical Systems, Best, The Neth-
erlands) with a dedicated breast coil was used in
all cases to obtain axial T2 turbo spin echo, axial
short T1 inversion recovery/fluid attenuation in-
version recovery, and coronal T2 turbo spin echo
views. Two consultant radiologists reported the
scans. Both had an interest in breast magnetic
resonance imaging, were geographically separate,
and were not professionally known to each other.
Neither was given any implant or patient details.
Patients who had one or both implants reported
as ruptured by one or both radiologists were coun-
seled and offered bilateral explantation and im-
plant replacement. The integrity of the implants
at explantation was used to evaluate the sensitivity
and specificity of the magnetic resonance imag-
ing/paired reporting combination in detecting
implant rupture.
Statistical Analysis
The cross-sectional nature of the data meant
that more commonly used methods of survival
analysis, applicable to longitudinal data, could not
strictly be used. Statistical advice was sought and
a method for the maximum likelihood estima-
tion of survival curve for cross-sectional data was
developed. The method was then found to have
been previously published as isotonic regres-
sion in 1972.1 The estimated cumulative prob-
ability of rupture was calculated. See Table 1 for
definitions.
RESULTS
One hundred forty-nine nine patients with
bilateral subglandular Mentor Siltex gel implants
accepted the magnetic resonance imaging scan in-
vitation. The details of the patients’ ages at magnetic
resonance imaging and implant age are listed in
Table 2. Table 3 lists the range of implant sizes.
Twenty-three patients had 33 radiologic ruptures,
one possibly being extracapsular, reported by one or
both radiologists. Figure 1 shows the distribution of
radiologic implant integrity as a function of implant
age. Figure 2 shows the same information, but for
patients with neither, one or both implants ruptured

Table 1. Definitions
Term Definition Formula
Positive predictive value The probability of an implant being ruptured True positive/(true-positive ⫹ false-positive)
when the MRI scan reports rupture
Negative predictive value The probability of an implant being intact True negative/(true-negative ⫹ false-negative)
when the MRI scan reports no rupture
Sensitivity The probability of the MRI scan predicting a True positive/(true-positive ⫹ false-negative)
ruptured implant
Specificity The probability of the MRI scan predicting an True negative/(true-negative ⫹ false-positive)
intact implant
MRI, magnetic resonance imaging.

1402
Volume 120, Number 5 • Silicone Gel Implant Integrity

Table 2. Patient and Implant Details range, 6.5 to 11.8 years). The false-positive im-
No. Mean Median SD Range plants (intact, reported ruptured) had a mean
age of 11.3 ⫾ 2.4 years (median, 10.6 years;
Patient age at
MRI, years 149 41 40 8.9 23–62 range, 6.8 to 13.5 years) in situ. None of the
Implant ages, ruptures were caused by explantation and all
years in vivo 298 8.8 8.9 2.3 4.8–13.5 were confirmed to be intracapsular.
MRI, magnetic resonance imaging. One radiologist correctly predicted 18 rup-
tured and 10 intact implants (of 42), with another
Table 3. Implant Sizes 12 being false-positive (intact but radiologically
Size No. ruptured). The second radiologist was correct in
175 cc 22
15 ruptured and 20 intact implants, with the other
200 cc 70 six being false-negative (ruptured but radiologi-
225 cc 42 cally intact). As a reporting pair, they correctly
250 cc 46
275 cc 18 predicted 19 ruptured and nine intact implants.
300 cc 8 One or the other incorrectly predicted ruptures
325 cc 6 for 12 implants, and both were wrong (a false-
350 cc 8
375 cc 2 negative) for two implants. Table 4 shows the cal-
Total 298 culated sensitivity, specificity, and positive and
negative predictive values for both radiologists in-
dividually and as a pair. The latter two terms are
radiologically. Twenty-one patients with 31 radio- the probability of a radiologically ruptured im-
logically ruptured implants agreed to bilateral plant actually being ruptured and the probability
explantation. At operation, 21 of the 42 im- of a radiologically intact implant being intact, re-
plants were actually ruptured, of which 19 were spectively. Estimated cumulative probability of rup-
expected. There were therefore two unexpected ture (Table 5) shows that implant ruptures start to
ruptures (false-negatives), and 12 were expected appear at 6 years and that, after 13 years in vivo, 19.3
to be ruptured but were found to be intact (false- percent of subglandular implants can be expected to
positives). In three patients, both implants were have ruptured. This represents an overestimate be-
intact (6.8, 12.5, and 13.5 years), correctly pre- cause it is calculated using radiologic ruptures. Tak-
dicted by one of the reports. There were four ing into account the unexpected explant results re-
bilateral ruptures (6.5, 8.0, 9.2, and 10.2 years) duces the overall ruptures from 33 to 23 of 298 (7.7
and 13 unilateral ruptures (7.6 to 11.8 years). percent). Estimated cumulative probability of rup-
Statistically, the ruptured implants had a mean ⫾ ture then reduces from 19.3 percent to 11.8 percent
SD age of 9.5 ⫾ 1.6 years (median, 9.5 years; at 13 years (Table 6).

Fig. 1. Radiologic implant integrity with age (implants).

1403

Fig. 2. Radiologic implant integrity with age (patients).
Table 4. Accuracy of Radiologic Reporting
Sensitivity (%) Specificity (%)
Radiologist 1 86 48
Radiologist 2 71 95
Combined 90 43
DISCUSSION
Silicone breast implants were originally en-
visaged as lasting forever. However, despite the
well-documented phenomenon of silicone breast
implant rupture, we are only just beginning to un-
derstand the possible mechanisms and magnitude of
the problem in terms of timing and frequency. Al-
though there are not thought to be any serious
health problems associated with silicone breast im-
plant rupture, prolonged intracapsular rupture
could, but not necessarily, lead to extracapsular
spread with the possible risk of silicone migration
and formation of silicone granulomas in the breast
parenchyma.2 The continued and increasing use of
silicone breast implants means that there is a steadily
increasing number of quietly aging implants in our
communities.
The body of evidence surrounding implant
rupture is growing. Explantation cohorts2– 8 and
meta-analyses have given way to magnetic reso-
nance imaging studies.9,10 However, the number of
variables makes any conclusions difficult. Any co-
hort of patients will suffer from inevitable selec-
tion bias. Subpectoral implants in some studies
seem to have a higher problem with rupture than
subglandular implants,2 whereas in other studies
the opposite has been found.11 There are several
1404
Plastic and Reconstructive Surgery • October 2007
Positive Predictive Value (%) Negative Predictive Value (%)
62 77
94 77
61 82
past and present implant manufacturers. In addi-
tion, implants have evolved over the past 40 years,
often grouped into three “generations” that ap-
pear to have different long-term integrities.2,3 The
advent of surface texturing and more recently the
development of varying degrees of cohesive gel
may also have an effect on implant longevity. Fi-
nally, the declaration of an implant rupture, by
either explantation or magnetic resonance imag-
ing , does not tell us when and over what period
that implant lost its integrity.
The ability to screen asymptomatic implants,
without any risk to the patient, by magnetic res-
onance imaging is a great improvement over ex-
plantation studies. However, in addition to the
variables mentioned above, magnetic resonance
imaging is not 100 percent accurate12–14 and re-
quires considerable financial resources to scan the
necessary numbers of patients.
In our study, we have reduced the number of
variables by magnetic resonance imaging of a sin-
gle type of currently available implant (Mentor
Siltex Gel) in a single position (subglandular). By
explanting the majority of the radiologically rup-
tured implants, the accuracy of the magnetic res-
onance imaging reporting team can be calculated,
because this underpins the results of the study as
Volume 120, Number 5 • Silicone Gel Implant Integrity

Table 5. Estimated Probability of Rupture Based on implant recipients. Given that there are not
Magnetic Resonance Imaging Reports (Overestimate) thought to be any serious systemic health risks
Years since Estimated 95% associated with the presence of a ruptured breast
Implantation Probability Cumulative Confidence Interval implant,15 that all the ruptures in this study were
5 0.0000 — intracapsular, and that 12 percent of implants
6 0.0000 — were ruptured at 13 years, any recommendations
7 0.0926 0.0118–0.1734 for screening asymptomatic breast implants may
8 0.1053 0.0249–0.1856
9 0.1250 0.0098–0.2402 only need to start, perhaps, at 15 years and per-
10 0.1250 0.0526–0.1974 haps every 5 years thereafter. Continued improve-
11 0.1935 0.0212–0.3658 ments in imaging techniques will possibly allow
12 0.1935 0.0969–0.2902
13 0.1935 0.0969–0.2902 greater sensitivity, providing better, more accurate
information with which to make clinical decisions.
We hope that this study provokes continued re-
Table 6. Revised Estimate of Probability of Rupture, search in this area and stimulates implant manu-
Taking into Account the Result of Explantation factures to continue evolving and improving their
Years since products.
Implantation Estimated 95%
(cumulative) Probability Confidence Interval Nick Collis, M.Phil., B.Sc., F.R.C.S.Plast.(Ed.)
Royal Victoria Infirmary
5 0.0000 — Queen Victoria Road
6 0.0000 —
7 0.0500 0.0000–0.1232 Newcastle Upon Tyne NE1 4LP, United Kingdom
8 0.0789 0.0032–0.1547 nick.collis@nuth.nhs.uk
9 0.1181 0.0000–0.2370
10 0.1181 0.0616–0.1745 ACKNOWLEDGMENTS
11 0.1181 0.0716–0.1645
12 0.1181 0.0716–0.1645 This study was supported by the Capio Research
13 0.1181 0.0716–0.1645 Foundation and the Burns and Plastic Surgery Research
Fund of the Department of Plastic Surgery at the Bradford
Royal Infirmary. A Mentor Corporation grant to the
a whole. Although there were two false-negatives research fund financed some of the magnetic resonance
[two of 42 explanted implants (4.8 percent)], it imaging scans, and as a gesture of good will, Mentor
was obviously not ethical to remove all of these provided implant replacements for those patients who
asymptomatic, radiologically intact implants to had implants removed because of suspected rupture on
quantify them. The results suggest that these im- the magnetic resonance imaging scan. Mentor had no
plants start to rupture at approximately 6 to 7 involvement in the study design, data collection, anal-
years, and by 13 years approximately 12 percent ysis, interpretation, or writing of this report.
can be expected to have ruptured. Recently, a
serial magnetic resonance imaging study by DISCLOSURE
Hölmich et al.9 showed a similar rupture com- None of the authors has any commercial or financial
mencement age but a 15 percent rupture at 10 interest in the Mentor Corporation or the outcome of this
years for a mixture of “modern” implants. Brown study.
et al.10 performed magnetic resonance imaging on
344 patients with 687 silicone gel implants. How- REFERENCES
ever, of first and third implant generations, there 1. Barlow, R. E., and Brunk, H. D. The isotonic regression
problem and its dual. J. Am. Stat. Assoc. 67: 140, 1972.
were only 13 and six patients, respectively. The 2. Collis, N., and Sharpe, D. T. Silicone gel filled breast implant
conclusions based on the more rupture-prone sec- integrity: A retrospective review of 478 explanted implants.
ond-generation implants provide no more infor- Plast. Reconstr. Surg. 105: 1979, 2000.
mation than previous explantation studies and 3. Peters, W., Smith, D., and Lugowski, S. Failure properties of
yet are apt to be misquoted and misinterpreted 352 explanted silicone-gel breast implants. Can. J. Plast. Surg.
4: 1, 1996.
if applied indiscriminately to all implants with- 4. Robinson, O. G., Bradley, E. L., and Smith, D. Analysis of
out clarification. explanted silicone implants: A report of 300 patients. Ann.
Despite the lack of an imaging method that is Plast. Surg. 34: 1, 1995.
100 percent accurate, our study provides informa- 5. Beekman, W. H., Feitz, R., Hage, J. J., and Mulder, J. W. Life
tion about the long-term rupture of modern sili- span of silicone gel-filled mammary prostheses. Plast. Recon-
str. Surg. 100: 1723, 1997.
cone gel breast implants, for subglandular Mentor 6. Cohen, B. E., Biggs, T. M., Cronin, E. D., and Collins, D. R.
Siltex gel implants in particular, and we are now Assessment and longevity of the silicone gel breast implant.
better placed to counsel current and prospective Plast. Reconstr. Surg. 99: 1597, 1997.

1405
 Plastic and Reconstructive Surgery • October 2007

7. Rohrich, R. J., Adams, W. P., Beran, S. J., et al. An analysis of
silicone gel-filled breast implants: Diagnosis and failure rates.
Plast. Reconstr. Surg. 102: 2304, 1998.
8. Morotta, J. S., Goldberg, E. P., Habal, M., et al. Silicone gel
breast implant failure: Evaluation of properties of shells and
gels for explanted prostheses and meta-analysis of literature
data. Ann. Plast. Surg. 49: 227, 2002.
9. Hölmich, L. R., Friis, S., Fryzek, J., et al. Incidence of breast
implant rupture. Arch. Surg. 138: 801, 2003.
10. Brown, S. L., Middleton, M. S., Berg, W. A., Soo, M. S., and
Pennello, G. Prevalence of rupture of silicone gel breast im-
plants revealed on MR imaging in a population of women in
Birmingham, Alabama. A. J. R. Am. J. Roentgenol. 175: 1057,
2000.
11. Feng, L. J., and Amini, S. B. Analysis of risk factors associated
with rupture of silicone breast implants. Plast. Reconstr. Surg.
104: 955, 1999.
12. Cher, D. J., Conwell, J. A., and Mandel, J. S. MRI for detecting
silicone implant rupture: Meta-analysis and implications.
Ann. Plast. Surg. 47: 367, 2001.
13. Ikeda, D. M., Borofsky, H. B., Herfkens, R. J., Sawer-
Glover, A. M., Birdwell, R. L., and Glover, G. H. Silicone
breast implant rupture: Pitfalls of magnetic resonance
imaging and relative efficacies of magnetic resonance,
mammography and ultrasound. Plast. Reconstr. Surg. 104:
2054, 1999.
14. Herborn, C. U., Marinek, B., Erfmann, D., Meuli-Simmen,
C., Wedler, V., and Bode-Lesniewska, B. Breast augmentation
and reconstructive surgery: MR imaging of implant rupture
and malignancy. Eur. Radiol. 12: 2198, 2002.
15. Hölmich, L. R., Kjöller, K., Fryzek, J., et al. Self-reported
diseases and symptoms by rupture status among unselected
Danish women with cosmetic silicone breast implants. Plast.
Reconstr. Surg. 111: 723, 2003.

Online CME Collections

This partial list of titles in the developing archive of CME article collections is available online at www-
.PRSJournal.com. These articles are suitable to use as study guides for board certification and/or recertification, to help
readers refamiliarize themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old
can be taken for CME credit.
Cosmetic
The Silicone Gel-Filled Breast Implant Controversy: An Update—Arshad R. Muzaffar and Rod J. Rohrich
Understanding the Nasal Airway: Principles and Practice—Brian K. Howard and Rod J. Rohrich
Lateral Canthal Anchoring—Clinton McCord et al.
Male Rhinoplasty—Rod J. Rohrich et al.
The Cosmetic Use of Botulinum Toxin (October 2003 Supplement)—Rod J. Rohrich et al.
Thrombolytic Therapy following Rhytidectomy and Blepharoplasty—Stephanie L. Mick et al.
Current Concepts in Aesthetic Upper Blepharoplasty—Rod J. Rohrich et al.
Breast Augmentation: Cancer Concerns and Mammography—A Literature Review—Michael G. Jakubietz et al.
Prevention of Venous Thromboembolism in the Plastic Surgery Patient—Steven Paul Davison et al.
Breast Augmentation—Scott L. Spear et al.
Otoplasty: Sequencing the Operation for Improved Results—James Hoehn and Salman Ashruf
Thromboembolism in Plastic Surgery—Daniel Most et al.
Otoplasty—Jeffrey E. Janis et al.
Fire in the Operating Room: Principles and Prevention—Stephen P. Daane and Bryant A. Toth
Patient Safety in the Office-Based Setting—J. Bauer Horton et al.
Frequently Used Grafts in Rhinoplasty: Nomenclature and Analysis—Jack P. Gunter et al.
Injectable Soft-Tissue Fillers: Clinical Overview—Barry L. Eppley and Babak Dadvand

1406
 COSMETIC

Interest in Cosmetic Surgery and Body

Image: Views of Men and Women across
the Lifespan
David A. Frederick, M.A.
Janet Lever, Ph.D.
Letitia Anne Peplau, Ph.D.
Los Angeles, Calif.
Background: Little is known about interest in cosmetic surgery among the
general public or how this interest is related to gender, age, relationship status,
body mass index, or body image satisfaction.
Methods: The present study tested these associations among a sample of 52,677
heterosexual men and women aged 18 to 65 years who completed the online
“ELLE/MSBNC.com Sex and Body Image Survey” in 2003.
Results: Many women were interested (48 percent) or possibly interested (23
percent) in cosmetic surgery. A substantial minority of men were also interested
(23 percent) or possibly interested (17 percent) in cosmetic surgery. Individuals
interested in cosmetic surgery did not report poorer global body image than
individuals not interested in cosmetic surgery. Individuals specifically interested
in liposuction, however, tended to have poorer body image, and interest in
liposuction was greater among heavier individuals.
Conclusions: The finding that many women and men are interested in cosmetic
surgery has implications for research comparing cosmetic surgery patients to
individuals drawn from the general population. Specifically, researchers con-
ducting comparative studies should recognize that many individuals in their
control group may be strongly interested in cosmetic surgery, even if they have
not yet had any. Furthermore, individuals interested in different types of cos-
metic surgery may differ from each other on such attributes as body mass index
and body image. (Plast. Reconstr. Surg. 120: 1407, 2007.)

T
he popularity of plastic surgery as a socially
acceptable form of body modification has
created a booming cosmetic surgery indus-
try. More than 9 million cosmetic surgical pro-
cedures were performed in 2004, a 24 percent
increase over 2000.1 Despite the prevalence of
cosmetic surgery, little is known about who is
most interested in cosmetic surgery and why.
The present study of over 50,000 men and
women examined how gender, age, marital sta-
tus, body fat level, body satisfaction, and invest-
ment in one’s appearance were associated with
interest in cosmetic surgery. These findings may
be useful to researchers, plastic surgeons, and
From the University of California, Los Angeles, and Cali-
fornia State University.
Received for publication January 19, 2006; accepted June
27, 2006.
For additional articles on body image from this and other
projects, please contact David Frederick.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279375.26157.64
others seeking to understand the growing inter-
est in cosmetic surgery.
PERSONAL CHARACTERISTICS AS
PREDICTORS OF INTEREST IN
COSMETIC SURGERY
One’s physical attractiveness affects the way a
person is perceived and treated by others. Women
experience considerable pressure to look young
and attractive. One potential consequence is that
women are much more likely than men to express
interest in and receive cosmetic surgery, particu-
larly procedures that restore the appearance of
youth, such as liposuction, face lifts, and eyelid
surgery.1,2 Furthermore, older women may expe-
rience added pressure to obtain appearance-alter-
ing surgery because they feel they are competing
with younger women for the attentions of their
current or potential romantic partners. An addi-
tional characteristic that might relate to interest in
cosmetic surgery is body fat level (as assessed by
the body mass index). Surprisingly, however, a
recent study found no association between body

www.PRSJournal.com 1407
 Plastic and Reconstructive Surgery • October 2007
mass index and general interest in cosmetic
surgery.3 One possibility is that body mass index is
tied to interest in specific surgical procedures such
as liposuction, particularly among individuals dis-
satisfied with their weight.
INTEREST IN COSMETIC SURGERY
AND BODY IMAGE
Studies with nonpatient samples have docu-
mented only weak and inconsistent associations
between global body image satisfaction and a de-
sire for cosmetic procedures.3,4 Research finds that
cosmetic surgery patients generally do not differ
from nonpatients in body satisfaction, except that
they are more likely to express strong dissatisfac-
tion with the specific body region targeted for
surgery.5–7 (See Further Notes, number 1) In con-
trast to most cosmetic procedures, however, in-
terest in liposuction may be related to global body
dissatisfaction rather than to site-specific dissatis-
faction because body fat is distributed across sev-
eral regions of the body (e.g., stomach, hips,
thighs, arms).
A second aspect of body image related to in-
terest in cosmetic surgery is appearance orienta-
tion or appearance investment, a measure of how
much importance individuals place on their looks
and how much they pay attention to their
appearance.8 It seems reasonable that individuals
who invest more time and effort in monitoring
their physical appearance would report greater
interest in cosmetic procedures.4
PATIENTS AND METHODS
A 27-item survey was posted on the MSNBC.
com and ELLE.com Web sites in February of 2003.
Participants were visitors who volunteered for a sex
and body image survey. To avoid repeat participa-
tion, a computer program prevented multiple re-
sponses from any given computer.
Participants
For the current study, we conducted analyses
on the heterosexual men (n ⫽ 25,714) and women
(n ⫽ 26,963) in the sample aged 18 to 65 years.
Most respondents (98 percent) were from the
MSNBC.com Web site and only 2 percent were
from the ELLE.com Web site.9
Age
The mean age was 33.5 ⫾ 10.9 years for women
and 36.9 ⫾ 11.8 years for men. The percentages of
men and women, respectively, in each age cate-
gory were as follows: 18 to 25 years, 20 and 30
percent; 26 to 35 years, 29 and 32 percent; 36 to
1408
45 years, 24 and 22 percent; 46 to 55 years, 18 and
14 percent; and 56 to 65 years, 8 and 3 percent.
Body Mass Index
The mean body mass index score, an estima-
tion of level of body fat, was 26.6 ⫾ 4.1 for the men
and 24.2 ⫾ 4.8 for the women, which is roughly
comparable to national data.10 We used the Na-
tional Health and Nutrition Examination Survey
guidelines for interpreting body mass index scores,
where underweight is 14.5 to 18.49; healthy weight
is 18.5 to 24.99; overweight is 25 to 29.99; and
obese is 30 to 40.5.11 The categories were further
subdivided to examine finer distinctions among
body mass index categories that may better relate
to body dissatisfaction (e.g., lower underweight,
14.5 to 16.49; upper underweight, 16.5 to 18.49;
lower healthy, 18.5 to 21.74).
Measures
Interest in Cosmetic Procedures
To assess interest in cosmetic procedures, sub-
jects were asked, “If you could afford it, would you
ever consider getting cosmetic surgery or liposuc-
tion to improve your looks or body?” Response
options were as follows: cosmetic only (“Yes, I’d
consider cosmetic surgery”), liposuction only
(“Yes, I’d consider liposuction”), both (“Yes, I’d
consider both cosmetic surgery and liposuction”),
maybe (“Maybe, ask me again in a few years”), or
not interested (“No”). For some analyses, individ-
uals who selected the liposuction only or the both
liposuction and cosmetic surgery options were
combined into one category to examine correlates
of interest in liposuction.
Body Image: Self-Rated Attractiveness
To assess satisfaction with their body image,
subjects were asked, “How do you feel about your
body?” Response options were “I have a great
body” (4), “I have a good body” (3), “My body is
just okay” (2), and “I find my body unattractive”
(1), with higher numbers indicating better body
image. In a separate sample of 153 college men
and 313 college women, this one-item measure
was strongly correlated with the widely-used seven-
item Appearance Evaluation Scale for both men
(r ⫽ 0.75, p ⬍ 0.001) and women (r ⫽ 0.75, p ⬍
0.001), providing confidence in this item as a mea-
sure of body image.9
Body Image: Comfort in a Swimsuit
To assess comfort while wearing a swimsuit,
subjects were asked, “How do you think you look
in a swimsuit?” Response options were “Good; I’m
proud/not at all embarrassed to be seen in a swim-
suit” (3), “Okay; I do not flaunt it but my self-
Volume 120, Number 5 • Cosmetic Surgery and Body Image

consciousness doesn’t keep me from wearing a
swimsuit” (2), and “So uncomfortable that I avoid
wearing one in public” (1). In a separate college
sample, this one-item measure was significantly
correlated with the Appearance Evaluation Scale
(r ⫽ 0.62, p ⬍ 0.001 for men and r ⫽ 0.58, p ⬍
0.001 for women), providing confidence in this
item as a measure of body image.9
Satisfaction with Weight
To assess satisfaction with weight, subjects
were asked, “Are you self-conscious about your
weight?” Response options were “Yes, I’m too
thin,” “Yes, I’m too heavy,” and “No.”
Face Satisfaction
To assess satisfaction with their face, subjects
were asked, “How do you feel about your face?”
Response options were “My face is very attractive”
(4), “My face is nice/pleasant” (3), “My face is
plain” (2), and “My face is unattractive” (1).
Appearance Investment: Mirror Checking
To assess mirror checking, subjects were
asked, “Be honest: approximately how many times
per day do you check yourself out in a mirror?”
Response options were “never,” “one to three
times,” “four to seven times,” and “eight or more
times.” This item assessed the degree to which
participants were oriented toward and monitored
their appearance.
Statistical Analysis
Because our large sample allowed minuscule
effects to reach statistical significance, we estab-
lished p ⬍ 0.001 as our criterion for significance,
and we report effect sizes (Cohen’s d) where ap-
propriate. By convention, d values of 0.2, 0.5, and
0.8 correspond roughly to small, medium, and
large effects.12 Chi-square tests were used to assess
gender differences in interest in cosmetic surgery
and differences between the youngest age group
of women and the oldest age group. When con-
ducting the chi-square test, an interest in cosmetic
surgery (collapsed) variable was created by dichot-
omizing the interest variable into a not interested
(no) and interested (maybe; liposuction; cosmetic
surgery; both) category to simplify the presenta-
tion of results.
To test for differences in body satisfaction
(self-rated attractiveness; comfort in a swimsuit;
face satisfaction) as a function of interest in cos-
metic surgery, planned comparisons were con-
ducted to compare each level of interest in cos-
metic surgery variable (no; maybe; cosmetic
surgery; liposuction; both). These comparisons
were conducted within the context of a one-way
analysis of variance performed separately for men
and women. To control for possible differences in
body mass among the groups, these analyses were
also conducted with body mass index as a covari-
ate. Finally, to test whether mirror checking was
associated with interest in cosmetic surgery (col-
lapsed), a Goodman and Kruskal ␥ test was
conducted.13
RESULTS
Gender Differences in Interest in Cosmetic
Surgery and Liposuction
Table 1 lists findings concerning women’s and
men’s interest in cosmetic surgery and liposuc-
tion. Nearly half the women (48 percent) were
interested in one or more cosmetic procedures,
and a sizeable minority of women (23 percent)
indicated possible interest (maybe). Approxi-
mately one-fifth of men (23 percent) indicated
interest in cosmetic procedures, and an additional
17 percent of men reported possible interest
(maybe). Individuals who indicated any interest

Table 1. Percentage of Women and Men Interested in Cosmetic Surgery in Five Age Groups
Not Interested Maybe Cosmetic Only Liposuction Only Both
Women
18–25 yr 34% 27% 11% 15% 13%
26–35 yr 27% 25% 14% 15% 19%
36–45 yr 24% 21% 18% 12% 25%
46–55 yr 26% 17% 21% 9% 27%
56–65 yr 29% 14% 25% 7% 25%
Overall 29% 23% 15% 13% 20%
Total no. 7641 6273 4144 3509 5396
Men
18–25 yr 65% 18% 7% 6% 4%
26–35 yr 59% 18% 8% 9% 6%
36–45 yr 55% 18% 10% 9% 8%
46–55 yr 58% 16% 10% 8% 8%
56–65 yr 62% 13% 11% 7% 7%
Overall 60% 17% 9% 8% 6%
Total no. 15,175 4462 2300 2119 1658

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 Plastic and Reconstructive Surgery • October 2007

(maybe, yes, cosmetic, yes, liposuction, or yes,
both) were combined into one category for each
sex. As predicted, women were much more likely
than men to express an interest in cosmetic sur-
gery (collapsed) [chi-square test (df ⫽ 1, n ⫽
52,677) ⫽ 5044.34; p ⬍ 0.001].
Interest in Cosmetic Surgery among Men and
Women across the Lifespan
Contrary to our prediction that the percent-
age of women desiring cosmetic surgery would
increase with age, similar percentages of women
reported some interest in cosmetic surgery (col-
lapsed) across age groups. However, the percent-
age of women indicating maybe was 27 percent in
the youngest age group and 14 percent in the
oldest age group [chi-square test (df ⫽ 1, n ⫽
8892) ⫽ 75.51; p ⬍ 0.001], indicating greater cer-
tainty of interest among older women. In contrast,
for men, whose attractiveness may be less tied to
the appearance of youth, interest in cosmetic sur-
gery was not associated with age (Table 1).
Interest in Cosmetic Surgery as a Function of
Body Mass Index and Satisfaction with Weight
In our sample, the level of interest in liposuc-
tion only was fairly low, averaging 13 percent
among women and 8 percent among men (Table
1). An additional 20 percent of women and 6
percent of men indicated interest in liposuction
combined with cosmetic surgery. We predicted
that body mass index would not be associated with
a general interest in cosmetic surgery but would be
associated with an interest in liposuction. In the
analyses described below, individuals expressing
an interest in liposuction only were combined with
individuals expressing interest in both cosmetic
surgery and liposuction. These individuals were
then compared with those expressing an interest
only in cosmetic surgery.
Women
Figure 1 presents the association of body mass
index to interest in liposuction for women. As
predicted, body mass index was strongly associated
with an interest in liposuction. Interest in liposuc-
tion increased steadily from 22 percent among
women with body mass index scores of 20 (slen-
der) to 53 percent among women with body mass
index scores of 40 (very obese). Figure 2 shows
that across the weight span, women who felt they
were too heavy were more likely to express an
interest in liposuction than were women who were
satisfied with their weight. Consistent with the idea
that some underweight women may have an ex-
aggerated fear of being fat, many underweight
women who rated themselves as too heavy ex-
pressed an interest in liposuction.
Men
As shown in Figure 1 and as predicted, men’s
body mass index scores were associated with a
desire for liposuction (those who chose liposuc-
tion only or both liposuction and cosmetic sur-

Fig. 1. Men’s and women’s interest in liposuction as a function of body mass index
(BMI) scores. The percentage of men and women interested in liposuction gener-
ally increased as body mass index increased.

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Volume 120, Number 5 • Cosmetic Surgery and Body Image

Fig. 2. Women’s interest in liposuction as a function of satisfaction with weight

and body mass index (BMI) category. Across the weight span, women who were not
satisfied with their weight were more likely to be interested in liposuction than
women who were satisfied.

Fig. 3. Men’s interest in liposuction as a function of satisfaction with weight and

body mass index (BMI) category. Across the weight span, men who were not sat-
isfied with their weight were more likely to be interested in liposuction than men
who were satisfied.

gery). The percentage of interest in liposuction
increased steadily from 3 percent among men with
body mass indexes of 20 (slender) to 36 percent
among men with body mass index scores of 40
(very obese). In addition some very slender men
(body mass index, 15 to 18) expressed an interest
in liposuction. Consistent with the idea that
women are under greater societal pressure than
men to be slender, more women than men re-
ported an interest in liposuction at nearly every
level of body fat. Consistent with the findings for
women, across the weight span, men who were

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 Plastic and Reconstructive Surgery • October 2007

satisfied with their weight were less likely to express
an interest in liposuction than were men who felt
they were too heavy (Fig. 3) (see Further Notes,
number 2).
Interest in Cosmetic Surgery and Body Image
Satisfaction
Women
Figure 4 presents women’s mean scores on two
measures of body satisfaction (self-rated attractive-
ness and comfort in a swimsuit) and the measure
of face satisfaction, based on women’s degree of
interest in cosmetic surgery and liposuction. As
predicted, planned comparisons revealed no dif-
ference between women interested versus not in-
terested in cosmetic surgery only on measures of
self-rated attractiveness, comfort in a swimsuit, or
satisfaction with one’s face (p ⬎ 0.001). Also as
predicted, planned comparisons revealed that
women interested in liposuction and those inter-
ested in both liposuction and cosmetic surgery
reported poorer self-rated attractiveness and less
comfort in a swimsuit than individuals not inter-
ested (p ⬍ 0.001). The magnitude of these differ-
ences was moderate to large, as shown by the effect
sizes presented in Table 2. This pattern of results
occurred even when body mass index was entered
as a covariate in the analysis of variances described
above.
Men
Figure 5 presents men’s mean scores on body
image measures, based on their degree of interest
in cosmetic surgery and liposuction. As predicted,
men interested in cosmetic surgery only did not
report poorer body image satisfaction than men
not interested in cosmetic surgery. Men interested
in cosmetic surgery reported significantly less face
satisfaction (p ⬍ 0.001), although the effect size
was very small (d ⫽ 0.11). As predicted, planned
comparisons revealed that men interested in lipo-
suction or both liposuction and cosmetic surgery
reported poorer self-rated attractiveness and less
comfort in a swimsuit than those not interested
(p ⬍ 0.001 for all), and these differences were
moderate to large in size (Table 2). Similar to the
pattern of results found with women, this effect
occurred even when body mass index was entered
as a covariate in analysis of variance (see Further
Notes, number 3).
Interest in Cosmetic Surgery and Appearance
Investment
We predicted that individuals scoring higher
in mirror checking would report more interest in
cosmetic procedures. To test this prediction, we

Fig. 4. Mean satisfaction scores for face, self-rated attractiveness, and comfort in a swim-
suit among women with varying levels of interest in cosmetic surgery. Women interested
in cosmetic surgery only and women not interested in any procedure reported similar
levels of body image satisfaction. Women interested in liposuction or both cosmetic sur-
gery and liposuction, however, reported poorer body image than other women.

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Volume 120, Number 5 • Cosmetic Surgery and Body Image

Table 2. Effect Sizes for Planned Comparisons between Individuals Not Interested versus Individuals
Interested in Cosmetic Procedures on Two Measures of Body Image*
Self-Rated Attractiveness Comfort in a Swimsuit

Women Men Women Men

Planned comparisons of individuals not interested
versus individuals:
Interested in cosmetic procedures only –0.03 –0.16† –0.05 –0.10†
Interested in liposuction only 0.57† 0.61† 0.45† 0.59†
Interested in both 0.54† 0.41† 0.43† 0.44†
*Effect sizes (d) for comparisons of mean body image scores between individuals not interested in cosmetic procedures and those who are
interested. A positive effect size indicates that the not-interested group had better body image. A negative effect size indicates that the
not-interested group had worse body image.
†Comparisons were significant at the p ⬍ 0.001 level.

Fig. 5. Mean satisfaction scores for face, self-rated attractiveness, and comfort in a swim-
suit among men with varying levels of interest in cosmetic surgery. Men interested in
cosmetic surgery only reported better body image than men who were not interested in
cosmetic surgery. Men interested in liposuction or both cosmetic surgery and liposuction,
however, reported poorer body image than other men.

compared interest in cosmetic surgery (collapsed)
among individuals who looked in the mirror none,
one to three, four to seven, or more than eight
times per day. As shown in Table 3, looking in the
mirror more often was associated with a greater
likelihood of being interested in cosmetic surgery
for both women and men. These results indicate
that individuals who are more oriented toward
maintaining their appearance are more likely to
express interest in cosmetic procedures.
DISCUSSION
This study, based on a large sample of adults
aged 18 to 65, provides evidence that interest in
cosmetic surgery is widespread. Consistent with
the idea that women are under greater pressure
than men to attain current ideals of beauty and
thinness, more women than men expressed an
interest in cosmetic procedures and liposuction.
Nonetheless, a substantial minority of men also
expressed at least some interest in these body-
changing procedures. Age was related only to the
percentage of women shifting from maybe inter-
ested to interested in cosmetic surgery.
Although Henderson-King and Henderson-
King found no association of body mass index to
general interest in cosmetic surgery, we found that
heavier individuals were more interested in lipo-
suction than other individuals, especially among
those who were not satisfied with their weight. This

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 Plastic and Reconstructive Surgery • October 2007
Table 3. Association of Mirror Checking to Interest in
Cosmetic Procedures among Women and Men*
Frequency of Looking at
Interest in Self in Mirror per Day
Cosmetic
Procedures 0 1–3 4 –7 8ⴙ ␥ p
Women 63% 68% 73% 77% 0.15 0.001
Men 32% 40% 48% 53% 0.18 0.001
*Individuals who looked in the mirror more often were more likely
to be interested in cosmetic procedures (individuals who indicated
they were maybe interested in cosmetic procedures or interested in
cosmetic surgery and/or liposuction). The ␥ statistic can be inter-
preted as showing that this measure of mirror checking explained 15
percent of the variance in interest in cosmetic procedures for women
and 18 percent of the variance for men.
may reflect a widely held belief among the general
public that liposuction is a form of weight control
rather than a body contouring procedure. It is
important to note, however, that some very slen-
der individuals expressed an interest in liposuc-
tion, suggesting perhaps an unhealthy preoccu-
pation with thinness by some.
Our findings provide further evidence that
individuals interested in cosmetic surgery do not
consistently report less satisfaction with their body
or face than individuals not interested in surgery.
Interest in liposuction was an exception to this
pattern, perhaps because “excess” body fat is dis-
tributed across many body regions. In addition,
Americans may experience greater pressure to be
slender than to have ideal noses, breasts, and so
forth, which could explain why individuals inter-
ested in liposuction reported the worst body image.
Finally, individuals who frequently monitored
their appearance were more likely to report in-
terest in cosmetic procedures than individuals
who paid less attention to their looks. This sug-
gests that a strong investment in one’s appearance
may motivate individuals to consider body modi-
fication techniques, including cosmetic surgery.3
Limitations
To increase participation rates, the survey was
necessarily short and relied on single-item mea-
sures of key variables, although these measures
correlated highly with existing validated measures.
Although large, this sample was not nationally rep-
resentative and was limited to individuals who visit
the Internet. The proxy for body fat level, body
mass index, is an imperfect index because it can
be influenced by factors besides body fat, such as
muscularity. On the whole, however, body mass
index is highly correlated with other measures of
body fat level.14,15
1414
Future Research
First, although women typically outnumber
men by an 8:1 ratio among actual cosmetic surgery
patients, women in this study outnumbered men
only 2:1 in their interest in cosmetic surgery.1 Fu-
ture research should identify factors inhibiting
men from pursuing cosmetic surgery. Second, we
found that body image and body mass index were
associated with interest in liposuction but were not
associated with general interest in cosmetic sur-
gery. Consequently, it may be useful to revise some
existing measures (e.g., Henderson-King and
Henderson-King) so that they assess both interest
in specific procedures and general interest in cos-
metic surgery. Finally, our findings suggest that
interest in cosmetic surgery should be assessed
when comparing cosmetic surgery patients to con-
trol groups of non– cosmetic surgery patients,
many of whom may actually also be interested in
surgery.
FURTHER NOTES
1. Despite the general similarity of cosmetic
surgery patients and controls on global body im-
age satisfaction, there is a subset of cosmetic sur-
gery patients who suffer from body dysmorphic
disorder, which is typified by pathologic concerns
with their appearance or specific body parts. Es-
timates of body dysmorphic disorder prevalence
in the general population range from 0.7 to 5.3
percent, whereas estimates of body dysmorphic
disorder prevalence among cosmetic surgery pa-
tients range from 6 to 15 percent.10,16
2. Readers may also be interested in the asso-
ciation of relationship status to interest in cos-
metic surgery. Participants indicated whether they
were married, dating, cohabiting, or single. Men’s
interest in cosmetic procedures differed little
based on relationship status. The percentage of
single women in each age group expressing no
interest in cosmetic surgery differed by less than
10 percent from their married, cohabiting, and
dating counterparts. The exception was that
among women aged 56 to 65, single individuals
reported less interest in cosmetic procedures than
did dating or cohabiting women and levels of in-
terest similar to those of married women.
3. Although we did not make predictions re-
garding the association of interest in liposuction
to face satisfaction, we report the results here for
interested readers. Face satisfaction did not differ
between those not interested in cosmetic surgery
and those interested in liposuction among either
women or men (p ⬎ 0.001). Less face satisfaction
Volume 120, Number 5 • Cosmetic Surgery and Body Image
was reported among individuals interested in both
cosmetic surgery and liposuction (p ⬍ 0.001), al-
though the effect sizes were small for both women
(d ⫽ 0.11) and men (d ⫽ 0.16).
David A. Frederick, M.A.
Department of Psychology
1285 Franz Hall, 3rd Floor Mailroom
University of California, Los Angeles
Los Angeles, Calif. 90095-1563
enderflies1@aol.com.
ACKNOWLEDGMENTS
The authors thank Elle magazine for access to the
data from the “ELLE/MSNBC.com Sex and Body Image
Survey.” The authors are grateful for financial support
to the first author from the University of California, Los
Angeles Graduate Division; the Psychology Department;
the Communication Studies Program; and the Center for
Culture, Brain, and Development. Support to the first
author was also provided by National Institutes of
Health grant 1F31MH072384-01. The authors thank
Sheila Allameh, Anna Berezovskaya, Lisa Burklund,
Jeremy Casey, David Creswell, Martie Haselton, Johanna
Jarcho, Kelsey Laird, Kathleen Lambert, Henry Madrid,
Traci Mann, Leila Sadeghi-Azar, Janet Tomiyama, An-
drew Ward, and Erika Westling for assistance with this
database and article. They are also grateful to Carol
Edwards, who helped to create the database.
DISCLOSURES
None of the authors has a financial interest in any
of the products, devices, or drugs mentioned in this
article. The first author was supported by a grant from
the FPR-UCLA Center for Culture, Brain, and Devel-
opment while he was working this article.
REFERENCES
1. American Society of Plastic Surgeons. Statistics. Available
at: http://www.plasticsurgery.org/public_education/2004
Statistics.cfm. Accessed June 12, 2005.
2. American Society for Aesthetic Plastic Surgery. New survey
shows many American approve of cosmetic surgery. Available
at: http://www.surgery.org/press/news-archives2003.php.
Accessed June 12, 2005.
3. Henderson-King, D., and Henderson-King, E. Acceptance of
cosmetic surgery: Scale development and validation. Body
Image 2: 137, 2005.
4. Sarwer, D. B., Cash, T. F., Magee, L., et al. Female college
students and cosmetic surgery: An investigation of experi-
ences, attitudes, and body image. Plast. Reconstr. Surg. 115:
931, 2005.
5. Pertschuk, M. J., Sarwer, D. N., Wadden, T. A., et al. Body
image dissatisfaction in male cosmetic surgery patients. Aes-
thetic Plast. Surg. 22: 20, 1998.
6. Simis, K. J., Verhulst, F. C., and Koot, H. M. Body image,
psychosocial functioning, and personality: How different are
adolescents and young adults applying for plastic surgery?
Child Psychol. Psychiatry 42: 669, 2001.
7. Sarwer, D. B., and Crerand, C. E. Body image and cosmetic
medical treatments. Body Image 1: 99, 2004.
8. Cash, T. F. The Multidimensional Body-Self Relations Question-
naire Users’ Manual, 3rd Revision. 2000. Available at: http://
www.body-images.com. Accessed January 14, 2003.
9. Frederick, D. A., Peplau, L. A., and Lever, J. The swimsuit
issue: Correlates of body image in a sample of 52,677
heterosexual adults. Body Image 4: 413, 2006.
10. Aouizerate, B., Pujol, H., Grabot, D., et al. Body dysmorphic
disorder in a sample of cosmetic surgery applicants. Eur.
Psychiatry 18: 365, 2003.
11. National Center for Health Statistics. Guidelines. Available
at: http://www.cdc.gov/nchs/. Accessed February 4, 2005.
12. Cohen, J. Statistical Power Analysis for the Behavioral Sciences,
2nd Ed. Hillsdale, N.J.: Lawrence Earlbaum, 1988.
13. Fleiss, J. L. Statistical Methods for Rates and Proportions, 2nd Ed.
New York: Wiley, 1981.
14. Strain, G. W., and Zumoff, B. The relationship of weight-
height indices of obesity to body fat content. J. Am. Coll. Nutr.
11: 715, 1992.
15. Welborn, T. A., Knuiman, M. W., and Vu, H. T. Body mass
index and alternative indices of obesity in relation to
height, triceps skinfold and subsequent mortality: The
Busselton health study. Int. J. Obes. Relat. Metab. Disord. 24:
108, 2000.
16. Sarwer, D. B., Wadden, T. A., Pertschuk, M. J., and Whitaker,
L. A. Body image dissatisfaction and body dysmorphic dis-
order in 100 cosmetic surgery patients. Plast. Reconstr. Surg.
101: 1644, 2003.
1415
 CME

Management of Wrist Injuries

Kenji Kawamura, M.D., Ph.D.
Kevin C. Chung, M.D., M.S.
Ann Arbor, Mich.
Learning Objectives: After studying this article, the participant should be able
to: 1. Understand the anatomy and the biomechanical properties of the wrist.
2. Understand the standard examination process for wrist injuries. 3. Accurately
diagnose common wrist conditions. 4. Establish a management plan for wrist
problems.
Background: Although common, wrist injuries and conditions are difficult to
treat if the physician is unfamiliar with their management.
Methods: Wrist anatomy and kinematics are discussed. Physical and radio-
graphic examinations that are mandatory for diagnosing wrist conditions are
presented. Common wrist injuries are reviewed.
Results: Understanding the anatomy and kinematics of the wrist is important
in diagnosing and treating wrist conditions and in predicting outcomes after
treatment. Physical examination of the wrist requires an understanding of the
surface anatomy and a number of specific maneuvers. Physicians should also be
familiar with other diagnostic tests, which include radiography, arthrography,
computed tomography, magnetic resonance imaging, and arthroscopy.
Conclusions: Physicians who treat wrist injuries should be able to establish an
adequate management plan for common wrist injuries and conditions and be
able to predict outcomes based on these treatment plans. (Plast. Reconstr. Surg.
120: 73e, 2007.)

T
he complexity and limited size of the wrist
joint make diagnosis and treatment of wrist
injuries difficult. Misdiagnosis and injudi-
cious management can result in permanent dis-
abilities. Physicians who treat wrist injuries must
(1) understand the anatomy and mechanism of
the complex wrist joint; (2) be able to perform
accurate physical examination; (3) be familiar
with tests for the wrist such as radiography, ar-
thrography, computed tomography, magnetic
resonance imaging, and arthroscopy; and (4) be
able to accurately diagnose and establish a man-
agement plan. Management may vary from con-
servative to surgical and will depend on the se-
verity of injury, whether the injury is acute or
chronic, the demands of the patient, and the
physician’s experience. In treating wrist injuries,
physicians should also be able to predict the
outcomes based on the treatments.
ANATOMY
Understanding the anatomy of the wrist is es-
sential for treating wrist injuries. The wrist is the
From the Section of Plastic Surgery, Department of Surgery,
University of Michigan Health System.
Received for publication March 6, 2006; accepted June 15, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279385.39997.34
link between the forearm and hand, consisting of
the distal ends of the radius and ulna, eight carpal
bones, and the proximal bases of the five meta-
carpal bones. The eight carpal bones are divided
into a proximal row and a distal row. The proximal
row consists of the scaphoid, lunate, triquetrum,
and pisiform, and the distal row consists of the
trapezium, trapezoid, capitate, and hamate. The
scaphoid spans these two rows and is the key in
maintaining wrist stability.1 Morphologically, there
are two types of lunate: type I (approximately 30
percent of all lunates), which lack a medial facet;
and type II (approximately 70 percent), which
have a medial facet that articulates with the
hamate (Fig. 1).2 The pisiform is considered a
sesamoid bone that enhances the action of the
flexor carpi ulnaris.3 Although each distal carpal
bone is independent, the distal carpal row is func-
tionally considered to be a single unit.4
There are numerous articulations in the
wrist. The three major joints are as follows: (1)
the distal radioulnar joint, which has trochoid
articulation between the sigmoid notch of the
distal radius and the ulnar head, allowing pro-
nation and supination of the forearm5; (2) the
radiocarpal joint, which has ellipsoidal articu-
lation between the biconcave surface of the dis-
tal radius and the convex facets of the proximal
carpal bones6 (the distal ulna does not articulate

www.PRSJournal.com 73e
 Plastic and Reconstructive Surgery • October 2007

Fig. 1. Lunate morphology. (Left) A type I lunate lacks a medial facet. (Right) A type II lunate has
a medial facet that articulates with a hamate. S, scaphoid; L, lunate; Tq, triquetrum; P, pisiform;
Tm, trapezium; Td, trapezoid; C, capitate; H, hamate.

directly with the proximal carpal bones because
of interposing triangular fibrocartilage com-
plex); and (3) the midcarpal joint, which has
several articulations between a proximal carpal
row and a distal carpal row.7 Specifically, artic-
ulation between the scaphoid, trapezium, and
trapezoid is termed the scaphotrapeziotrap-
ezoid joint.
Wrist ligaments can be classified as extrinsic
and intrinsic.8 Extrinsic ligaments connect the
distal radius and ulna to the carpal bones, and
intrinsic ligaments have their origins and inser-
tions within the carpal bones (Fig. 2). Palmar
extrinsic ligaments are thought to play a major
role in stabilizing the wrist.8,9 In contrast, the
dorsal extrinsic radiocarpal ligament, which is
reinforced by the extensor tendons, consists
of only dorsal radiotriquetral ligament.8,10 In-
trinsic scapholunate ligaments consist of three
structures: the palmar scapholunate ligament,
the dorsal scapholunate ligament, and the prox-
imal fibrocartilaginous membrane.11 The dorsal
scapholunate ligament is thought to be the key
in scapholunate stability.12 The lunotriquetral
joint is also stabilized by the palmar and dorsal
ligaments and proximal fibrocartilaginous mem-
brane.13 The lunotriquetral ligaments are tighter
throughout the entire range of wrist motion com-
pared with the scapholunate ligaments, resulting in
a close kinematic relationship between the lunate
and triquetrum.4,7,14 The distal carpal bones are
tightly connected by numerous interosseous liga-
ments, which contribute to the behavior of the distal
carpal row as a single functional unit, and the mid-
carpal joint is stabilized by several dorsal and palmar
intercarpal ligaments.4,8
KINEMATICS
Carpal kinematics is extremely complex. A de-
tailed understanding of the kinematics of the car-
pal bones during wrist motion is important not
only in diagnosis and treatment of wrist injuries
but also in predicting surgical outcomes. Al-
though numerous theories explaining carpal ki-
nematics have been suggested, no conclusive the-
ory has yet to be accepted.15–18 Recent quantitative
three-dimensional studies of carpal motion have
demonstrated that a single theory is not sufficient
to explain carpal kinematics.19 –21
Generally, the distal carpal row is considered
a relatively rigid single unit.4 During wrist flex-
ion, the distal carpal row flexes, pronates, and
deviates ulnarly at the midcarpal joint, whereas
it extends, supinates, and slightly deviates radi-
ally during wrist extension.7 By simulating lim-
ited wrist fusion models, Gellman et al. showed
that 36 percent of wrist flexion and 46 percent
of wrist extension occurs in the midcarpal joint,
with the remaining flexion and extension oc-
curring in the radiocarpal joint.22 Radioulnar
deviation of the wrist occurs mostly through the
midcarpal joint, with a lesser contribution from

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Fig. 2. Ligamentous anatomy of the wrist. (Left) Palmar ligaments. RS, radioscaphoid; RSC,
radioscaphocapitate; RL, radiolunate; UC, lunocapitate; UL, ulnolunate; UT, ulnotriquetral; SL,
scapholunate; LT, lunotriquetral; ST, scaphotrapezial; SC, scaphocapitate; THC, triquetral-
hamate-capitate; PH, pisohamate. (Right) Dorsal ligaments. RT, radiotriquetral; SL, scapholu-
nate; LT, lunotriquetral; DIC, dorsal intercarpal.

the radiocarpal joint.23,24 Kaufmann et al. showed
that 86 percent of radial deviation and 66 percent
of ulnar deviation occurs at the midcarpal joint.24
In radial deviation, the distal carpal row extends
and supinates, whereas it flexes and pronates in
ulnar deviation.
In contrast to the distal carpal row, there is
large intercarpal motion within the proximal car-
pal row. Especially, the scaphoid appears to move
independently. Understanding the scaphoid move-
ment during wrist motion is important for perform-
ing the physical and radiographic examinations and
treating wrist injuries. The scaphoid flexes in radial
deviation, whereas it extends in ulnar deviation. Dur-
ing wrist flexion from neutral, the scaphoid flexes,
pronates, and deviates ulnarly, whereas it extends,
supinates, and deviates ulnarly during wrist exten-
sion from neutral.25 A recent in vivo study by Moojen
et al. revealed that the scaphoid has a larger amount
of rotation than the lunate. The scaphoid was shown
to flex 19 degrees more than the lunate in 60 degrees
of wrist flexion and extend 13 degrees more than the
lunate in 60 degrees of wrist extension.26 Further-
more, they showed that contribution of the scaphoid
to wrist flexion and extension was 62 and 87 percent,
respectively, and contribution of the lunate to wrist
flexion and extension was 31 and 66 percent,
respectively.21 These findings might be useful for
predicting outcomes after limited intercarpal fu-
sions; for example, radioscaphoid fusion will cause a
greater loss of motion than radiolunate fusion.27
PHYSICAL EXAMINATION
Radial Wrist Examination
The tuberosity of the scaphoid is easily pal-
pated at the radial-volar aspect. At the radial-dor-
sal aspect, the anatomical snuffbox can be iden-
tified just distal to the radial styloid between the
tendons of the first extensor compartment and
the extensor pollicis longus (Fig. 3). The waist
of the scaphoid is located at the floor of the
anatomical snuffbox. Tenderness in the ana-
tomical snuffbox or scaphoid tuberosity may
suggest a scaphoid fracture.28,29 The scaphotra-
peziotrapezoid joint can be palpated by follow-
ing the second dorsal metacarpal proximally
until the examiner’s thumb falls into a recess.
Following the third dorsal metacarpal proxi-
mally reveals a recess that lies over the capitate.
The scapholunate joint is just proximal to this
recess.30 The scapholunate joint can also be iden-
tified by following a line distally from the Lister’s
tuberosity of the dorsal distal radius. The lunate
is the most bony prominence on the dorsum of
the flexed wrist. Tenderness in the scapholunate
joint area is suggestive of scapholunate ligamen-

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 Plastic and Reconstructive Surgery • October 2007

Fig. 3. Surface anatomy of the wrist. (Left) Dorsal aspect. EPL, extensor pollicis longus; EPB,
extensor pollicis brevis; APL, abductor pollicis longus; SL, scapholunate joint; STT, scaphotra-
peziotrapezoid joint; LT, lunotriquetral joint. (Right) Palmar aspect. FCR, flexor carpi radialis;
FCU, flexor carpi ulnaris; PL, palmaris longus.

tous injury, Kienböck disease, or fracture of the normal palmar tilting of the scaphoid during ulnar
lunate.28,30 to radial deviation. If laxity of the scapholunate lig-
The scaphoid shift test is used to assess scapholu- ament is present, the scaphoid is forced dorsally
nate instability (Fig. 4).31 This maneuver prevents onto the dorsal rim of the radius. Pain or feeling of

Fig. 4. Scaphoid shift test showing the starting (left) and end (right) positions. The examiner
holds the wrist on the radial side, placing the thumb on the scaphoid tuberosity. The wrist is
then moved from ulnar to radial deviation using the other hand while applying pressure to the
tuberosity and providing counterpressure with the fingers. If laxity of the scapholunate liga-
ment is present, the examiner’s thumb can feel a “clunk.”

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Volume 120, Number 5 • Wrist Injuries
a clunk is suggestive of scapholunate instability. This
maneuver should also be performed with the con-
tralateral asymptomatic wrist because asymptomatic
laxity could be present in both wrists.32
Ulnar Wrist Examination
The pisiform is easily palpated at the ulnar-
volar aspect (Fig. 3). The hook of the hamate is
located deep in the hypothenar eminence. Ten-
derness in this area may suggest a fracture of the
hook of the hamate.
In the ulnar-dorsal area, the dorsal tuberosity
of the triquetrum is palpated as the bony promi-
nence just distal to the ulnar head. Tenderness in
this area is suggestive of lunotriquetral ligamen-
tous injury or triquetral fracture. The lunotrique-
tral ballottement test is used to assess instability of
the lunotriquetral joint by applying dorsal pres-
sure to the lunate using the thumb and volar pres-
sure to the triquetrum using the index finger (Fig.
5).33 If lunotriquetral instability is present, this
maneuver results in a painful click.
The ulnar styloid is readily palpated at the
ulnar wrist. Tenderness in the ulnar styloid may
suggest a fracture or a triangular fibrocartilage
complex injury. The ulnocarpal stress test is per-
formed by applying compression load to the wrist
while in ulnar deviation.34 Pain or clicking with
this test may suggest triangular fibrocartilage com-
plex injury or ulnocarpal abutment syndrome.
Pain with pronation and supination of the forearm
Fig. 5. Lunotriquetral ballottement test. Instability of the
lunotriquetral joint is assessed by applying dorsal pressure to the
lunate and volar pressure to the triquetrum.
may indicate distal radioulnar joint abnormality.35
Over the ulnar head, a positive “piano key” sign is
suggestive of distal radioulnar joint instability,
which is the ulnar head springing back like a piano
key when depressed while supporting the forearm
in pronation.36
RADIOGRAPHIC EXAMINATION
Routine radiographic images of the wrist should
include posteroanterior, lateral, and oblique views.
The posteroanterior view should be obtained with
the shoulder abducted at 90 degrees, the elbow
flexed at 90 degrees, the forearm in neutral rota-
tion, and the hand and wrist flat on the cassette.
With this view, the axis of the middle metacarpal
should be aligned with the radius axis. On the
posteroanterior view, one should examine the
joint space width, normal carpal arcs, and shape of
the carpal bones. All joint space widths within the
carpal bones are normally 1 to 2 mm.37 Articulat-
ing surfaces should be parallel, with no overlap-
ping. Any distortion of these joint space configu-
rations suggests ligamentous injury or dislocation
or subluxation of the carpal bones.38,39 Gilula de-
scribed three normal carpal arcs on a posteroan-
terior view: arc I is the proximal convex curvature
of the proximal carpal row, arc II is the distal
concave curvature of the proximal carpal row, and
arc III is the proximal convex curvature of the
capitate and hamate (Fig. 6).40 These three arcs
are normally smooth, and a disrupted or broken
Fig. 6. Gilula’s arcs (I, II, and III) on the posteroanterior view. Nor-
mally, three Gilula’s arcs are smooth.
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 Plastic and Reconstructive Surgery • October 2007
arc may indicate ligamentous injury, dislocation of
the carpal bones, or a carpal bone fracture.
It is also important to be familiar with the
shapes of the scaphoid and lunate on the pos-
teroanterior view. On a neutral posteroanterior
view, the scaphoid is shaped like a top-heavy kid-
ney bean, whereas the lunate is trapezoidal.39 Un-
der radial deviation and palmar flexion, the scaph-
oid foreshortens and forms a signet ring sign,
whereas the lunate appears more triangular in
shape.37,40 Under ulnar deviation and dorsal ex-
tension, the scaphoid elongates and no longer
presents as a signet ring sign, whereas the lunate
appears more trapezoidal.37,40 A signet ring sign on
a neutral posteroanterior view might indicate lig-
amentous instability or subluxation of the scaph-
oid (Fig. 7).38,39 In contrast, a triangular lunate
might indicate abnormal palmar tilting.38,39
Configurations of the distal radioulnar joint
including the joint space width and relative length
of the radius and ulna (ulnar variance) should also
be examined on posteroanterior images (Fig. 8).41
A greater gap between the ulnar head and distal
radius on the posteroanterior view is suggestive of
dorsal dislocation of the ulnar head.42
On a lateral view of the wrist, the middle meta-
carpal bone, capitate, lunate, and radius should
be aligned in a collinear longitudinal axis, and the
radial and ulnar styloid processes should appear
superimposed and parallel.37 A true lateral view can
Fig. 7. Posteroanterior view of scapholunate dissociation. The
scaphoid is foreshortened with a signet ring sign (white arrow),
and there is abnormal widening between the scaphoid and lu-
nate (black arrows).
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Fig. 8. Ulnar variance is the difference in length between the
ulnar head and ulnar aspect of the distal radius. This patient
shows ulnar positive variance (between arrows).
be confirmed by having the pisiform project over
the midportion of the scaphoid.39 Normally, the
scapholunate angle is 30 to 60 degrees and the capi-
tolunate angle is 0 to 30 degrees (Fig. 9).37 Malalign-
ment of the wrist leads to abnormal scapholunate
and capitolunate angles. With dorsal intercalated
segment instability, the lunate is more dorsiflexed
and the capitate is tilted palmarly, leading to an
increased scapholunate angle of more than 60 de-
grees and an increased capitolunate angle of more
than 30 degrees.37,43 Dorsal intercalated segment in-
stability deformity is seen with scapholunate disso-
ciation, scaphoid malunion, and dorsal malunion of
distal radius fractures.37,38,44 With ventral intercalated
segmental instability, in contrast, the lunate is flexed
palmarly and the capitate is tilted dorsally, leading to
a decreased scapholunate angle of less than 30 de-
grees and increased capitolunate angle of more than
30 degrees.37,43 Ventral intercalated segmental insta-
bility deformity is seen with lunotriquetral dissocia-
tion and palmar midcarpal instability.43,45,46
A 45-degree pronated oblique view is useful
for evaluating radial-side anatomy, including the
radial styloid, scaphotrapeziotrapezoid joint, and
thumb carpometacarpal joint; a 45-degree supi-
nated oblique view shows the hook of the hamate,
pisiform, and pisotriquetral joint.39 Additional views
such as a scaphoid view (for scaphoid fracture),
clenched fist view (for scapholunate instability), and
carpal tunnel view (for hamate hook and pisiform
fractures) can be performed, depending on clinical
suspicions.28
Volume 120, Number 5 • Wrist Injuries

Fig. 9. Scapholunate (SL) and capitolunate (CL) angles on the lateral view. (Left) Normally, the scapholunate angle
is 30 to 60 degrees and the capitolunate angle is 0 to 30 degrees. (Center) Dorsal intercalated segment instability
results in an increased scapholunate angle of more than 60 degrees and an increased capitolunate angle of more
than 30 degrees. (Right) Ventral intercalated segmental instability results in a decreased scapholunate angle of less
than 30 degrees and an increased capitolunate angle of more than 30 degrees.

ing is useful for evaluation of both bony and

soft-tissue problems, such as occult fractures,
avascular necrosis, and triangular fibrocartilage
complex abnormality.28,39 Arthrography followed by
computed tomography or magnetic resonance im-
aging is also useful for evaluating ligament and car-
tilage abnormality.48,49

Fig. 10. Distal radioulnar joint arthrography demonstrates per-
foration of the triangular fibrocartilage complex (arrow).
Wrist arthrography is a useful method for eval-
uating the interosseous ligaments and cartilage
abnormality (Fig. 10).47 Magnetic resonance im-
aging and computed tomography might be indi-
cated when plain radiographs are equivocal or
further investigation is required. Computed to-
mography is useful for defining fractures and
dislocations, whereas magnetic resonance imag-
FRACTURES
Distal Radius Fractures
Distal radius fractures are the most common
type of upper extremity fracture.50 Such fractures
tend to occur in adults older than 40 years and are
more common in women than in men because of
the higher incidence of osteoporosis in women.51
The most common mechanism of this type of in-
jury is a fall onto an outstretched hand. Physical
examination reveals tenderness, swelling, and ec-
chymosis around the wrist, and severely displaced
fractures might present with abnormal posture of
the hand as a result of deformity of the distal
radius. Diagnosis is made by standard radio-
graphs including posteroanterior, lateral, and
oblique views. Computed tomography is used
only in rare cases to evaluate the amount of
displacement of articular joint surfaces.52 Deter-
mination of the type of fracture is important,
which includes assessment of displacement, ra-
dial shortening, intraarticular involvement, the
amount of comminution, and the presence of an
ulnar styloid fracture.

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 Plastic and Reconstructive Surgery • October 2007

Although numerous classification systems
have been suggested for identification of distal
radius fractures,53–56 none is universal and capable
of predicting outcomes.57 Important radiographic
parameters that might affect wrist functional out-
comes are radial inclination (normal average, 23
degrees), radial length (normal average, 12 mm),
palmar tilt (normal average, 11 degrees), and con-
gruity of articular surfaces (Fig. 11).58 Loss of ra-
dial inclination causes radial deviation of the wrist
and radial shortening leads to incongruity of the
distal radioulnar joint and positive ulnar variance.
Excessive dorsal tilt results in carpal malalignment
(dorsal intercalated segment instability defor-
mity), causing midcarpal instability and arthritis.44
Incongruity of articular surfaces also causes pain
and arthritis.
The purpose of treatment is to restore anatom-
ical alignment. Although nondisplaced or minimally
displaced stable fractures can be treated with cast
immobilization, displaced irreducible unstable frac-
tures require surgical treatment. Radial inclination
less than 20 degrees, radial shortening greater than
2 mm, dorsal tilt greater than 10 degrees, and ar-
ticular step-off greater than 2 mm are unacceptable
after closed reduction.58 The surgical options for
treatment of distal radius fractures include percuta-
neous pinning and external and internal fixation.
The following are the authors’ preferred treatment
techniques. For distal radius metaphyseal fractures
with dorsal displacement (apex volar angulation)
occurring in young patients with good bone stock,
the Kapandji intrafocal pinning technique followed
by cast immobilization is applied.59 The external fix-
ation technique is applied for metaphyseal commi-
nuted fractures because of reliability for maintaining
extraarticular parameters such as radial inclination,
radial length, and palmar tilt. The external fixation
technique, however, does not necessarily achieve
articular congruity in comminuted intraarticular
fractures.60 Open reduction and plate fixation is ap-
plied for comminuted intraarticular fractures.61– 63
Furthermore, plate fixation can provide rigid fixa-
tion for early range of motion. For osteoporotic
bones, the authors prefer internal fixation tech-
niques to prevent secondary collapse and deformity.
Recent innovation of the volar plating system with
fixed-angle plates can be applied to even dorsally
displaced fractures that have been traditionally
treated with dorsal plate fixation (Fig. 12).61,62 The
use of volar plating avoids complications of dorsal
soft-tissue irritation associated with dorsal plate
fixation.63,64
Scaphoid Fractures
The scaphoid is the most commonly fractured
carpal bone, accounting for 50 to 70 percent of all

Fig. 11. Radiographic parameters of the distal radius. (Left) Radial inclination (RI) is measured
off the perpendicular to the shaft of the radius (normal average, 23 degrees). Radial length (RL)
is the difference in length between the ulnar head and the tip of the radial styloid (normal
average, 12 mm). (Right) Palmar tilt (PT) is measured off the perpendicular to the shaft of the
radius on the lateral view (normal average, 11 degrees).

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Volume 120, Number 5 • Wrist Injuries
Fig. 12. Distal radius fracture. (Left) Distal fractured fragments are displaced and an-
gulated dorsally. (Right) The fracture is reduced and fixated with a volar fixed-angle plate
and screws.
carpal fractures.51,65 Scaphoid fractures tend to
occur in young adult men between the age of 15
and 40 years and are rare under the age of 10.66
The typical mechanism of injury is a fall onto a
hyperextended wrist. Approximately 70 to 80 per-
cent of scaphoid fractures occur at the midpor-
tion, 10 to 20 percent at the proximal pole, and the
remainder at the distal pole.67 Physical examina-
tion may reveal tenderness in the anatomical
snuffbox or scaphoid tuberosity, and wrist range of
motion can be slightly restricted. Thumb move-
ment may be painful. Initial wrist radiographs
should include standard posteroanterior, lateral,
and oblique views and a scaphoid view. The scaph-
oid view may visualize the fracture because ulnar
deviation of the wrist distracts unstable fracture
fragments (Fig. 13).
It has been reported that approximately 7 per-
cent of scaphoid fractures are initially invisible
even with excellent quality radiographs.68 If there
is high clinical suspicion for scaphoid fracture
without radiographic evidence of a fracture, a
thumb spica cast is applied for 2 weeks. Follow-up
radiographs after 2 weeks may show bone resorp-
tion or early callus formation adjacent to the frac-
ture site if an occult fracture does exist.29 If plain
radiographs are still negative but the clinical sus-
picion remains high after 2 weeks, bone scintig-
raphy and magnetic resonance imaging are help-
ful for more definitive evaluation.69,70
Nondisplaced stable scaphoid fractures can be
treated with a thumb spica cast for 8 to 12 weeks.
There has been no consensus regarding whether
the cast should include the elbow joint; however,
an above-elbow cast may be preferred in the initial
immobilization for 3 to 4 weeks, followed by a
short-arm cast. The healing rate of nondisplaced
midportion scaphoid fractures with cast immobi-
lization is 90 to 100 percent if treatment is started
within 3 weeks after injury.71 Unstable fractures
have a high risk of delayed union, nonunion, or
malunion. Unstable scaphoid fracture is defined
as displacement of the fractured fragments by
more than 1 mm in any view.71 Internal fixation
with a compression screw is recommended for
unstable scaphoid fractures (Fig. 14). Currently,
internal fixation for scaphoid fractures has been
recommended even if the fracture is not dis-
placed. Early internal fixation for a nondisplaced
scaphoid fracture could reduce problems associ-
ated with cast immobilization, which include the
inconvenience of a long period of immobilization,
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 Plastic and Reconstructive Surgery • October 2007
Fig. 13. The scaphoid view (ulnar deviation of the wrist) visual-
izes a fracture line (arrow).
stiffness of the wrist joint, decreased grip strength,
and delayed return to work.72,73 Proximal pole frac-
tures are more likely to progress to nonunion or
avascular necrosis because the blood supply of the
proximal pole of the scaphoid enters around the
midportion.74 The incidence of avascular necrosis
in proximal pole fractures is reportedly 16 to 42
percent; therefore, early internal fixation and
Fig. 14. A scaphoid fracture is stabilized by open reduction and
internal fixation with a compression screw.
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even primary bone grafts are recommended for
proximal pole fractures.75
Other Carpal Bone Fractures
The triquetrum is the second most commonly
fractured carpal bone.65 Most triquetral fractures
are dorsal ridge fractures that appear as avulsion
fractures on lateral view wrist radiographs.76 Such
fractures can heal with cast immobilization. Iso-
lated fractures of the body of the triquetrum are
rare and can be treated successfully with cast im-
mobilization.
Hamate fractures occur in the body or hook.
Hook of the hamate fractures are best detected with
a carpal tunnel view or computed tomography.51
Excision of the displaced hook is generally rec-
ommended because of the high potential of pain-
ful nonunion, which occurs in up to 46 percent of
cases.77,78 Nondisplaced hamate body fractures can
be treated with cast immobilization, but displaced
body fractures require open reduction and inter-
nal fixation.
Isolated capitate fractures are rare and usually
occur in association with other carpal bones inju-
ries, particularly scaphoid fractures.79 In the latter,
termed scaphocapitate syndrome, the displaced
proximal fragment of the capitate often rotates by
90 or 180 degrees. Immediate open reduction and
internal fixation is required because the capitate
and scaphoid have a retrograde blood supply, and
delay can cause avascular necrosis of the proximal
fragments of both bones.80
Fractures of the trapezium and trapezoid are
rare, and isolated trapezoid fractures are even
rarer.65 Nondisplaced fractures of the trapezium
and trapezoid can be treated with cast immobili-
zation, but displaced intraarticular fractures of the
trapezium and trapezoid require accurate reduc-
tion and internal fixation.81
Isolated lunate fractures are rare.82 Avulsion
fractures of the dorsal ridge of the lunate are often
confused with dorsal chip fractures of the tri-
quetrum and are sometimes associated with dorsal
scapholunate ligament injury, necessitating surgi-
cal reattachment of the ligament to prevent fur-
ther destabilization.76,83 Generally, osteonecrosis is
not a complication of lunate fractures.82
Pisiform fractures are uncommon, accounting
for approximately only 1 percent of all carpal bone
fractures.84 Physical examination reveals tender-
ness over the pisiform, and fractures are clearly
detected in a 45-degree supinated oblique or car-
pal tunnel view. Most fractures heal with cast im-
mobilization; however, pisiform excision is some-
Volume 120, Number 5 • Wrist Injuries
times recommended if symptomatic nonunion
occurs.81
AVASCULAR NECROSIS
Kienböck Disease
Avascular necrosis of the lunate, or Kienböck
disease, primarily occurs in young adult men in-
volved in manual labor.85 It generally affects the
dominant wrist and rarely both wrists. Patients
present with dorsal swelling and tenderness over
the lunate. They also have decreased grip strength
and loss of wrist motion. Extension is affected
more than flexion. Occasionally, symptoms of car-
pal tunnel syndrome are seen in patients with
Kienböck disease.86 Diagnosis is usually made by
radiographs, but in the earliest stage, radiographs
can be negative and therefore further investiga-
tion by magnetic resonance imaging or bone scin-
tigraphy is sometimes necessary (Fig. 15).87 Kien-
böck disease is often associated with negative ulnar
variance.88 Staging of Kienböck disease is usually
performed based on radiographic findings ac-
cording to the methods of Ståhl that were modi-
fied by Lichtman et al. (Table 1).89,90
This system is useful for determining the treat-
ment plan. Stage I patients are usually treated con-
servatively with wrist immobilization for 2 to 4
months, whereas in stage II and III patients, various
surgical procedures have been attempted to salvage
the lunate. These procedures can be divided into
two categories: biomechanical and biological. Bio-
Fig. 15. Kienböck disease. (Left) The plain radiograph shows abnormal density and a slight
collapse of the lunate (stage IIIA). (Right) Magnetic resonance imaging demonstrates avascu-
larity of the lunate.
Table 1. Staging of Kienböck Disease
Stage Characteristics
I The lunate is normal on plain radiographs
but abnormal on magnetic resonance
imaging or bone scintigraphy
II The density of the lunate is abnormal on
plain radiographs without lunate or carpal
collapse
IIIA Collapse of the lunate is visible without carpal
collapse
IIIB Static carpal collapse is visible
IV Extensive osteoarthritic changes are observed
mechanical approaches, which include joint leveling
procedures,85,91 wedge osteotomy of the radius,92
capitate shortening,93 and intercarpal fusions,94 –96
aim to reduce the excessive load acting on the lu-
nate. Joint leveling procedures, radial shortening or
ulna lengthening,85,91 can be performed in patients
with negative ulnar variance. In ulnar-neutral or ul-
nar-positive cases, wedge osteotomy of the radius92 or
capitate shortening93 can be performed. Intercarpal
fusions such as scaphotrapeziotrapezoid fusion,94
scaphocapitate fusion,95 and capitohamate fusion96
can diminish lunate loading and prevent or correct
carpal collapse. Intercarpal fusions are reportedly
effective for pain relief, but some loss of wrist motion
is inevitable. Biological approaches aim to revascu-
larize the lunate with vascular bundle implantation
or vascularized bone grafts.97–101 Currently, numer-
ous successful outcomes with various vascularized
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 Plastic and Reconstructive Surgery • October 2007

bone grafts (dorsal or volar distal radius,98,99 second

metacarpal head,100 and pisiform101) have been re-
ported. In advanced cases (stage III with extensive
lunate fragmentation and stage IV), salvage proce-
dures are required. Salvage procedures include
proximal row carpectomy, lunate replacement with
various implants, total wrist fusion, and total wrist
arthroplasty.102

LIGAMENTOUS INJURIES
Carpal Dislocation
Perilunate dislocation, which is characterized by
a disruption of ligamentous connections between
the lunate and other carpal bones and the radius, is
the most common form of carpal dislocation.103 Usu-
ally, patients with perilunate dislocation report a fall
from a height or other type of high-energy fall with
hyperextension of the wrist. Physical examination
reveals dorsal wrist pain and swelling and decreased
range of motion, especially wrist flexion. Diagnosis is
made by careful radiographic examination. In luno-
capitate dislocation, the distal carpal row is dislo-
cated dorsally from the lunate, whereas the lunate
maintains its normal articulation with the radius
(Fig. 16). Unfortunately, these dislocations are oc-
casionally misdiagnosed after acute injury (in 16 to
25 percent of cases according to various case se-
ries104 –106), and such delay in treatment will result in
poor functional outcomes. Lunate dislocation into
the carpal tunnel may cause median nerve compres-
sion and the lunate should be reduced immediately
Fig. 16. Perilunate dislocation. On the lateral view, the lunate
remains normally situated but the capitate and other carpal
bones are displaced dorsally.
Fig. 17. The lateral view shows lunate dislocation into the carpal
tunnel.
(Fig. 17). The recent consensus for treatment of
acute perilunate dislocation consists of open reduc-
tion and internal fixation of the carpal bones in
addition to repair of scapholunate and lunotrique-
tral ligaments.83,104,107 For chronic irreducible cases,
either a proximal row carpectomy or total wrist fu-
sion is indicated.108
Carpal Instability
Carpal instability occurs because of disruption
of the interosseous ligaments109 and can be clas-
sified as predynamic, dynamic, or static according
to the severity of subluxation of carpal bones.32
Predynamic instability, which cannot be identified
on radiographs, is partial ligament tears with no
carpal malalignment under stress. Both dynamic
and static instabilities have complete ligament
ruptures. Carpal malalignment can be identified
on plain radiographs in static instability, whereas
in dynamic instability, it can be identified only on
stress radiographs or fluoroscopy.
Scapholunate instability is the most common
instability pattern in clinical situations.37,43 Pa-
tients with scapholunate instability usually report
a fall or strong force, with hyperextension of the
wrist. Physical examination reveals dorsal swelling
and tenderness and decreased range of motion. A
positive scaphoid shift test may be found in dy-
namic and static instabilities.31 Static scapholunate
instability (scapholunate dissociation) is diagnosed
radiographically as widening of greater than 3 mm
between the scaphoid and lunate on a standard pos-

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Volume 120, Number 5 • Wrist Injuries
teroanterior view (Fig. 7).37 In scapholunate disso-
ciation, dorsal intercalated segment instability de-
formity is frequently seen on a lateral view.37,43 Stress
views, including the clenched-fist view, posteroante-
rior maximal radial deviation, and posteroanterior
maximal ulnar deviation, are used to diagnose dy-
namic scapholunate instability. The clenched-fist
view accentuates the widening between the scaphoid
and lunate because fist compression forces the cap-
itate head into the scapholunate joint.110 If plain
radiographs are equivocal, arthrography or mag-
netic resonance imaging might demonstrate disrup-
tion of the scapholunate ligament.51 Recently, ar-
throscopic examination has become the standard
method of evaluation of interosseous ligamentous
injuries and can precisely diagnose predynamic
instability.111
Once scapholunate instability is recognized,
appropriate management is necessary. Predy-
namic instability is usually treated with immobili-
zation followed by rehabilitation, and surgical
treatment is recommended for dynamic and static
scapholunate instabilities. Untreated scapholu-
nate instability causes carpal collapse, which leads
to degenerative arthritis in the radiocarpal and
capitolunate joints.112 Acute scapholunate insta-
bility (within 3 weeks after injury) can be treated
with closed reduction and percutaneous pin fix-
ation or open reduction and internal fixation, fol-
lowed by cast immobilization.109,110 An open tech-
nique with a dorsal approach allows direct reduction
and repair of the dorsal scapholunate ligament,113
which is considered the most important structure for
stabilization of the scapholunate joint.12 Repair of
the dorsal scapholunate ligament is achieved by di-
rect suture of the torn ligament stumps, or by using
transosseous sutures,114 or by using tag suture
anchors.115 For chronic cases, capsulodesis,116 liga-
ment reconstruction using tenodesis,117 bone-liga-
ment-bone grafts,118 or limited intercarpal fusion
(scaphotrapeziotrapezoid, scapholunate, or scapho-
capitate fusions)119 has been advocated.
Lunotriquetral instability is less common than
scapholunate instability and typically manifests as
ulnar-sided wrist pain, which is often confused
with other ulna-wrist problems such as triangular
fibrocartilage complex injury or distal radioulnar
joint abnormality,120 Examination reveals tender-
ness over the lunotriquetral joint and a positive
lunotriquetral ballottement test.33 Plain radio-
graphs are usually normal. Unlike scapholunate
dissociation, no lunotriquetral gap is seen on ra-
diographs. Only when there is complete disrup-
tion and attenuation of both intrinsic and extrin-
sic lunotriquetral supporting ligaments might
ventral intercalated segmental instability defor-
mity and disruption of Gilula’s line be present.14,46
Arthrography might demonstrate direct commu-
nication between the radiocarpal and midcarpal
joints through the lunotriquetral interval.47 Bone
scintigraphy might be useful for screening pa-
tients with ulnar-side wrist pain, but magnetic res-
onance imaging is not yet reliable for diagnosis of
lunotriquetral ligament injuries.42,51 At present, ar-
throscopy is the most definitive diagnostic tool for
interosseous ligamentous injuries.111
Generally, conservative treatment with a cast
or splint immobilization is performed for acute
dynamic lunotriquetral instability.33 Surgical treat-
ment is considered for chronic static instability
and after failure of conservative treatment. Surgi-
cal techniques include arthroscopic debridement
with and without percutaneous pinning, direct
ligament repair, ligament reconstruction, limited
intercarpal fusion, and proximal row carpectomy
or total wrist fusion as salvage procedures.121
Triangular Fibrocartilage Complex Injury
The triangular fibrocartilage complex is com-
posed of the horizontal disk (triangular fibrocar-
tilage complex proper), extrinsic ulnocarpal lig-
aments, the ulnar collateral ligament, and the
extensor carpi ulnaris subsheath.122 The horizon-
tal disk is divided into a central portion and pe-
ripheral structures composed of the dorsal and
palmar radioulnar ligaments. The triangular fi-
brocartilage complex is important in transmission
of load from the wrist to the ulna and in stabilizing
the distal radioulnar joint. Injuries occur with
acute trauma or degenerative processes, with de-
generative lesions being more common than trau-
matic lesions (Table 2).123
Table 2. Classification of Triangular Fibrocartilage
Complex Lesions
Class Description of Lesion
1 (traumatic)
1A Central portion
1B Ulnar avulsion
1C Distal avulsion
1D Radial avulsion
2 (degenerative)
2A TFCC wear
2B 2A ⫹ chondromalacia of the lunate
or ulna
2C TFCC perforation
2D 2C ⫹ chondromalacia of the lunate
or ulna ⫹ lunotriquetral ligament
perforation
2E 2D ⫹ ulnocarpal arthritis
TFCC, triangular fibrocartilage complex.
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 Plastic and Reconstructive Surgery • October 2007
Triangular fibrocartilage complex injury can
cause ulnar-side wrist pain, clicking during fore-
arm rotation, or distal radioulnar joint instability.
A positive ulnocarpal stress test indicates triangu-
lar fibrocartilage complex injury.34 Although ra-
diographs are usually normal, the posteroanterior
view might demonstrate positive ulnar variance,
which is associated with degenerative triangular
fibrocartilage complex lesions, referred to as ul-
nocarpal abutment syndrome.124 If distal radioul-
nar joint instability is present, a true lateral view
might demonstrate dorsal subluxation of the ul-
nar head. A computed tomographic scan in neu-
tral, pronation, and supination is useful for re-
vealing distal radioulnar joint instability.125 An
arthrogram can accurately detect perforations of
the triangular fibrocartilage complex (Fig. 10).47
Magnetic resonance imaging is also accurate in
predicting perforations of the central portion of
the horizontal disk but is less reliable in detecting
peripheral detachments of the triangular fibro-
cartilage complex.126 At present, arthroscopy is the
most valuable diagnostic tool for triangular fibro-
cartilage complex injuries, providing detailed in-
formation by direct visualization (Fig. 18).127
Treatment of triangular fibrocartilage com-
plex injuries depends on the location of the tears.
Central tears have little healing capacity because
of the lack of vascularity; however, small tears may
become asymptomatic; therefore, conservative
treatment with a cast or splint immobilization is
recommended.128 Persistent symptomatic central
tears are amenable to arthroscopic debridement,
allowing preservation of the peripheral structure
including the dorsal and palmar radiocarpal lig-
aments. Usually, excision of the central portion
Fig. 18. Arthroscopy demonstrates a central tear of the disk
proper (arrow).
86e
causes no instability of the distal radioulnar joint
and dysfunction of load-bearing.129 In contrast,
peripheral tears have the capacity to heal because
of abundant vascularity.128 Arthroscopic and open
repair of peripheral tears have been reported with
favorable results,130,131 and ulnar shortening is
sometimes performed for patients with positive
ulnar variance.132
CONCLUSIONS
Understanding the anatomy and mechanism
of the wrist is necessary for managing all types of
wrist injury. Familiarity with physical examination
methods is also mandatory for accurate diagnosis.
Physicians who treat wrist injuries should be able
to establish a management plan according to the
type of injury and predict the posttreatment out-
come regardless of the treatment plan.
Kevin C. Chung, M.D., M.S.
Section of Plastic Surgery
University of Michigan Health System
2130 Taubman Center
1500 East Medical Center Drive
Ann Arbor, Mich. 48109-0340
kecchung@umich.edu
DISCLOSURES
Neither of the authors has financial or other rela-
tionships that influence assessment of the data or that
would constitute a conflict of interest.
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106. Siegert, J. J., Frassica, F. J., and Amadio, P. C. Treatment of
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112. Watson, H. K., and Ballet, F. L. The SLAC wrist: Scapholu-
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113. Weil, C., and Ruby, L. K. The dorsal approach to the wrist
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115. Packer, G. J., Gill, P. J., and Stirrat, A. N. Repair of acute
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117. Linscheid, R. L., and Dobyns, J. H. Treatment of scapholu-
nate dissociation: Rotatory subluxation of the scaphoid.
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118. Weiss, A. P. Scapholunate ligament reconstruction using a
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119. Watson, H. K., Ryu, J., and Akelman, E. Limited triscaphoid
intercarpal arthrodesis for rotatory subluxation of the
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between ulnar variance and triangular fibrocartilage com-
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of radiography and computerized tomography in the diag-
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128. Bednar, M. S., Arnoczky, S. P., and Weiland, A. J. The
microvasculature of the triangular fibrocartilage complex:
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131. Trumble, T. E., Gilbert, M., and Vedder, N. Isolated tears
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132. Minami, A., and Kato, H. Ulnar shortening for triangular
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89e
 SPECIAL TOPIC

Objective Interpretation of Surgical Outcomes:

Is There a Need for Standardizing Digital
Images in the Plastic Surgery Literature?
Wendy L. Parker, M.D.,
Background: Subjective interpretation of preoperative and postoperative pho-
Ph.D. tographs is heavily relied on for evaluating standards of care. For preoperative
Marcin Czerwinski, M.D. and postoperative digital images to accurately reflect surgical outcomes, image
Hani Sinno, B.Sc. characteristics, other than acquisition, must be rigidly standardized. The authors
Photis Loizides, M.D. investigated, using objective methodology, the consistency of published images
Chen Lee, M.D. within the plastic surgery literature.
Montreal, Quebec, Canada Methods: A panel reviewed four plastic surgery journals (Aesthetic Plastic Surgery,
Aesthetic Surgery Journal, Plastic and Reconstructive Surgery, and the British Journal
of Plastic Surgery), with 100 consecutive, color, digital, paired preoperative and
postoperative images per journal compared. Image characteristics, including
color, brightness, contrast, resolution, view, zoom, size, image labeling, back-
ground, patient clothing, accessories, makeup/tan, facial expression, and hair-
style, were objectively assessed using a five-point Likert scale; mean values were
tabulated and compared among journals; and statistical significance was deter-
mined (p ⬍ 0.05).
Results: The most consistent characteristics among journals included labeling
(4.782) and size (4.867), in contrast to clothing (3.097) and hairstyle (3.724) (p ⬍
0.001). Much variability was also present in color, brightness, and view. Plastic
and Reconstructive Surgery and American Aesthetic Plastic Surgery were the two most
consistent journals when all image characteristics were combined, scoring 4.6
and 4.5, respectively (p ⱕ 0.01).
Conclusions: Standardization of photographic images is essential in plastic
surgery for validity of results. Overall, the authors have demonstrated that much
variability exists for all image characteristics between preoperative and postop-
erative images. Many are crucial to the evaluation of the surgical outcome
depicted. In a specialty with a dramatically increasing trend toward communi-
cation by means of digital imaging, an effort toward standardization is
essential. (Plast. Reconstr. Surg. 120: 1419, 2007.)

F
our categories of assessment tools are avail-
able to determine surgical outcomes, in-
cluding satisfaction indices, objective assess-
ments, psychological profiles, and quality-of-life
measures. Of these, subjective interpretation of
preoperative and postoperative photographs is
the mainstay of grading surgical outcomes in
plastic surgery. Photographs are often evaluated
by surgeons, independent observers, and the pa-
tients themselves and may be considered to re-
flect both patient and surgeon satisfaction. How-
From the Division of Plastic Surgery, Montreal Children’s
Hospital.
Received for publication June 22, 2005; accepted April 2, 2006.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279390.73401.de
ever, the methodology of image presentation in
plastic surgery lacks imposed standardization,
potentially resulting in inconsistency that may
prohibit objective, reproducible interpretation.
If our specialty is to rely on comparison of these
images to evaluate the achieved or intended sur-
gical goal (i.e., to determine whether they accu-
rately reflect surgical change), image consistency
is imperative.
Because of its ease, the use of digital imaging
within plastic surgery has grown exponentially.
Despite this, standardization of image quality
remains essential. The understanding of compo-
sitional characteristics of images will enable their
standardization and use as a more valid outcome
measure. Image acquisition, the actual capture
of the image, which is dependent on camera

www.PRSJournal.com 1419
 Plastic and Reconstructive Surgery • October 2007
model and its settings, is also responsible for
image quality. There are obvious differences ap-
parent in raw images acquired with cameras of
different models because of differences in pro-
cessors. Similarly, changing gray cards, white bal-
ance, resolution, compression, and focal dis-
tance within the same system can result in
inconsistency of image quality. However, these
characteristics should be not altered if the same
system is used by the photographer. Moreover,
assessment of these features by an independent
observer is difficult and reliance on the integrity
of the photographer is key.
Therefore, attempts should be made to limit
variability of image characteristics beyond those
of image acquisition. These include patient fac-
tors, environmental settings, and photographer
and publisher modifications. All can significantly
alter images, reducing the validity and reliability
of their comparison. In plastic surgery, photo-
graphic images are relied on heavily for docu-
mentation, assessing surgical results, teaching or
education, and communication within the
speciality.1 Clearly, there are advantages to stan-
dardizing digital imaging if we are to use them as
an assessment tool to grade our surgical out-
comes in a reliable and valuable manner. Our
objective was to investigate, using a reliable tool,
the consistency of published digital images
within the plastic surgery literature.
METHODS
For evaluation of the consistency of published
paired preoperative and postoperative digital im-
ages, a panel was constructed of four independent
observers. Four prominent plastic surgery journals
were assessed: Aesthetic Plastic Surgery, Aesthetic Surgery
Journal, Plastic and Reconstructive Surgery, and the Brit-
ish Journal of Plastic Surgery. From these journals, 100
consecutive image pairs were chosen from five to 12
journal issues, depending on the number of images
published within each issue. Selection criteria in-
cluded the following: the presence of both preop-
erative and postoperative images, both photographs
within the same field of vision of the observer (on
one page), published in the preceding 2 years (2002
to 2003), and in full color.
Fourteen image characteristics determined us-
ing digital imaging literature and in consultation
with a professional photographer as most relevant
in comparing image quality and consistency were
evaluated. These were grouped into photogra-
pher-dependent criteria (i.e., view, background,
and zoom), publisher-dependent criteria (i.e., size
1420
and image labeling), publisher/photographer-de-
pendent criteria (i.e., color, brightness, contrast,
and resolution), and patient-dependent criteria
(i.e., clothing, accessories, makeup/tan, facial
expression, and hairstyle) (Table 1). In a single-
blinded manner, the panel of observers indepen-
dently compared the consistency of each character-
istic between the images in each image pair using a
five-point Likert scale. The scale was as follows: 1 ⫽
very different, 2 ⫽ different, 3 ⫽ middle, 4 ⫽ similar,
and 5 ⫽ same (Fig. 1). This scale was objectified
as much as possible to increase reliability. For ex-
ample, for accessories, one point from the scale was
deducted for a small item and two points were de-
ducted for a large item that differed between the
preoperative and postoperative images. Further-
more, two small jewelry items counted as one large
item, and so forth. For size, one point was deducted
if the preoperative and postoperative images dif-
fered in size by 10 percent; two points were deducted
for a 20 percent difference, and so on. The remain-
ing categories were scored similarly.
Interobserver reliability was analyzed statisti-
cally for each image characteristic using Spear-
man’s two-tailed correlation for nonparametric
data. Those characteristics found unreliable were
excluded from further analysis. To determine
which image characteristics were most or least con-
sistent among all journals, statistical analysis was
performed using the two-tailed t test for paired
samples. In addition, the t test for equality of
Table 1. Digital Image Characteristics Scored for
Consistency between Preoperative and
Postoperative Images of Each Image Pair
Photographer criteria
● View (particular position, angle, and/or orientation
of the image subject)
● Background (ground or scenery located behind the
image subject)
● Zoom (degree of magnification of the image subject)
Publisher-based criteria
● Size (physical dimensions of the image)
● Image labeling (item or items used to specify parts of
the image)
Publisher/photographer-based criteria
● Color
● Brightness
● Contrast (difference in brightness between the light
and dark areas of an image)
● Resolution (the apparent quality/pixels of the image)
Patient-based criteria
● Patient clothing
● Accessories (supplementary items, including glasses,
earrings, hair bands, and so forth)
● Makeup/tan
● Facial expression
● Hairstyle
Volume 120, Number 5 • Digital Imaging Standardization
Fig. 1. Working sheet used by the panel of observers to score image pair consistency.
means was used to determine the consistency of
image presentation between journals.
RESULTS
Assessment of interobserver reliability re-
vealed that assessment of contrast, clarity/resolu-
tion, and makeup did not adequately correlate
between observers (r ⬍ 0.45) and thus these char-
acteristics were excluded from further analysis.
Table 2 lists average Likert scale values of all ob-
server ratings for each image characteristic, for
each journal. In addition, average journal values
for all characteristics and average image charac-
teristic values for all journals are listed. Most con-
sistent characteristics (except those omitted for
lack of interobserver reliability) between preop-
erative and postoperative images were labeling
(4.78), image size (4.87), and zoom (4.51). Least
consistent characteristics included clothing (3.1),
hairstyle (3.72), and color (3.98). The latter im-
age-pair groups, and brightness, view, and back-
ground, were significantly different between
1421
 Plastic and Reconstructive Surgery • October 2007

*The calculated means of all image characteristics for each journal are included in the final column. The calculated means for each image characteristic for all journals are included in the

Each observer graded the consistency of the paired images on a Likert scale (1 to 5) for each characteristic: †the observers’ mean Likert values for each image characteristic in each journal;
Journal Color Brightness Contrast Resolution Views Labeling Background Accessories Tanning Expression Clothing Hairstyle Size Zoom Mean§
preoperative and postoperative photographs (av-

4.28
4.50
3.00
4.60
erage value, ⬍4.5). In addition, the differences
between most and least consistent characteristics
were statistically significant (p ⬍ 0.001).

4.05
4.77

4.61
4.51
4.6
Aesthetic Surgery Journal and Plastic and Recon-
structive Surgery were the most consistent journals
4.62
4.93
4.94
4.97
4.87
when all image characteristics were combined,
scoring 4.5 and 4.6, respectively. This superior
consistency reached statistical significance (p ⱕ
4.38
4.22
2.17
4.12
3.72 0.01) for all image characteristics apart from

‡the overall Likert mean among the journals for each image characteristic; §the overall Likert mean for each journal including all image characteristics.
color. In both journals, image color, brightness,
patient clothing, and hairstyle were the least con-
3.50
3.99
1.20
3.70

sistent. The British Journal of Plastic Surgery and

3.1

Aesthetic Plastic Surgery scored 4.3 and 3.7, respec-

tively, as noted, significantly less than the other
two journals. In Aesthetic Plastic Surgery, the only
Facial

4.54
4.82
1.80
4.82
4.00

regularly consistent characteristics between im-

BJPS, British Journal of Plastic Surgery; ASJ, Aesthetic Surgery Journal; APS, Aesthetic Plastic Surgery; PRS, Plastic and Reconstructive Surgery.

ages in a pair were labeling and size.

Table 2. Likert Scale Means of All Observer Ratings for Each Image Characteristic for Each Journal*

DISCUSSION
Makeup/

4.87
4.44
4.30
4.57
4.55

The first medical image was produced in 1845

by Alfred Donne using a daguerreotype process
where a direct positive method created a detailed
image on a sheet of copper coated with silver
Jewelry/

4.68
4.65
4.05
4.59
4.49

halides.2 It was then at the First International Con-

gress of Plastic Surgery that Gillies stated that pho-
tography was the single most important advance-
ment to the speciality.3 However, it was not until
years later that the first digital photography was
3.58
4.63
3.95
4.42
4.14

made available by Sony and their Promavica mag-

netic videocamera.2 Digital photography has since
undergone significant growth and evolution.
Currently, digital imaging in medicine offers
4.75
4.84
4.67
4.84
4.78

many advantages over standard 35-mm photog-

raphy, including decreased costs of high-quality
images, archiving and retrieving ease, improved
3.79
4.57
4.45
4.62
4.36

communication, patient education, and computer

simulation.3 Other notable advantages are improved
database organization, permanence, possibility of
Clarity/

4.57
4.60
4.44
4.67
4.57

immediate review, editing, labeling, copying, and

Internet transmission.3,4
Continued growth and refinements of digital
imaging will undoubtedly allow for increased ac-
4.32
4.41
4.25
4.57
4.39

ademic application. Already, evaluation of preop-

erative and postoperative published digital images
has become the mainstay of grading outcomes in
plastic surgery. Galdino et al. suggest that this will
4.01
4.15
4.04
4.19
4.10

be accompanied by better clinical outcome, re-

search, and education.3 This, however, is contin-
gent on a high level of quality and consistency of
4.17†

images presented.
3.96
3.91
3.88
3.98

Despite early guidelines for use of preoperative

final row.

and postoperative photography,5 increased pressure

Mean‡

for standardization of techniques led to the devel-

BJPS

APS
PRS
ASJ

opment of a clinical photographic committee within

1422
Volume 120, Number 5 • Digital Imaging Standardization
the Plastic Surgery Educational Foundation in
1991.6 In parallel, Talamas and Pando in 2001 set
forth guidelines to achieve comparable preoperative
and postoperative 35-mm images, which are also
applicable to digital imaging.7 The strict guidelines
to promote image consistency are even more essen-
tial in this arena, as the ability to change and distort
digital images is evident. The applicability and level
of adherence to these guidelines has not been pre-
viously investigated.
First, there must be an understanding of vari-
ables that affect the photograph’s quality and con-
sistency, other than those related to image acqui-
sition. Camera processor and settings will partly
affect brightness, contrast, color, and overall im-
age quality; their regularity rests on the integrity of
the photographer. Other factors, including light-
ing, patient positioning, zoom, and postacquisi-
tion processing can dramatically influence the re-
sult and give false impressions when altered.
Our objective was to determine the consis-
tency of published images in the plastic surgery
literature to assess the validity of this outcome
measurement tool. A panel of four independent
observers graded the consistency of 14 character-
istics of images published in major plastic surgery
journals using a five-point Likert scale.
The results reveal an overall poor consistency
between preoperative and postoperative images.
Characteristics essential to reliable clinical outcome
assessment, including color (3.98), brightness (4.1),
views (4.36), background (4.14), patient clothing
(3.1), and hairstyle (3.72), were significantly differ-
ent between the paired images in all journals. Dis-
similarities in color, brightness, and contrast may
hinder accurate appreciation of image details. Dif-
ferent views, backgrounds, patient clothing, and
hairstyle can mask and divert attention away from
areas important for proper evaluation of the result.
In contrast, image labeling (4.78), size (4.87), and
zoom (4.51) were on average significantly the same
between paired images. These criteria are more eas-
ily controlled by the publisher and thus their uni-
formity is not surprising. Plastic and Reconstructive
Surgery and Aesthetic Surgery Journal were the most
consistent when all image characteristics were com-
bined. Surprisingly, Aesthetic Plastic Surgery scored the
lowest overall consistency rating. These results may
reflect stricter publication criteria of the American
plastic surgery literature.
In view of these findings, we feel that consis-
tency in digital image characteristics must be im-
proved if these are to be used as valid outcome
measures. At present, there exist important dis-
crepancies that can potentially alter true interpre-
tation of the results. Maintenance of constant cam-
era settings, no post–image acquisition changes
using computer software, and use of identical
views and patient preparation will significantly in-
crease standardization. Creation and imposition
of strict digital photography guidelines that con-
trol all image characteristics will significantly en-
hance the potential of these images to objectively
illustrate treatment success while aiding in the
evaluation of case studies where standard photo-
graphic approaches are used.
Marcin Czerwinski, M.D.
Division of Plastic Surgery
Montreal Children’s Hospital
2300 Tupper Street, C1139
Montreal, Quebec H3G 1P3, Canada
marcin.czerwinski@mail.mcgill.ca
ACKNOWLEDGMENT
The authors acknowledge Sebastien Dube of the
Montreal University Health Centre Statistics Department
for assistance in performing the statistical analysis.
DISCLOSURES
The authors of this article do not have any financial
interest in any of its contents. The authors do not have
any commercial associations, and no sources of funds
were used in the creation of the article.
REFERENCES
1. Galdino, G. M., Vogel, J. E., and Vander Kolk, C. A. Stan-
dardizing digital photography: It’s not all in the eye of the
beholder. Plast. Reconstr. Surg. 108: 1334, 2001.
2. Papier, A., Peres, M. R., Bobrow, M., and Bhatia, A. The digital
imaging system and dermatology. Int. J. Dermatol. 39: 561,
2000.
3. Galdino, G. M., Swier, P., Manson, P. N., and Vander Kolk, C.
A. Converting to digital photography: A model for a large
group or academic practice. Plast. Reconstr. Surg. 106: 119,
2000.
4. DiSaia, J. P., Ptak, J. J., and Achauer, B. M. Digital photography
for the plastic surgeon. Plast. Reconstr. Surg. 102: 569, 1998.
5. Thomas, J. R., Tardy, M. E., Jr., and Przekop, H. Uniform
photographic documentation in facial plastic surgery. Otolar-
yngol. Clin. North Am. 13: 367, 1980.
6. DiBernardo, B. E., Adams, R. L., Krause, J., Fiorillo, M. A., and
Gheradini, G. Photographic standards in plastic surgery. Plast.
Reconstr. Surg. 102: 559, 1998.
7. Talamas, I., and Pando, L. Specific requirements for preop-
erative and postoperative photos used in publication. Aesthetic
Plast. Surg. 25: 307, 2001.
1423

It’s Okay to Say “I’m Sorry”
Rod J. Rohrich, M.D.
Dallas, Texas
An apology reminds us that each person (in-
cluding ourselves) deserves to be and treated
fairly.
—Beverly Engel
E
ver since I was a resident, I had been per-
plexed that we were ingrained to be empa-
thetic but not to admit that we, as physi-
cians, are human and thus could say we are sorry
to ourselves and, more importantly, to our pa-
tients. It was frowned upon to say to our patients,
“I’m sorry you have cancer. I’m sorry that I can’t
cure you. I’m sorry that the procedure did not
work.” I have always felt I could not be com-
pletely forthright with my patients in this impor-
tant area during my surgery training and devel-
opmental years.
We all make errors in life and in our practices,
although eventually, as mature practicing sur-
geons, these become more minor and almost
inconsequential. Nevertheless, we always learn so
much from them; we alter our surgical tech-
nique, how we treat patients, and how we teach
our residents—all by the lessons learned from
our past mistakes or errors in judgment.
It is this new culture of “self-effacement and
positive feedback,” which signals an enormous
step in enhancing patient safety and error pre-
vention, that is, it is hoped, going to replace the
culture of “blame and punishment” that sur-
rounds health care today. The current climate
has largely been ingrained in our profession in
our country by our immensely overburdening
legal climate. National tort reform will be man-
datory to make this culture disappear eventually.
In the interim, we must learn to say “I’m sorry”
with some qualification, depending on the state
or county in which we reside!
SCENARIO A: 1997
A carefully selected middle-aged patient un-
dergoes plastic surgery to correct eyelid ptosis.
Postoperatively, the eyelid is too low. After revision
surgery, the eyelid is once again too low; a third
surgery is needed. Adhering to hospital, malprac-
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000244302.03603.cd
www.PRSJournal.com
EDITORIAL
tice insurance, and state medical association
guidelines, the surgeon offers only to conduct a
third surgery. No statement of apology, regret, or
personal responsibility comes from either the sur-
geon or the hospital. The angry patient sues and
eventually obtains a large settlement. Disgruntled,
the patient finds a new surgeon and undergoes a
third surgery that corrects the original problem.
SCENARIO B: 2007
A carefully selected middle-aged patient un-
dergoes plastic surgery to correct eyelid ptosis.
Postoperatively, the eyelid is too low. After revision
surgery, the eyelid is once again too low; a third
surgery is needed. Adhering to new hospital, mal-
practice insurance, and state medical association
guidelines, the surgeon says “I’m sorry” to the
patient. The surgeon does not admit to making a
mistake but, after careful review of the case, fully
and immediately discloses the problem to the pa-
tient. The surgeon fosters the relationship already
established between him- or herself and the pa-
tient, suggests a third surgery, and retains a satis-
fied patient after a third (and successful) opera-
tion. There is no lawsuit, no settlement, and no
lingering anger in the patient.
THE “I’M SORRY” MOVEMENT: IT’S
BECOMING OKAY TO SAY “I’M SORRY”
The second of the above two scenarios is based
on a true story.1 It is one of many stories in the “I’m
sorry” movement in medicine in the United States.
This movement empowers doctors to promptly
and fully inform patients of errors, mistakes, or
complications and, when appropriate, to apolo-
gize to the patient. The movement recognizes that
many patients initiate malpractice litigation not
out of greed but because they are angry at a phy-
sician’s abrasive manner and failure to apologize
for a medical mistake or bad outcome.2 Apologies
may help dissipate patient anger and avoid
lawsuits.1
The “I’m sorry” movement, alternatively called
the “disclosure and apology” movement, has
moved rapidly throughout the healthcare system
in the last few years. In 2005, at least 15 state
legislatures had passed legislation saying that doc-
tors’ apologies may not be used against them in
1425
 Plastic and Reconstructive Surgery • October 2007
court.2 By 2007, the number had grown to at least
27.1 In addition to legislatures passing legislation
to protect the admission of physician mistakes at
the state level, many medical schools and hospitals
are adopting policies requiring that doctors and
other healthcare providers promptly disclose er-
rors and apologize to patients and families when
warranted.3
“The Sorry Works! Coalition” (www.sorryworks.
net) is a nonprofit collaboration of doctors, attor-
neys, insurance providers, and patient advocates
begun in 2005 by Doug Wojcieszak, whose brother
died after a medical error in 1998. The coalition
coordinates state programs and insurance com-
panies to offer complete disclosure and apologies.
Their protocol entails healthcare providers and
their insurers to apologize if a review indicates that
an error took place or a standard of care wasn’t
met. As appropriate, fault is admitted, explana-
tions of what happened are given, a plan to avoid
similar errors in the future is made, and compen-
sation is offered on a proactive basis.”3
THE DEBATE OVER AN APOLOGY
Not everyone is in agreement over the “I’m
sorry” movement in medicine. On one side, de-
fense attorneys and malpractice insurance com-
panies across the country argue that any hint at a
doctor apology is an essential admission of guilt if
the patient files a malpractice suit. Traditionally,
hospitals and our training programs have in-
grained into doctors and residents a policy of “de-
fend and deny”; patients have faced walls of silence
and denials after encountering mistakes made by
their doctors. Even blatant mistakes (administer-
ing wrong medications, operating on the incorrect
side of the patient’s body, leaving surgical instru-
ments inside a patient after a surgery, and so on)
have often been dismissed, treated as unimpor-
tant, or left undiscussed with patients.
In a more moderate position, some states
(such as Vermont) allow oral statements of regret
or apology to be given to patients but not written
apologies (because written apologies constitute
liability on behalf of the physician). Illinois pro-
vides doctors a 72-hour time period to apologize
after they learn about a medical mistake. Pro-
Mutual Group, a malpractice insurance group that
insures 18,000 doctors, dentists, and healthcare
facilities in the Northeast, warns clients against
making apologies that admit guilt. It distributes
information to doctors against using the words
“error,” “mistake,” “fault,” and “negligence”; apol-
ogies should relate to the outcome, not necessarily
1426
to any errors that may have occurred. In other words,
an apology is not a confession or admission.1
On the other side of the debate is the group
that believes that apologies are more helpful than
not and should be encouraged. In an MSNBC poll,
82 percent of respondents thought that a doctor
who said “I’m sorry” when a medical procedure
didn’t go as planned would help the doctor-pa-
tient relationship and alleviate bad feelings.1 An-
ecdotes from patients indicate that a compassion-
ate, gentle, and honest apology from a doctor can
go a long way toward dissipating their anger. More
quantitative data on promoting doctor apologies
come from two studies. One malpractice insurer
in Denver that promoted apologies and quick set-
tlements among a group of physicians made av-
erage settlement payments of $6,000, compared
with average settlements of $284,000 to patients of
doctors who were not in the program.2 In a second
example, the University of Michigan Health Sys-
tem adopted new policies that encourage full dis-
closure of errors and apologies to patients when
appropriate. Since implementation of the new
policies in July of 2001, the number of pending
malpractice claims and lawsuits has dropped from
260 to less than 100, with the average legal expense
per case down more than 50 percent.3 These two
programs offer evidence that a policy of apology
can be financially and legally advantageous.
THE VALUE OF AN APOLOGY
Offering a warranted apology in the face of a
medical mistake certainly can mitigate legal and
financial costs for physicians. Beyond these costs
in terms of money and time, however, there are
additional benefits to the making of a fitting apol-
ogy. First, every surgeon is human and occasion-
ally makes a mistake (albeit rarely) or encounters
a disappointing result. Thus, admitting to our own
humanity and mistakes is simply honest, simply
human, and simply humane. Admissions of our
humanity, second, help (rather than hurt) the
patient-doctor relationship. Every patient who un-
dergoes surgery explicitly places his or her trust in
the surgeon. The patient trusts that the surgeon
will perform his or her absolute best on the day of
surgery, even if that “best” is not quite good
enough to avoid every conceivable mistake. If a
mistake or suboptimal outcome does occur, the
patient trusts the doctor to own up to it, to be
honest with him or her. Admission of mistakes or
a complication enables the patient and doctor to
continue to work together toward a mutually sat-
isfying conclusion rather than placing them at
odds.
Volume 120, Number 5 • Editorial
Third, saying “I’m sorry” facilitates learning.
The best teachers become successes because they
learn and benefit from their failures and mistakes.
Identifying, admitting to, analyzing, and correct-
ing mistakes serves as a powerful cycle of learning.4
Rather than spend time and effort on denying or
covering up a mistake, it is highly valuable to learn
from it, in order to avoid mistakes in the future.
Learning from the frank admission of mistakes
and errors has also received a mandate from the
U.S. government. The Patient Safety and Quality
Improvement Act of 2005 encourages the report-
ing of medical errors to a patient safety organiza-
tion without fear of reprisal.5 This law was written
to help transform the “culture of blame and pun-
ishment” surrounding healthcare errors into one
of “open communication and prevention.” Not
only does it foster improved delivery of health
care, it also is intended to improve patient safety
in the long run.
Providing ever-improving care for our patients
is one of the superintending goals of all plastic
surgeons and, indeed, of all physicians. Admitting
to mistakes, and saying “I’m sorry” when war-
ranted, is an integral element in aspiring to that
goal. An apology helps us focus on our patients
and our relationship with them rather than on
Contacting the Editorial Office
To reach the Editorial Office, please use the following contact information:
Plastic and Reconstructive Surgery
Rod J. Rohrich, M.D., Editor-in-Chief
St. Paul’s Hospital
5909 Harry Hines Boulevard
Room HD01.544
Dallas, Texas 75235-8820
Tel: 214-645-7790
Fax: 214-645-7791
E-mail: PRS@plasticsurgery.org
defending our pride. Apologies facilitate learning
and refinement of our art and science as we serve
others. It is okay to say, “I’m sorry.”
When you realize you’ve made a mistake,
make amends immediately. It’s easier to eat
crow while it’s still warm.
—Dan Heist
Rod J. Rohrich, M.D.
Editor-in-Chief
University of Texas Southwestern Medical Center
5909 Harry Hines Boulevard, HD01.544
Dallas, Texas 75235-8820
rjreditor_prs@plasticsurgery.org
REFERENCES
1. States making it safer for doctors to say “sorry”: Apologizing
isn’t always allowed, but can defuse anger, avoid lawsuits.
MSNBC. April 11, 2007. Available at www.msnbc.msn.com/
id/18059841/. Accessed April 11, 2007.
2. When doctors say “I’m sorry.” Hartford Courant September 2,
2005. Available at www.sorryworks.net. Accessed May 1, 2007.
3. Landro, L. Doctors learn to say “I’m sorry”: Patients’ stories of
hospital errors serve to teach staff. Wall Street Journal January
24, 2007. P. D5.
4. Rohrich, R. J. “See one, do one, teach one”: An old adage with
a new twist. Plast. Reconstr. Surg. 118: 257, 2006.
5. Rohrich, R. J. Patient safety and quality improvement act of 2005:
What you need to know. Plast. Reconstr. Surg. 117: 671, 2006.
1427
EDITORIAL
Our Complication, Your Problem
Steven P. Davison, D.D.S.,
M.D.
Wajhma Massoumi, M.D.
Washington, D.C.
I
n reading the Journal and teaching residents,
we have sensed a disturbing trend with regard
to complications. There is an invisible line be-
tween those complications for which surgeons take
ownership and the rest, which are the patients’
“fault.” In the first group, we include hematomas,
wound infections, dehiscence, flap necrosis, and
scars. More disturbing are the complications in the
second group, such as stroke, myocardial infarc-
tion, and thromboembolism. This was emphasized
to us personally when we were compiling our
monthly morbidity and mortality list. We inadver-
tently omitted a postoperative death of a healthy
49-year-old patient who died of a cardiac event 17
days after an otherwise successful outpatient Mohs’
reconstruction. The omission was rectified the
next month, but it illustrates our point. Could our
patient have had a myocardial infarction without
surgery? Certainly. Was it related to anesthesia?
Probably.
As we have a keen interest in thromboembo-
lism, having written reviews and taught courses
on the subject, we thought it the best complica-
tion on which to elaborate. Thromboembolism
is a good example of a complication that the
patient “gets.” It is nonsurgical, is related to
perioperative stasis, and occurs even in medical
patients. To make matters worse, its treatment or
prophylaxis increases the risk of the surgical
complication of bleeding.
Thromboembolism is like a big white elephant
for plastic surgery. As so much of our care is
elective, part of our election should be to protect
the patient from subsequent harm. Yet since the
risk of prophylaxis is bleeding, the balance is
weighted away from thromboembolism protec-
tion. A recent survey showed that 60 percent of
American Society for Aesthetic Plastic Surgery
members believe that chemoprophylaxis is not
From the Division of Plastic Surgery, Georgetown University
Hospital.
Received for publication January 25, 2007; accepted Janu-
ary 26, 2007.
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279376.12476.b4
1428 www.PRSJournal.com
worth the risk. Yet from the same study, 7.8
percent of surgeons had experienced an episode
of deep venous thrombosis in at least one patient
in a 3-month period.1 Extrapolated over a period
of 12 months, the incidence rate is 31.2 percent
that a surgeon will have at least one case of deep
venous thrombosis each year. Another survey of
board-certified plastic surgeons published in
Plastic Surgery News in January of 2007 gave sim-
ilarly disturbing results. Despite surgeon experi-
ence of thromboembolism and associated mor-
tality rates, as high as 13 percent and 3 percent,
respectively, in combined procedures, prophy-
laxis was sporadic. No prophylaxis was utilized in
18.4 percent of face lifts, 25.2 percent of liposuc-
tion procedures, and 8.6 percent of combined
procedures. Only 48.7 percent of surgeons per-
forming face lifts, 43.7 percent of those perform-
ing liposuction, and 60.8 percent of surgeons
performing combined procedures used prophy-
laxis all the time. This means that, in essence,
prophylaxis was utilized less than 50 percent of
the time. The survey found enormous variation,
inconsistency, and deviation from practice
norms for patients managed by plastic surgeons
after thromboembolism was diagnosed.
Since developments in European plastic sur-
gery can be ahead of the curve (e.g., vertical scar
reduction, cohesive gel implants, and liposuc-
tion), a recent article should be mentioned. Pe-
ter Durnig and Walther Jungwirth2 reported a
series of face lift patients treated with low molec-
ular weight heparin, stating that there is signifi-
cant pressure for prophylaxis in Europe. This
retrospective review showed a statistically signif-
icant increase in bleeding in face lift patients
treated preoperatively with low molecular weight
heparin prophylaxis. However, before this article
is used as a torch to champion that prophylaxis is
indeed too great a risk, there are important neg-
atives to the conclusions that should be consid-
ered. First, there was no risk stratification or
selective prophylaxis. Second, the dose was pre-
operative, a regimen that is recommended in the
United States only for the highest-risk patients
(80 percent deep venous thrombosis rate), such
Volume 120, Number 5 • Editorial
as those undergoing joint replacement. In the
working algorithm, Davison, the first author of
this editorial, proposed a postoperative dose of
low-molecular-weight heparin 12 hours after sur-
gery, for a substantially decreased bleeding risk.3
Two recent articles on patient safety touch on
thromboembolism. Clayman and Seagle exam-
ined Florida office-based safety data.4 Only 11
deaths out of 600,000 procedures were attribut-
able to plastic surgeons, yet seven of the 11
deaths (or 64 percent) were due to thromboem-
bolism. In their recent review of circumferential
body contouring, Rohrich et al.’s only major
complication was thromboembolism in 2 per-
cent of the patient group.5 In recent discussions,
eminent cosmetic surgeons Stuzin6 and Mustoe7
reported no deep venous thrombosis in 600 face
lifts or 3000 outpatient procedures, respectively,
yet both emphasized that they use only intrave-
nous sedation and not general anesthesia. This is
one of the known prophylactic measures for
thromboembolism.
Certain patient populations have considerably
greater risk for this type of complication. We
cannot categorize all plastic surgery patients or
procedures into one group. A higher risk with
abdominoplasty, especially abdominoplasty com-
bined with other procedures, is being revealed.4,8
Despite a very high acuity for deep venous
thrombosis risk and prophylaxis, we experienced
three thromboembolic complications in 570 op-
erations in the last year. Our population group
was a higher-risk group than the average surgeon
sees, but it underscores the need for apprecia-
tion of this problem. Every surgeon needs to
understand the risk and utilize a rational regi-
men based on the science as we have rather than
on a fear of hematomas, whether that regimen
be intravenous sedation, sequential compression
devices, or anticoagulation in the highest-risk
patient.
A hematoma is a medical stress, an inconve-
nience, an embarrassment, or an additional pro-
cedure, but rarely does it kill a patient. Throm-
boembolism that progresses to a pulmonary
embolism kills the patient 50 percent of the
time.9,10 Let’s not think of a hematoma as a
complication the surgeon causes and a throm-
boembolism as a complication the patient ac-
quires. As a specialty, we should do everything
possible to maximize patient safety. When we do
have a patient who “gets” this complication, let’s
involve consultants to assist in treatment.
Steven P. Davison, D.D.S., M.D.
Division of Plastic Surgery
Georgetown University Hospital
3800 Reservoir Road NW
Washington, D.C. 20007-2113
spd2@gunet.georgetown.edu
WXM108@gunet.georgetown.edu
DISCLOSURE
The authors have no financial interests to disclose.
REFERENCES
1. Spring, M. A., and Gutowski, K. A. Venous thromboembolism
in plastic surgery patients: Survey results of plastic surgeons.
Aesthetic Surg. J. 26: 522, 2006.
2. Durnig, P., and Jungwirth, W. Low molecular weight heparin
and postoperative bleeding in rhytidectomy. Plast. Reconstr.
Surg. 118: 502, 2006.
3. Davison, S. P. Prevention of venous thromboembolism in the
plastic surgery patient. Plast. Reconstr. Surg. 114: 43e, 2004.
4. Clayman, M. A., and Seagle, B. M. Office surgery safety: The
myths and truths behind the Florida Moratoria–-Six years of
Florida data. Plast. Reconstr. Surg. 118: 777, 2006.
5. Rohrich, R. J., Gosman, A. A., Conrad, M. H., and Coleman,
J. Simplifying circumferential body contouring: The central
body lift evolution. Plast. Reconstr. Surg. 118: 525, 2006.
6. Stuzin, J. M. Low-molecular weight heparin and postopera-
tive bleeding in rhytidectomy (Discussion). Plast. Reconstr.
Surg. 118: 508, 2006.
7. Mustoe, T. A. Abdominoplasty: A comparison of outpatient
and inpatient procedures shows that it is a safe and effective
procedure for outpatients in an office-based surgery clinic
(Discussion). Plast. Reconstr. Surg. 118: 523, 2006.
8. Broughton, G., II, Rios, J. L., Rohrich, R. J., and Brown, S. A.
Deep venous thrombosis prophylaxis practice and treatment
strategies among plastic surgeons: Survey results. Plast. Re-
constr. Surg. 119: 157, 2007.
9. Van Uchelen, J. H., Werler, P. M., and Kon, M. Complications
of abdominoplasty in 86 patients. Plast. Reconstr. Surg. 107:
1869, 2001.
10. Caprini, J. A., Arcelus, J. I., and Rayna, J. J. Effective risk strat-
ification of surgical and nonsurgical patients for venous throm-
boembolic disease. Semin. Hematol. 38(2 Suppl. 5): 12, 2001.
1429
REVIEWS
A s a service to our readers, Plastic and Recon-
structive Surgery® reviews books, DVDs, prac-
tice management software, and electronic media
items of educational interest to reconstructive
and aesthetic surgeons. All items are copyrighted
and available commercially. The Journal actively
solicits information in digital format (e.g., CD-
ROM and Internet offerings) for review.
Reviewers are selected on the basis of relevant
interest. Reviews are solely the opinion of the
reviewer; they are usually published as submit-
ted, with only copy editing. Plastic and Reconstruc-
tive Surgery® does not endorse or recommend
any review so published. Send books, DVDs, and
any other material for consideration to: Jack A.
Friedland, M.D., Review Editor, Plastic and Recon-
structive Surgery, UT Southwestern Medical Cen-
ter, 5323 Harry Hines Boulevard, HD1.544, Dal-
las, Texas 75390-8820.
Jack A. Friedland, M.D.
Review Editor
Local Flap Reconstruction: A Practical
Approach
By Anthony J. Penington. Pp. 280. McGraw Hill Publishing
Co., Sydney, Australia. 2006. Price: $195.
D r. Penington’s text-
book, Local Flap Recon-
struction: A Practical Ap-
proach, is an important
contribution to a subject
with comparatively few
textbooks. The oversize
book consists of more than
70 photographic case stud-
ies with results, including
more than 300 color pho-
tographs. The textbook it-
self is divided into three
sections–-Part A: Principles, Part B: Case Studies,
and Part C: Common Problems and Solutions–-
that cover not only head and neck reconstruc-
tion but also extremity and trunk reconstruction.
The first section, Principles, describes clearly
the thoroughly skilled and thoughtful author’s
approach to patient care and flap selection. He
then addresses the pertinent anatomic and phys-
iologic principles of flap orientation and design,
and then proceeds to describe the basic flaps.
Even in this section, there are multiple clinical
illustrations, and the line drawings are uniformly
excellent.
Copyright ©2007 by the American Society of Plastic Surgeons
1430 www.PRSJournal.com
Part B, Case Studies, is composed of six differ-
ent chapters. The first two describe flaps and
continuity and island flaps, and the remaining
four cover specific anatomic subsections, includ-
ing the nose, lip, eyelid, and ear. For each chap-
ter, there are seven to 18 richly photographed,
illustrated cases with preoperative, intraopera-
tive, and postoperative photographs. The last
section, Common Problems and Solutions, is a
single chapter with eight sections.
The entire book comprises a 2-year case col-
lection by a single author. Dr. Penington took
great effort to show illustrative workhorse cases,
not simply one-of-a-kind cases. By his own admis-
sion, this book is intended to be not a compre-
hensive selection of techniques to cover all situ-
ations but rather an example of tried and true
procedures that will work reliably.
The real beauty of this book lies in the photo-
graphs. All are uniform and of good quality. The
majority were taken by a dedicated photogra-
pher. The all-important follow-up photographs
are also included.
My criticisms are few. The illustrations and re-
sults for nasal reconstruction are not terribly so-
phisticated, and the beginning practitioner would
benefit by studying the techniques of established
nasal reconstruction masters, such as Burget, Menick,
and Rohrich. At times, Penington is somewhat overly
reliant on V-Y flap advancements. There are numer-
ous illustrations of V-Y flap advancement to the
point where a different technique would perhaps
have provided superior results. Finally, there is no
discussion of dermabrasion, although judicious
use of postoperative dermabrasion would have im-
proved nearly all of the results.
This textbook was a pleasure to read. The
photographic layout and results are uniformly
excellent. Local Flap Reconstruction: A Practical Ap-
proach will be a valuable edition to any library.
DOI: 10.1097/01.prs.0000280563.87667.0a
James Thornton, M.D.
Surgical Management of Vitiligo
Edited by Somesh Gupta, Mats J. Olsson, Amrinder J.
Kanwar, and Jean-Paul Ortonne. Pp. 304. Blackwell Pub-
lishing, Malden, Mass., 2006. Price: $179.95.
V itiligo is a cosmetically debilitating, depig-
menting condition that has long intrigued
researchers and physicians worldwide. Fortu-
nately, it is a relatively rare condition; unfortu-
nately, treatment is rarely uniformly successful.
During the last two decades, outstanding new
therapies have emerged to treat it. Professors
Volume 120, Number 5 • Reviews

Somesh Gupta, Mats J. Ol-
sson, Amrinder J. Kanwar,
and Jean-Paul Ortonne
are to be commended for
amassing a comprehen-
sive, 38-chapter textbook
exploring the surgical
management of vitiligo.
This text represents the re-
search and scientific stud-
ies of 48 experts from 13
countries. They provide a
concise description and overview of the disease.
All of the treatment topics presented deal with
the surgical management of vitiligo, which goes
beyond the typical medical therapies seen in
most dermatological practices.
The text begins with an explanation of the
pathogenesis of vitiligo and then launches into
an impressive breadth of specific surgical op-
tions. Section 3 devotes nine chapters to tissue
grafting, while section 4 encompasses six
equally impressive chapters on cellular graft-
ing. No textbook is perfect, and multiauthored
ones can be uneven in consistency. This text
lacked substantial information on excimer la-
sers, one of the few treatments that have some
success in repigmenting patches of vitiligo. Al-
though excimer lasers are a widely accepted
option, they are mentioned only briefly in the
final section, under Miscellaneous.
Overall, the book provides organized, well-
written, and well-referenced chapters that provide
insight for physicians as to what surgical modalities
are available for vitiligo. Most importantly, it offers
hope for patients that alternatives exist for their
disfigurement. We believe, however, that it is prob-
ably a rare situation where one would encounter a
patient with vitiligo who requires surgical interven-
tion, such as skin grafting or melanocyte transplan-
tation. Ironically, the future may arise from the
skin itself. Stem cell technology in rodents has
been successful in reprogramming new adult skin
cells to embryonic form, by way of inserting four
genes into a mature skin cell.
Surgical Management of Vitiligo provides a fine,
comprehensive review of this disfiguring disease,
though the need for surgical treatment or for a
plastic surgeon to incorporate this into his or her
practice is likely to be rare. While it provides a
brilliant summary of surgical options, the book
more likely serves as a handy reference for der-
matologists and plastic surgeons, offering the
ability to educate patients about the other treat-
ment options for this disease.
DOI: 10.1097/01.prs.0000280564.25786.bf
Gervaise L. Gerstner, M.D.
Alan Matarasso, M.D.

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endorses, these services. Their use does not guarantee acceptance of a manuscript for publication.

1431
LETTERS
GUIDELINES
Letters to the Editor, discussing
material recently published in
the Journal, are welcome. They
will have the best chance of ac-
ceptance if they are received
within 8 weeks of an article’s pub-
lication. Letters to the Editor
may be published with a re-
sponse from the authors of the article being discussed.
Discussions beyond the initial letter and response will not
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Discussions of articles will not be printed. Letters to the
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All Letters are published at the discretion of the Editor.
Authors will be listed in the order in which they appear in
the submission. Letters should be submitted electronically
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We reserve the right to edit Letters to meet requirements
of space and format. Any financial interests relevant to the
content of the correspondence must be disclosed. Submis-
sion of a Letter constitutes permission for the American
Society of Plastic Surgeons and its licensees and asignees to
publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the
Letters to the Editor represent the personal opinions of the
individual writers and not those of the publisher, the Edi-
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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 Editorial Board,
and the sponsoring organizations assume no responsibility
for the content of such correspondence.
The Zygomatic-Orbital Artery
Sir:
I read the article by Beheiry and Abdel-Hamid entitled
“An Anatomical Study of the Temporal Fascia and
Related Temporal Pads of Fat.”1 I would like to em-
phasize the anatomical presence of the zygomatic-
orbital artery as a branch of the superficial temporal
artery. I reviewed the literature after my coauthors
and I published “The Forehead Zygomatic-Orbital
Artery–Based Island Flap,”2 and I found this new
article and another by Pinar and Govsa3 citing the
zygomatic-orbital artery. Although I am aware of the
infrequent use of the zygomatic-orbital artery as an
axial artery of the frontotemporal flap, it is important
that future clinical investigations take into account
the opportunities offered by this artery. Along these
lines, it was very interesting to see how much larger
the caliber of the zygomatic-orbital artery is even
compared with the frontal branch in the authors’
Figure 7, which shows the cadaver vascular anatomy
of the temporal region.1 The zygomatic-orbital artery
was found to be absent in 9.1 percent of 22 cadaver
Copyright ©2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000279466.17039.b4
1432 www.PRSJournal.com
specimens, in accordance with the 8 percent of 50
Doppler investigations reported in our study.2
Pinar and Govsa3 reported that in six of 27 spec-
imens (22.2 percent), the zygomatic-orbital artery
was absent, whereas in 21 of 27 specimens (77.8
percent), it ran toward the face, parallel to the zy-
gomatic arch and distributed in the orbicularis mus-
cle. The second value is close to our 72.7 percent.
Unfortunately, the supraorbital terminal segment is
still neglected in anatomical and radiological studies.
The only information showing that the zygomatic-or-
bital artery reaches the frontal territory in 35 percent
is that revealed in our study.2
I think the inconsistent presence of the zygomatic-
orbital artery should not dissuade researchers from
extending the study in the fronto-orbital territory or
surgeons from trying to harvest a flap based on it,
especially if we consider that the frontal branch of the
superficial temporal artery can also be absent in 8 per-
cent, according to Marano et al.4
DOI: 10.1097/01.prs.0000279452.24685.d7
Egidio Riggio, M.D.
Division of Plastic and Reconstructive Surgery
Fondazione I.R.C.C.S. Istituto Nazionale Tumori
Via G. Venezian 1
Milan 20133, Italy
egidio.riggio@istitutotumori.mi.it
REFERENCES
1. Beheiry, E. E., and Abdel-Hamid, F. A. M. An anatomical
study of the temporal fascia and related temporal pads of fat.
Plast. Reconstr. Surg. 119: 136, 2007.
2. Riggio, E., Spano, A., and Nava, M. The forehead zygomatic-
orbital artery– based island flap. Plast. Reconstr. Surg. 115: 226,
2005.
3. Pinar, Y. A., and Govsa, F. Anatomy of the superficial tem-
poral artery and its branches: Its importance for surgery. Surg.
Radiol. Anat. 16: 248, 2006.
4. Marano, S. R., Fischer, D. W., Gaines, C., and Sonntag,
V. K. Anatomical study of the superficial temporal artery.
Neurosurgery 16: 786, 1985.
Reply
Sir:
I appreciate Dr. Riggio’s interest in studying the
zygomatico-orbital artery as a substitute pedicle for the
forehead flap, especially in cases of an absent or small-
caliber frontal branch of the superficial temporal ar-
tery, as reported by Marano et al.1 However, certain
points should be considered; in our research, my
coauthors and I reported the presence (not the ab-
sence, as he mentioned) of the zygomatico-orbital
artery in 9.1 percent of specimens (four of 44). This
percentage referred to the zygomatico-orbital artery
arising from the main trunk of the superficial tem-
poral artery in 44 cadaver dissections. It may pass
toward either the lateral angle of the eye2 or the
forehead region.3,4
Dr. Riggio reported that the zygomatico-orbital ar-
tery crossed the zygomatic arch either to reach the
Volume 120, Number 5 • Letters
superciliary region in 16 out of 46 specimens or to stop
at the lateral canthus in 17 out of 46 specimens (in total,
33 out of 46, or 71.7 percent, not 72.7 percent).
The zygomatico-orbital artery was reported by Pinar
and Govsa4 to arise from the frontal branch of the
superficial temporal artery in samples where the bifur-
cation point of the superficial temporal artery was over
the zygomatic arch (Figs. 2, 3, and 5), as the authors
mentioned. However, in Figures 2 and 5 the zygo-
matico-orbital artery was absent and in Figure 3 it arose
from the main trunk of the superficial temporal artery,
not from its frontal branch!
DOI: 10.1097/01.prs.0000279453.10376.71
Eman Elazab Beheiry, M.B.Ch.B., M.Sc., Ph.D.
Department of Anatomy and Embryology
Alexandria University School of Medicine
Alexandria, Egypt
Correspondence to Dr. Beheiry
155 Teeba Street
Sporting
Alexandria 21521, Egypt
emanazab@yahoo.com
REFERENCES
1. Marano, S. R., Fischer, D. W., Gaines, C., and Sonntag,
V. K. Anatomical study of the superficial temporal artery.
Neurosurgery 16: 786, 1985.
2. Beheiry, E. E., and Abdel-Hamid, F. A. M. An anatomical
study of the temporal fascia and related temporal pads of fat.
Plast. Reconstr. Surg. 119: 136, 2007.
3. Riggio, E., Spano, A., and Nava, M. The forehead zygomatic-
orbital artery-based island flap. Plast. Reconstr. Surg. 115: 226,
2005.
4. Pinar, Y. A., and Govsa, F. Anatomy of the superficial tem-
poral artery and its branches: Its importance for surgery. Surg.
Radiol. Anat. 16: 248, 2006.
Surgical Treatment of Ear Defects
Sir:
I read with great interest the communication entitled
“Surgical Treatment of Partial Defects of the External
Ear” by Abenavoli et al.1 Since the authors did not
mention it, I would like to remind readers and colleagues
that wounds and defects of the ear heal spontaneously
with excellent aesthetic results.2–5 Furthermore, the case
shown in the report underwent secondary healing after
necrosis of the distal flap.
I presume that several of their five cases probably
could have been treated conservatively by waiting and
watching for spontaneous healing. I have reported sev-
eral clinical situations in which this approach is highly
recommended.2–5
DOI: 10.1097/01.prs.0000279454.55499.e2
Isaac J. Peled, M.D.
Department of Plastic Surgery
Rambam Medical Center
4 Haalyia
Haifa 91005, Israel
i_peled@rambam.health.gov.il
REFERENCES
1. Abenavoli, F. M., Servili, A., and Correlli, R. Surgical treat-
ment of partial defects of the external ear. Plast. Reconstr. Surg.
119: 434, 2007.
2. Peled, I. J., Ramon, Y., Shoshani, O., Risin, Y., and Ulllmann,
Y. Spontaneous healing of ear defects. Clin. Exer. Plast. Surg.
32: 137, 2000.
3. Peled, I. J. Composite chondro-cutaneous grafts. Ann. Plast.
Surg. 34: 559, 1995.
4. Peled, I. J. Healing of ear defects: Primary or secondary.
Plast. Reconstr. Surg. 100: 277, 1997.
5. Peled, I. J. Reconstruction of defects involving the upper
one-third of the auricle. Plast. Reconstr. Surg. 103: 1327, 1999.
Reply
Sir:
My coauthors and I thank Dr. Peled for his interest
in our article. I believe that in many cases it is possible
to achieve spontaneous healing, and it is not surprising
that the final results of this process are satisfactory. The
problem is that, as a general rule, when possible, it is
preferable to close the area that has been operated on,
avoiding a long process of healing with local dressing
changes. Furthermore, when my colleagues and I treat
patients who are not young and who have other dis-
eases, such as hyperglycemia, it is more convenient to
avoid a healing process that it is longer and, in some
cases, dangerous as well.
I conclude, therefore, that spontaneous healing is
still an interesting opportunity, as suggested by Dr.
Peled, for cases where it is not possible or not indicated
to use flaps or other techniques to close partial defects
of the external ear.
DOI: 10.1097/01.prs.0000279455.78609.e4
Fabio M. Abenavoli, M.D.
Department of Head and Neck Surgery
San Pietro Hospital, Fatebenefratelli
Via Savoia 72
Rome 00198, Italy
f.abenavoli@mclink.it
An Alternative Approach to Brow Lift Fixation:
Temporoparietal Fascia, Galeal, and Periosteal
Imbrication
Sir:
W e read with interest the article entitled “An Al-
ternative Approach to Brow Lift Fixation: Tem-
poroparietalis Fascia, Galeal, and Periosteal Imbrica-
tion” by Tuccillo et al.1 The authors evaluated the
results of a frontotemporal suspension-fixation tech-
nique by means of temporoparietalis fascia, galeal,
and periosteal flap imbrication through an open or
endoscopically assisted approach. However, there is
no mention of identifying and protecting the su-
praorbital nerve.
The anatomy of the connective tissues of the tem-
poral and periorbital areas has been eloquently
1433
 Plastic and Reconstructive Surgery • October 2007
described.2,3 These articles detail the relationship of the
connective tissue planes to local nerves and vessels.The
deep branch of the supraorbital nerve is of particular
clinical importance. It always passes between the galea
and the periosteum, 0.5 to 1 cm medial to the superior
temporal fusion line. Various branching patterns have
been found (34 percent single, 60 percent double, and
6 percent multiple). The deep branch of the supraor-
bital nerve provides sensation to the frontoparietal re-
gion, and it is commonly believed that the postopera-
tive symptoms of scalp anesthesia and “itching”
associated with a coronal incision are due to transection
of this nerve.4
The procedure described by Tuccillo et al. follows
the principles of a limited-incision forehead lift with
regard to dissection and surgical planes, but it differs
with regard to the method of fixation. Bitemporal 3- to
4-cm incisions were placed 2 cm behind and parallel to
the hairline. A frontotemporal flap was dissected
through a combined subperiosteal and subtemporopa-
rietalis fascia plane, dividing the superior temporal fu-
sion line and releasing and dividing the orbital rim
periosteum lateral to the supraorbital notch and the
orbital ligament. The operative technique demon-
strated clearly shows the proposed temporal incisions
extending medial to the superior temporal fusion line,
with dissection down to the periosteum. There is no
mention of the deep branch of the supraorbital nerve,
which should be readily identifiable at this stage.
After temporoparietalis fascia, galeal, and periosteal
flap imbrication, the deep branch of the supraorbital
nerve would simply telescope upward with the flap,
provided suitable measures had been taken to ensure
its protection.
DOI: 10.1097/01.prs.0000279456.19533.97
Colin Morrison, M.Sc., F.R.C.S.(Plast.)
James Zins, M.D.
Department of Plastic Surgery
The Cleveland Clinic Foundation
Cleveland, Ohio
Correspondence to Dr. Morrison
Department of Plastic Surgery
The Cleveland Clinic Foundation
9500 Euclid Avenue
Cleveland, Ohio 44195
morrisc5@ccf.org
REFERENCES
1. Tuccillo, F., Jacovella, P., Zimman, O., and Repetti, G. An
alternative approach to brow lift fixation: Temporoparietalis
fascia, galeal, and periosteal imbrication. Plast. Reconstr. Surg.
119: 692, 2007.
2. Knize, D. M. An anatomically based study of the mechanism
of eyebrow ptosis. Plast. Reconstr. Surg. 97: 1321, 1996.
3. Moss, C. J., Mendelson, B. C., and Taylor, I. G. Surgical
anatomy of the ligamentous attachments in the temple and
periorbital regions. Plast. Reconstr. Surg. 105: 1475, 2000.
4. Knize, D. M. A study of the supraorbital nerve. Plast. Reconstr.
Surg. 96: 564, 1995.
1434
Reply
Sir:
We thank the authors for their interest in our
article. Frequently, when you make an incision in the
frontotemporal region, a sensitive disorder is pro-
duced as a result. In our series, this involved a numb-
ing sensation that lasted between 3 and 6 months,
with a short interval of paresthesia before complete
recovery. We have not seen any cases of painful dys-
esthesia; in one patient, there was a more prolonged
paresthesia after distension of the nerve trunk near
its emergence from the supraorbital notch during an
endoscopic procedure. Of course, we have preserved
the deep supraorbital nerve branches described by
Knize1 when we can identify them, but this has been
rare. We believe there is a wider variation in anatomic
distribution and that at the place of the incision, the
nerve may already be divided into multiple and more
superficial thin rami. This may explain the sensory
recovery in the vast majority of patients.2 In another
anatomic study of 40 cadaver dissections, Malet et al.3
described the supraorbital nerve as divided into four
branches [the lateral superficial, deep medial, peri-
osteal (probably corresponding to the deep supraor-
bital nerve branches described by Knize), and cuta-
neous branches] supplying the upper eyelid. In this
study, the lateral branch had a more superficial po-
sition on the frontal muscle, and the periosteal
branch, arising from the latter within a mean dis-
tance of 13 mm from the main trunk, had a shorter
trajectory (mean, 45.35 mm) and was “closely adher-
ent to the superficial layer of the periosteum from
which it cannot be separated.”3 Due to the paucity of
communications in the literature, assessing a con-
stant pattern in nerve distribution would imply more
anatomic studies based on a higher number of ca-
daver dissections. Meanwhile, shorter incisions, pre-
operative patient warnings and reassurance, and
careful dissection in the medial part of the incision
are required for a better outcome.
DOI: 10.1097/01.prs.0000279457.89412.b0
Fernando O. Tuccillo, M.D.
Oscar Zimman, M.D., Ph.D.
Patricio Jacovella, M.D., Ph.D.
Gabriel Repetti, M.D.
Plastic Surgery Division
Hospital de Clinicas
University of Buenos Aires
Buenos Aires, Argentina
Correspondence to Dr. Tuccillo
Plastic Surgery Division Hospital de Clinicas
University of Buenos Aires
Av. Cordoba 2351
1120 Buenos Aires, Argentina
tuccillo@ubbi.com
REFERENCES
1. Knize, D. M. A study of the supraorbital nerve. Plast. Reconstr.
Surg. 96: 564, 1995.
Volume 120, Number 5 • Letters
2. Beard, C. Ptosis surgery: Past, present, and future. Ophthal.
Plast. Reconstr. Surg. 1: 69, 1985.
3. Malet, T., Braun, M., Fyad, J., and George, J. Anatomic study
of the distal supraorbital nerve. Surg. Radiol. Anat. 19: 377,
1997.
Did Hitler Have a Rhinoplasty?
Sir:
E xtensive literature exists on Adolph Hitler’s health,
physical features (particularly those of his face),1
and their possible significance to him and the course of
his life and of world history. It has recently come to our
attention that Hitler may have altered his facial features
and undergone cosmetic rhinoplasty while serving as
Chancellor of Germany. As reported by Time Magazine
in 1942,2 Frederick Oechsner, longtime United Press
Central European manager, recounted in his biogra-
phy of the German leader that Hitler had his nose
“streamlined by a plastic surgeon,” a report that was also
confirmed in an official press dispatch released by the
SS.3 According to Oechsner,4 Hitler’s nose had been “a
little bulbous at the end and fatty on the bridge,” and
Hitler, after having been referred by a physician in
Berlin, had his nasal shape corrected by a “well-known
Munich plastic surgeon.”
We were wondering whether any of the Journal’s
readers might have additional information pertaining
to this claim by Oechsner or thoughts on the identity
of the Munich plastic surgeon. We have examined mul-
tiple photographs of Hitler taken around the time of
Fig. 1. A photograph of Hitler from February of 1933, several
weeks after his appointment as Chancellor of Germany (courtesy
of United States Holocaust Memorial Museum photo archives).
the alleged rhinoplasty (Fig. 1), but have been unable
to determine conclusively a significant change in the
appearance of his nose.
We welcome any comments and can be reached via
e-mail at awarren@bidmc.harvard.edu.
DOI: 10.1097/01.prs.0000279458.49157.28
Anne G. Warren, B.A.
Robert M. Goldwyn, M.D.
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Mass.
Correspondence to Ms. Warren
Department of Surgery, Stoneman 9
Beth Israel Deaconess Medical Center
Harvard Medical School
330 Brookline Avenue
Boston, Mass. 02215
REFERENCES
1. Schmölders, C. Hitler’s Face: The Biography of an Image. Phil-
adelphia: University of Pennsylvania Press, 2006.
2. Inside Hitler. Time Magazine June 22, 1942.
3. Langer, W. C. The Mind of Adolf Hitler: The Secret Wartime
Report (Office of Strategic Services’ Hitler Source Book). New
York: Basic Books, 1972.
4. Oechsner, F. This Is the Enemy. Boston: Little, Brown, 1942.
Breast Cancer in the Previously Augmented
Breast and Sentinel Lymph Node Mapping:
Theoretical and Clinical Considerations
Sir:
I t is with interest that we read the article by McCarthy
et al.1 published in the January 2007 issue entitled
“Breast Cancer in the Previously Augmented Breast.”
This is a commendable account of the management of
breast cancer in previously augmented women. A few
theoretical aspects, some of which were perhaps
avoided due to conflicting evidence, do warrant atten-
tion, as they stimulate further research.
Augmentation mammaplasty is becoming one of the
most commonly performed aesthetic procedures. As
the patient population ages, however, major concerns
associated with the management of breast cancer are
being realized. As the authors mentioned, it is hypoth-
esized that transaxillary breast augmentation, by dis-
rupting the lymphatic drainage, might interfere with
sentinel lymph node detection. It has been our feeling
that this statement is not based on scientific evidence
and was formulated in the early days of the sentinel
lymph node technique.
We agree with McCarthy et al., and despite the sig-
nificance of these studies, the sentinel lymph node
technique was not validated by a planned backup ax-
illary lymph node dissection, and their conclusions are
based on clinical follow-up of a few patients and not
pathologic confirmation in a larger clinical series.
Thus, the potential influence of transaxillary breast
augmentation in axillary lymphatic drainage patterns
remains obscure.
1435
 Plastic and Reconstructive Surgery • October 2007
In 2005, the American Society of Clinical Oncology
offered guidelines to establish the indications for sen-
tinel lymph node biopsy based on scientific data.2 The
authors of the study state that lymphatic drainage from
the upper portions of the breast should be intact after
breast implants, particularly when the surgery has been
performed more than 6 months earlier. Despite this
statement, the authors report that more studies of sen-
tinel lymph node detection are required before guide-
lines can be recommended.
Given the overall lack of consensus and paucity of
literature, we performed a prospective study analyz-
ing sentinel lymph node detection through compar-
ative preoperative and postoperative lymphoscintig-
raphy in transaxillary breast augmentation patients.3
The results demonstrated a focal accumulation of
radioactivity in 93 percent of the patients, where the
“hot spots” identified corresponded to the same
axillary region observed in the preoperative situa-
tion. In two patients (three axillae), sentinel lymph
node identification was unsuccessful, but no statisti-
cal differences were observed. This divergence may
be explained by lymphatic rupture secondary to
axillary undermining or a transitory interruption as
a result of edema compression.
The results of our study indicated that the subfascial
transaxillary breast augmentation technique did not
totally disrupt the lymphatics in the majority of pa-
tients. However, it is important to respect the tech-
nique’s concepts,3,4 which are to remain high and an-
terior in the axilla within the subfascial plane, to
perform the dissection with gently sweeping maneu-
vers, and to minimize the pocket undermining in the
lateral aspect of the breast.4
Although transaxillary breast augmentation has be-
come an increasingly common technique for breast
augmentation and oncologic surgeons have gained
more practice with sentinel lymph node detection, the
consequences of combining both actions remain con-
troversial. Although many questions about cancer in
the augmented breast remain unanswered, our study
suggests that sentinel lymph node detection is feasible.3
We believe that additional studies and larger clinical
series are required to study the accuracy of sentinel
lymph node biopsy in subgroups of breast cancer pa-
tients with previous breast implants.
DOI: 10.1097/01.prs.0000279459.77292.be
Alexandre Mendonça Munhoz, M.D.
Breast Reconstruction Group
University of São Paulo–Brazil
Cláudia Maria Aldrighi, M.D.
Breast SurgeryUniversity of São Paulo School of Medicine
São Paulo, Brazil
Correspondence to Dr. Munhoz
Division of Plastic Surgery
University of São Paulo School of Medicine
Rua Oscar Freire 1702 ap. 78
São Paulo 05409-011, Brazil
munhozalex@uol.com.br
1436
REFERENCES
1. McCarthy, C. M., Pusic, A. L., Disa, J. J., Cordeiro, P. G., Cody,
H. S., and Mehrara, B. Breast cancer in the previously aug-
mented breast. Plast. Reconstr. Surg. 119: 49, 2007.
2. Lyman, G. H., Giuliano, A. E., Somerfield, M. R., et al. Am-
erican Society of Clinical Oncology guideline recommenda-
tions for sentinel lymph node biopsy in early-stage breast
cancer. J. Clin. Oncol. 23: 7703, 2005.
3. Munhoz, A. M., Aldrighi, C., Ono, C., et al. The influence of
subfascial transaxillary breast augmentation in axillary lym-
phatic drainage patterns and sentinel lymph node detection.
Ann. Plast. Surg. 58: 141, 2007.
4. Munhoz, A. M., Fells, K., Arruda, E., et al. Subfascial transax-
illary breast augmentation without endoscopic assistance:
Technical aspects and outcome. Aesthetic Plast. Surg. 30: 503,
2006.
Epinephrine Use in the Fingers
Sir:
W e read with great interest the article entitled “A
Critical Look at the Evidence for and against Elec-
tive Epinephrine Use in the Finger” by Thomson et al.
(Plast. Reconstr. Surg. 119: 260, 2007), on the use of epi-
nephrine-containing local anesthetic solutions in fingers.
We believe the article scrutinized the existing literature,
and the authors’ conclusions are bold but not unex-
pected. We were surprised to see that our own empirical
observations are in total agreement with these conclu-
sions.
Our own clinical experience on the subject com-
menced 10 years ago, when one of our nurses accidentally
used a lidocaine 1% ⫹ epinephrine 1:400,000 solution
(the standard 2% lidocaine with 1:200,000 epinephrine
solution, diluted 1:1 with sodium chloride 0.9%) in all our
elective hand operations. When the error was recognized,
we were pleasantly surprised with the level of anesthesia
achieved and the lack of bleeding in our cases.
We then started using the aforementioned solution of
lidocaine 1% with epinephrine 1:400,000, reluctantly, in
selected hand cases. Later, when we confirmed the lack of
complications, we generalized its use in all hand cases. In
fact, we now almost exclusively use this kind of anesthesia
for hand cases, over other types of anesthesia (general,
regional, local and sedation, and so on).
Of course, in this era of evidence-based medicine,
these anecdotal observations, as well as those of other
authors, must be confirmed with prospective, double-
blind studies.
DOI: 10.1097/01.prs.0000279460.23245.85
Apostolos D. Mandrekas, M.D.
George J. Zambacos, M.D.
Artion Plastic Surgery Center
Athens, Greece
Correspondence to Dr. Zambacos
Artion Plastic Surgery Center
11 D. Vasiliou Street
N. Psyhiko
Athens 15451, Greece
Volume 120, Number 5 • Letters
Reply
Sir:
We thank Drs. Mandrekas and Zambacos for their
interest in the elective use of epinephrine in the finger
and for their confirmation of its safety in their expe-
rience. We have heard from several other groups
around the world who have also been routinely using
adrenaline electively in the finger with no adverse
effects.
Our own interest in adrenaline in the hand began
with the large clinical experience of excellent Canadian
hand surgeons, including Bob MacFarlane, Pat Shoe-
maker, John Fielding, and Mike Bell, who had a com-
bined experience of well over 100 surgeon-years of
elective injection of epinephrine into fingers without a
single loss of a digit. There was a clear disconnect
between the real experience of these good surgeons
and the myth of epinephrine danger in the finger,
which is still erroneously taught to many medical stu-
dents and quoted in some major textbooks.
We confirmed that phentolamine was a reliable and
safe reversal agent for epinephrine-induced vasocon-
striction in the finger by enrolling 18 Dalhousie Uni-
versity alumni hand surgeons among volunteers to have
their own fingers injected with epinephrine and
phentolamine.1 We then undertook a prospective study
of 3110 consecutive cases of elective epinephrine in-
jections by nine surgeons in six cities. This study con-
firmed that not one patient experienced any necrosis,
and not even one patient required phentolamine
rescue.2
Keith Denkler’s landmark article3 showed that there
was not one case of lidocaine with epinephrine causing
finger infarction in the world literature from 1880 to
2000. This work led us to the discoveries in our current
article, which indicate that the likely source of the
epinephrine myth was degenerated acidic procaine.
Why is this topic a very important one? We were first
interested in elective use of epinephrine in the finger
so we could operate on these patients under pure local
anesthesia. The main goal was to avoid the tourniquet,
anesthesiology, and dependency on main operating
rooms, which can be difficult to access in Canada. We
then found other important benefits, which included
improving the results of our hand surgery team by
communicating with pain-free (tourniquet-free) pa-
tients during surgery and having them actively move
reconstructed structures so that adjustments could be
made before the skin was closed. This has been par-
ticularly helpful in tendon repair, tendon transfer,
tenolysis, finger fractures, and so on. We no longer have
to subject older hand patients with medical problems
to the risks of sedation. We have also found it much
cheaper and much more comfortable for patients to
have tourniquet-free carpal tunnel and trigger finger
releases in the clinic or office outside the main oper-
ating room.
Almost all of our hand surgery procedures are now
performed with the patient under pure local anesthe-
sia, with no tourniquet and no sedation (wide awake
approach), outside of the main operating room with
field sterility. For much of the world that cannot afford
the expense of a main operating room and general
anesthesia, this approach will be a major step forward
for hand surgery.
DOI: 10.1097/01.prs.0000279468.01557.9b
Donald H. Lalonde, M.D., M.Sc.
Christopher James Thomson, M.D.
Keith Denkler, M.D.
Anton Feicht, Ph.D.
Division of Plastic Surgery
Queen Elizabeth II Health Sciences Center
Dalhousie University
Halifax, Nova Scotia, Canada
Correspondence to Dr. Thomson
243 Sheppards Run
Beechvile, Nova Scotia B3T 2G2, Canada
ctdalplastics@yahoo.com
REFERENCES
1. Nodwell, T., and Lalonde, D. H. How long does it take
phentolamine to reverse adrenaline induced vasoconstriction
in the finger and hand? A prospective randomized blinded
study: The Dalhousie Project experimental phase. Can. J. Plast.
Surg. 11: 187, 2003.
2. Lalonde, D. H., Bell, M., Benoit, P., et al. A multicenter
prospective study of 3110 consecutive cases of elective epi-
nephrine use in the fingers and hand: The Dalhousie Project
clinical phase. J. Hand Surg. (Am.) 30: 1061, 2005.
3. Denkler, K. A. Comprehensive review of epinephrine in the
finger: To do or not to do. Plast. Reconstr. Surg. 108: 114, 2001.
The Evidence for and against the Effectiveness
of Pressure Garment Therapy for Scar
Management
Sir:
W ith regard to the recently published article enti-
tled “Review of Over-the-Counter Topical Scar
Treatment Products,”1 the authors should be com-
mended. This is an extremely important topic, as vir-
tually every plastic surgery patient receives advice re-
garding scar management. The myriad of products
available and the lack of high-quality scientific evidence
make it difficult to provide exact advice.
The aim of Shih et al.’s article was “to evaluate the
evidence from published controlled clinical trials in hu-
mans on some of the most commonly used over-the-
counter products for treatment of symptomatic scars.”
The article states, “retrospective clinical and ultrasonic
studies since the 1960s are supportive” of pressure ther-
apy. However, of the references provided, none is a clin-
ical study providing evidence of improved outcomes with
the use of pressure garment therapy. All are case studies
of patients treated with pressure therapy, and none has a
comparison group or control treatment.
The article goes on to state that “the only prospec-
1437
 Plastic and Reconstructive Surgery • October 2007
tive, randomized study on the efficacy of pressure gar-
ments demonstrated no significant difference in
wound healing” compared with control subjects.2 In
addition, the article recognizes that published studies
have shown that pressure therapy may in fact lead to
patient morbidity. Garments can be uncomfortable and
lead to skin breakdown, ulceration, and even bony
deformation. Given the available evidence, one must
conclude that the use of pressure therapy is not sup-
ported by the available evidence.
The article states that further evidence is not avail-
able because of a lack of interest by researchers. Several
centers have conducted studies to assess the effects of
pressure therapy.3,4 Other studies have been con-
ducted, but they are rarely published. This is most likely
a reflection of publication bias.5 Publication bias occurs
when research with statistically significant results is
more likely to be submitted and published than is work
with null or nonsignificant results.
Given the lack of currently available evidence and the
universal application of pressure therapy, I believe there
is a need for adequately powered studies of high meth-
odological quality to determine the effectiveness of pres-
sure garment therapy. The article states, more than once,
that “conducting a study on the efficacy of pressure ther-
apy would likely be either difficult or unethical, because
it would involve withholding an accepted treatment from
control subjects.” The continued use of an expensive,
unproven, and potentially harmful therapy without any
further evidence may also be unethical. The National
Institutes of Health is currently funding a large random-
ized control trial to assess the use of pressure therapy. It
is my hope that this study will be adequately powered to
shed light on this important issue.
DOI: 10.1097/01.prs.0000279461.18091.f6
Alexander Anzarut, M.D., M.Sc.
Division of Plastic and Reconstructive Surgery
University of Alberta
Edmonton, Alberta, Canada
Correspondence to Dr. Anzarut
10820-63 Avenue, North West
Edmonton, Alberta T6H 1P8, Canada
aanzarut@ualberta.ca
REFERENCES
1. Shih, R., Waltzman, J., Evans, G. R. D., and the Plastic Surgery
Educational Foundation Technology Assessment Committee.
Review of over-the-counter topical scar treatment products.
Plast. Reconstr. Surg. 119: 1091, 2007.
2. Chang, P., Laubenthal, K. N., Lewis, R. W., II, Rosenquist,
M. D., Lindley-Smith, P., and Kealey, G. P. Prospective, ran-
domized study of the efficacy of pressure garment therapy in
patients with burns. J. Burn Care Rehabil. 16: 473, 1995.
3. Van den Kerckhove, E., Stappaerts, K., Fieuws, S., et al. The
assessment of erythema and thickness on burn related scars
during pressure garment therapy as a preventive measure of
hypertrophic scarring. Burns 31: 696, 2005.
4. Groce, A., McCauley, R. L., Paal-Meyers, R., Herndon, D. N.,
and Chinkes, D. The effect of high versus low pressure gar-
ments in the control of hypertrophic scars in the burned child:
1438
A preliminary 6 month report. Proceedings of the American Burn
Association, 2000.
5. Olson, C. M., Rennie, D., Cook, D., et al. Publication bias in
editorial decision making. J.A.M.A. 287: 2825, 2002.
Reply
Sir:
My coauthors and I agree with Dr. Anzarut that more
definitive studies are necessary to determine the effi-
cacy of pressure garment therapy. The universal appli-
cation of pressure therapy is still controversial, and
studies of high methodological quality are necessary to
determine the effectiveness of this therapy. I thank Dr.
Anzarut for pointing out that the National Institutes
of Health is currently funding a large randomized
control trial to assess the use of pressure therapy.
Perhaps in future publications we will have the
answer to this question.
DOI: 10.1097/01.prs.0000279462.15453.73
Gregory R. D. Evans, M.D.
Aesthetic & Plastic Surgery Institute
University of California–Irvine Manchester Pavilion
Suite 650
200 S. Manchester Avenue
Orange, Calif. 92868
gevans@uci.edu
Quilting and Chloromycetin Ointment for the
Management of Full-Thickness Skin Grafts
Sir:
I read the article entitled “Quilting and Chloromyce-
tin Ointment: An Easier Way to Manage Full-Thick-
ness Skin Grafts”1 and was delighted to note the good
results from this commonsense technique. I would like
to make two suggestions regarding details of their
sound technique.
Plastic surgeons frequently perform minor cutane-
ous surgery on patients receiving anticoagulant ther-
apy. These patients are not at a significantly increased
risk of bleeding complications if the warfarin therapy is
continued.2 Importantly, manipulation of the Interna-
tional Normalized Ratio by adjusting the warfarin leads
to a significantly increased risk of a thromboembolic
event.3 Further, those who suffer a stroke in this setting
have a 50 percent risk of death or serious long-term
morbidity,3 which cannot be reasonably compared with
the perceived potential problems of surgical bleeding
in cutaneous surgery.
Chloramphenicol ointment is used by many plastic
surgeons, as many as 66 percent in a United Kingdom
survey.4 However, the risk of aplastic anemia is not only
dose-related but also idiosyncratic. Death has been re-
ported following topical usage, and absorption has
been reported following skin application.4 The risk of
reaction is very low, at one in 30,000 to 50,000,4 so only
a few clinicians will see a problem in their practice.
However, with such a serious consequence, the use of
Volume 120, Number 5 • Letters
chloramphenicol ointment should be avoided.5
DOI: 10.1097/01.prs.0000279463.10303.0b
David Wallace, M.R.C.S., M.Sc.
Department of Burns and Plastic Surgery
Selly Oak Hospital
Raddlebarn Road
Birmingham B29 6DJ, United Kingdom
davidandvix@aol.com
REFERENCES
1. Patterson, I., and Wong, T. E. Quilting and chloromycetin
ointment: An easier way to manage full-thickness skin grafts.
Plast. Reconstr. Surg. 118: 1551, 2006.
2. Otley, C. C., Fewkes, J. L., Frank, W., and Olbricht,
S. M. Complications of cutaneous surgery in patients who
are taking warfarin, aspirin, or nonsteroidal anti-inflammatory
drugs. Arch. Dermatol. 132: 161, 1996.
3. Blacker, D. J., Wijdicks, E. F. M., and McClelland,
R. L. Stroke risk in anticoagulated patients with atrial fibril-
lation undergoing endoscopy. Neurology 61: 964, 2003.
4. Erel, E., Platt, A. J., and Ramakrishnan, V. Chloramphenicol
use in plastic surgery. Br. J. Plast. Surg. 52: 326, 1999.
5. Doona, M., and Walsh, J. B. Topical chloramphenicol is an
outmoded treatment. B.M.J. 316: 1903, 1998.
Local Anesthesia and Ketamine Dissociation Are
Not Associated with Deep Venous Thrombosis
Sir:
T he questionnaire used in the survey regarding man-
agement of deep venous thrombosis (“Deep Ve-
nous Thrombosis Prophylaxis Practice and Treatment
Strategies among Plastic Surgeons: Survey Results,”
Plast. Reconstr. Surg. 119: 157, 2007) did not ask the
nature of the anesthesia used.1 This fault, acknowl-
edged by the authors, was a serious oversight.
Table 8, on page 166 of the article, shows that “Any
Prophylaxis” face lift patients had nearly twice the
incidence of deep venous thrombosis as “No Prophy-
laxis” patients did (2.8 percent versus 1.7 percent).
Also “Any Prophylaxis” liposuction patients had deep
venous thrombosis at more than twice the rate of their
“No Prophylaxis” counterparts (6.3 percent versus
2.6 percent). Only in the “Combined Procedure”
(combined abdominoplasty and liposuction) cate-
gory was the incidence higher in the “No Prophy-
laxis” group than it was in the “Any Prophylaxis”
group (28 percent versus 10.7 percent). The seem-
ingly counter-intuitive result for the face lift and
liposuction patients led the authors to make the fol-
lowing statement: “An assumption is made that
among those surgeons who use prophylaxis, there is
a higher awareness and surveillance for deep vein
thrombosis compared with those who do not use any
deep vein thrombosis prophylaxis” (page 170 of the
article). This unsupported assumption does not ex-
plain why the ordinarily less aware (according to the
authors) “No Prophylaxis” surgeons are more aware
of deep venous thrombosis in the combined proce-
dure than are the “Any Prophylaxis” surgeons.
Another explanation for the greater reporting of
deep venous thrombosis in the face lift and liposuc-
tion “Any Prophylaxis” groups versus the “No Pro-
phylaxis” groups that does not require an assumption
of selective physician incompetence is that face lifts
and liposuction can be performed with local anes-
thesia only or local anesthesia with ketamine disso-
ciation. Neither local anesthesia nor ketamine is as-
sociated with deep venous thrombosis. Neither
causes a decrease in peripheral venous tone or car-
diac output, and in addition, ketamine has an anti-
coagulant effect.2–5 Since it is unnecessary, physicians
understandably may not administer any of the listed
“Any Prophylaxis” modalities when local anesthesia
and ketamine are used.
Deep venous thrombosis was reported more often in
the “No Prophylaxis” combined group than in the “Any
Prophylaxis” combined group because it is likely that
all, or nearly all, of these procedures were performed
with the patient under general anesthesia. General an-
esthesia (including propofol sedation) increases the
risk of deep venous thrombosis by causing decreased
venous tone and cardiac output. This study’s results are
consistent with the notion that the deep venous throm-
bosis prophylaxis modalities listed are effective for gen-
eral anesthesia but are unnecessary for local anesthesia
only or local anesthesia with ketamine dissociation.
Not tabulating the type of anesthesia utilized in this
study seriously diminishes its significance. The conclu-
sion that the substantially lower reporting of deep ve-
nous thrombosis in the “No Prophylaxis” group for face
lift and liposuction was due to physician unawareness
is not supported. In fact, surgeons who operate with the
patient under local anesthesia only or local anesthesia
with ketamine dissociation may be doing so, among
other reasons, to decrease the incidence of deep ve-
nous thrombosis in their patients.
I agree that plastic surgeons need to incorporate a
deep venous thrombosis prophylaxis regimen into
their practices when general anesthesia is used. How-
ever, the best prophylaxis strategy continues to be the
avoidance, as much as possible, of the use of general
anesthesia.
DOI: 10.1097/01.prs.0000279464.13415.0f
Donato A. Viggiano, M.D.
Treasure Coast Cosmetic Surgery Center
1901 SE Port St. Lucie Boulevard
Port St. Lucie, Fla. 34952-5582
donotdoze@aol.com
REFERENCES
1. Broughton, G., Rios, J., Rohrich, R., and Brown, S. Deep
venous thrombosis prophylaxis practice and treatment strat-
egies among plastic surgeons: Survey results. Plast. Reconstr.
Surg. 119: 157, 2007.
2. Savage, T., Colvin, M., Blogg, C., et al. Cardio-respiratory
effects of some commonly used intravenous induction agents.
Acta Anaesthesiol. Belg. 3: 316, 1974.
3. Tweed, W., Minuck, M., and Mymin, D. Circulatory re-
sponses to ketamine anesthesia. Anesthesiology 37: 613, 1972.
1439
 Plastic and Reconstructive Surgery • October 2007
4. El-Naggar, M., Rao, T., and Marugia, M. Effect of ketamine
on the blood pressure and pulse rate (a comparison with
thiopental and fentanyl). Middle East. J. Anaesthesiol. 4: 29,
1975.
5. Nakagawa, T., Hirakata, H., Sato, M., et al. Ketamine sup-
presses platelet aggregation possibly by suppressed inositol
triphosphate formation and subsequent suppression of cyto-
solic calcium increase. Anesthesiology 96: 1042, 2002.
Professionalism: The End Product of the
Medical Profession
Sir:
T he editorial on professionalism contained some
troubling implications and contradictions.1 The ed-
itorial states that the “core concept underlying profes-
sionalism is a person’s character,” implying that a per-
son’s ability to achieve “professionalism” is determined
before the individual enters residency, perhaps as early
as birth or conception. The role of the plastic surgery
educator then is to “find good individuals with good
innate characteristics,” with the assumption that rec-
ognizing such individuals will lead to the next gener-
ation of “great” plastic surgeons.
Since great plastic surgeons are born and not made,
how can educators recognize the elect? The editorial
recommends that “some type of personality testing that
specifically tests for sociopathic personalities” be used
to eliminate flawed applicants. The applicant should
then be subjected by the educators to a test of social
compatibility with educators framed by the questions,
“Would you like to go out to a social function with this
individual? Would both of you be comfortable in this
situation?” Apparently, the educators should be asking
themselves these questions about the applicants.
Oh my. I am sad to see such concepts advocated
apparently without irony.
The history of “personality testing” has been a
century-long spectacle of social prejudices masked
as pseudoscientific evaluation. As Gould describes in
The Mismeasure of Man,2 personality and intelligence
testing have been used to justify racial discrimina-
tion, gender discrimination, forced sterilization,
and a host of other categorical injuries. Analysis of
such testing generally shows that the instruments
are thoroughly weighted with the preconceptions of
the group administering the test. Even if the tests
are openly used as crude screens for social
enforcements,3 individuals with sufficient skill and
motivation can learn to take the tests in such a way
as to appear desirable to the test administrators.
Social compatibility is an even more treacherous
standard. The answer to the question, “Would you like
to go out to a social function with this individual?” has
sadly often been answered “No!” for reasons of ethnic-
ity, gender, class, religion, citizenship, jealousy, or a
countless number of other attributes. Should an edu-
cator consider himself such a perfect standard that his
social likes and dislikes can serve as a screen for the
entry of candidates into “professionalism”? Such an
1440
egotistical stance runs the danger of recognizing only
social clones.
The editorial concludes that the “optimal way to
improve the arena of medicine is to more critically and
objectively choose those people who go into medicine.”
Unfortunately, the selection strategies preceding this
conclusion are uncritical and subjective.
I contend that effective surgical training profoundly
changes the character of the adults who undertake it.4
With this premise, I believe that the most important
characteristic a person can bring to surgical training is
the desire for surgical training. The surgical curriculum
is then obligated to provide a supportive environment
for the trainee’s observable performance of the clinical,
technical, academic, and ethical elements that define a
plastic surgeon. Within this framework, the exchange
of expectation and evaluation by residents and faculty
is a dynamic and mutual one, one that leads, it is hoped,
to an evolving expression of “professionalism” based on
tangible achievements. Trainees may reserve the full
dimensions of their personality profiles and social lives
to themselves.
I sincerely hope that such crude measures as psy-
chological testing and social screening are never offi-
cially promoted or sanctioned as part of the selection
processes for plastic surgery training programs.
DOI: 10.1097/01.prs.0000279465.28770.8b
William C. Lineaweaver, M.D.
Department of Plastic Surgery
University of Mississippi Medical Center
2500 North State Street
Jackson, Miss. 39216
wlineaweaver@surgery.umsmed.edu
REFERENCES
1. Rohrich, R. Professionalism: The end product of the med-
ical profession. Plast. Reconstr. Surg. 118: 1487, 2006.
2. Gould, S. J. The Mismeasure of Man. New York: W.W. Norton,
1981.
3. Peck, J. (Ed.). The Chomsky Reader. New York: Pantheon
Books, 1987. Pp. 199–202.
4. Lineaweaver, W. Surgery: An enabling profession? Microsur-
gery 22: 131, 2002.
Reply
Sir:
I appreciate Dr. Lineaweaver’s concerns and misin-
terpretation of my editorial, that we should prefer
wholesale implementation of psychological testing and
social screening for plastic surgery residents. His cau-
tion against educators erecting themselves as perfect
standards for social propriety are well taken, and I agree
with him completely that training program directors
must always take great care in keeping their egos in
check.
In reviewing Dr. Lineaweaver’s letter, however, I fear
he has missed the forest for the sake of a single tree.
Numerous elements go into making a professional, as
elaborated in the editorial. The editorial indeed dis-
Volume 120, Number 5 • Letters
cusses the use of personality “testing,” both formalized
and informal, for prospective plastic surgery residents.
It also argues that a person’s character is largely formed
before admission to a residency program. The editorial
does not, however, hint that a person’s character is set
as early as birth or conception, as is postulated by Dr.
Lineaweaver. To imply that it does is a misreading of the
editorial.
Implementing standardized psychological testing
and social screening for prospective residents, as men-
tioned in the editorial, would indeed pose challenges
and raises numerous issues. However, many high-stress
professions other than surgery utilize and rely heavily
on these sorts of tests, to their great advantage. Pilots
of military and commercial aircraft and other fields use
these types of screening tools very effectively, and that
is why they have such tremendous safety records in
contradistinction to that of physicians, who have had a
significantly higher error rate recently in patient
mortality.1 It is possible that, with great care and over-
sight, a parallel preresidency testing mechanism could
potentially be developed.
Dr. Lineaweaver’s prescriptive for success, instead of
such testing, is “desire.” A resident’s desire for surgical
training is the most important characteristic a person
can bring to surgical training. I think that “desire” is
even more vague and hard to calculate/quantify/esti-
mate than is a person’s “sanity,” as defined in the ed-
itorial. How does one gauge another’s “desire”? It is
clear in every endeavor of life that desire, even intense
desire, does not necessarily equate with ultimate suc-
cess. (In high school, I intensely “desired” to become
a basketball star, but no amount of desire, hard word,
or strategies to increase my height or skills enabled me
to become the star I wanted to be.) Although desire is
certainly important, success in any pursuit also involves
dedication to task, practice, excellent work ethic, char-
acter, and inherent skill, many of which are either
innate or developed early in life.
Dr. Lineaweaver also asserts that “trainees may re-
serve the full dimensions of their personality profiles
and social lives to themselves.” Plastic surgery residency
training, by design or not, de facto involves the entire life
of the resident. A residency training program will, to all
intents and purposes, encompass all areas of a resi-
dent’s life, including the social aspect. Furthermore,
even if a resident’s social life and personality profile can
be reserved to himself or herself, such reservation is
actually irrelevant. The full dimensions of a person’s
character are most clearly revealed during stressful sit-
uations, such as during surgery, during long hours,
during grueling rounding, and in resident confer-
ences, all of which are the grist of residency. Unlike
social situations, residency offers no place for a person’s
character to hide; the real self comes out under duress,
which is all-too-present during residency.
In conclusion, this ideal method of resident selec-
tion for any surgery field remains unanswered. It in-
volves personality, inherent talent, work ethic, and
compatibility with one’s work and training environ-
ment. Dr. Lineaweaver’s solution of assessing a resi-
dent’s “desire” as the determining benchmark of po-
tential success is vague and neglects the significant
challenge we have as program directors in developing
metrics to choose the “right person” to advance in the
art and science of plastic surgery.
DOI: 10.1097/01.prs.0000279466.17039.b4
Rod J. Rohrich, M.D.
Editor-in-Chief
University of Texas Southwestern Medical Center
5909 Harry Hines Boulevard, HD1.544
Dallas, Texas 75235-8820
rjreditor_prs@plasticsurgery.org
REFERENCE
1. Institute of Medicine of the National Academies. Preventing
Medical Errors: Quality Chasm Series. July 20, 2006. Available
at www.iom.edu/CMS/3809/22526/35939. Accessed March
12, 2007.
1441