LETTERS

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

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

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

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

Letters

Reconstruction of the Maxilla with PrefabricatedScapular Flaps in Noma PatientsSir:

We read with great interest the article entitled “Re-construction of the Maxilla with Prefabricated

Scapular Flaps in Noma Patients” by Vinzenz et al. (PlastReconstr Surg. 2008;121:1964-1973), and we wanted topoint out that although motivated by genuine human-itarian concerns, such projects may serve to promote“noma tourism” rather than significant improvementsin the local medical infrastructure.

Noma reconstructive surgery has become a chal-lenge for plastic surgeons in the industrialized West;noma continues to afflict sub-Saharan countries as acommunity disaster. As awareness of this problem hasbecome more widespread, increasing numbers ofAmerican and European surgeons are volunteer-ing to go on short-term medical mission trips toperform repair operations in African countries or toorganize transfer of patients to the industrializedcountries.

Why present a program with no chance of beingperformed locally and that implies enormous fundingthat could be used to promote local health programs?

Accurate data collection, thoughtful study design, crit-ical ethical oversight, logistical and financial support sys-tems, and the nurturing of local capacity should be em-phasized.

The most critical elements in the development ofsuccessful programs for treating noma patients are acommitment to developing holistic approaches thatmeet the multifaceted needs of the noma victim andidentifying and supporting local correspondents whocan provide long-term success for such programs.

In complete opposition to the strategies presented inthe article by Vinzenz et al., the senior author hasdeveloped a large program of cooperation over the past12 years regarding noma in Niger (Operation SourireMedecins du Monde), including three surgical mis-sions per year and acceptance of four Niger plasticsurgeons in our fellowship program. More than 70noma patients were treated locally.1 Our strategy was todevelop effective surgical techniques that could be per-formed locally by local surgeons with funding by thenongovernmental organization.

We present the case of a 12-year-old boy who wasinfected with human immunodeficiency virus and whodeveloped noma during his early childhood. After thebeginning of a classic World Health Organization anti–human immunodeficiency virus therapy and a com-plete nutrition program, we had to reconstruct thesecomplex noma sequelae (Fig. 1). Reconstruction wasperformed by means of a single-pedicle latissimusdorsi flap with four skin paddles in a first mission toNiger in November of 2006. The flap was able toreach the cheek because of a cervical inverted

Copyright ©2009 by the American Society of Plastic Surgeons Fig. 1. Preoperative view.

www.PRSJournal.com 1879

Z-plasty with the aim of shortening the cervical area(Fig. 2). At the same time, a frontal flap was used toreconstruct the nasal rim. Three months later, in asecond mission, a local Estlander flap and completeremodeling of the latissimus dorsi flap was per-formed. The result was achieved in only two missionswith soft-tissue neosegmentation (Fig. 3), giving thepatient a chance of socialization and the local sur-geon a chance of performing such operations on hisown one day.

The codes of conduct2,3 of nongovernmental orga-nizations clearly stipulate in Article 6 that we shall at-tempt to build disaster response on local capacities andin Article 7 that ways shall be found to involve programbeneficiaries in the management.

The principle of “responsibility”4 must remain in theethical guidelines for these humanitarian programs.The responsibility in this case is to build for the localsurgeons a chance to solve local problems.DOI: 10.1097/PRS.0b013e3181a3f49c

Alain M. Danino, M.D., Ph.D.Service de Chirurgie Plastique

Centre Hospitalier de l’Universite de MontrealHôpital Notre Dame

Montreal, Quebec, Canada

Jean Marie Servant, M.D.Service de Chirurgie Plastique

Hopital Saint LouisUniversite de Paris

Paris, France

Correspondence to Dr. DaninoHospital Notre Dame

1560 Rue de Sherbrooke EstMontreal, Quebec H2L4M1, Canada

REFERENCES1. Foussadier F, Servant JM. Activity report about Hospital Saint-

Louis’s team for taking in charge sequelae of noma (inFrench). Ann Chir Plast Esthet. 2004;49:345–354.

2. NGO Code of Conduct, 2001. Available at: http://www.bocongo.bw/code.pdf.

3. Stockton N The ‘Code of Conduct’ in Practice: A PersonalView. In: ‘Terms of Engagement’ Working Meeting; Geneva;May 2000.

4. Jonas H. The Imperative of Responsibility: In Search of Ethics for theTechnological Age. Chicago: University of Chicago Press; 1979.

Vascular Anatomy of the Supraclavicular AreaRevisitedSir:

We have read the article by Cordova et al. withinterest.1 The authors have performed an ana-

tomical investigation to assess the possibility of harvest-ing a free supraclavicular flap. There were two phasesfor the anatomical study: a static phase and a dynamicphase. They have discovered that most of the perfora-tors originating from the transverse cervical artery werelocated at the A3 area on the grid they described. Thecolumn A in their trapezoid grid mainly superposed tothe sternocleidomastoid muscle trace. Moreover, theyhave presented two successful clinical cases of the freesupraclavicular flap. However, we would like to makesome comments regarding their study from the aspectof both anatomical and clinical issues.

In any anatomical study, the dissection of a fresh orfixed cadaver without any injection of latex or stainingis called a static anatomical study. The dynamic studymight include colored latex injection to arteries or

Fig. 2. After the first step: pedicle latissimus dorsi with invertedcervical Z-plasty.

Fig. 3. After the second step: modeling of the latissimus dorsi,Estlander flap, and frontal flap to reconstruct the nasal rim.

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veins.2 The static study would enable dissection of anystructure with the difficulty of localization and identi-fication of the structures, as their cadaveric view isdifferent from the viable view. Thus, the dynamic studysimplifies the dissection; however, it should be focusedon a determined structure before dissection.2 The au-thors have performed a dynamic study on the arterialnetwork by injection through the axillary artery. In ouranatomical study, the supraclavicular artery branchedfrom the transverse cervical artery in all specimens (100percent). Although it arose from the middle third of theclavicle in 90 percent of the specimens, it arose from thelateral third of the clavicle in 10 percent of specimens.Moreover, the transverse cervical artery originated fromthe subclavian artery in 5 percent of specimens ratherthan from the thyrocervical trunk.3 Thus, we think thatanterograde latex injection through the subclavian arterymight be more significant, although the authors per-formed a retrograde injection from the axillary artery. Inaddition, the main problem with the free supraclavicularartery flap is the selection and localization of the appro-priate vein. The authors should have used dynamic ana-tomical studies to clarify the venous network, as we stillthink that the external jugular vein might be safer, basedon our clinical experience.4,5

The two clinical cases were presented wonderfully.However, from our point of view, the indications for thecases were constrained, as there were other, easieropportunities4 for these cases, especially for case 2 inwhich there were no concerns about the skin texture orcolor match, and the same operative fields were avail-able for the intraoral defect. However, much quicker,safer, infection-tolerable, and established techniquesmay be required for intraoral reconstruction. We be-lieve that supraclavicular flaps are rather suitable forthe neck region, especially for burn reconstruction ofneck contractures.3–5 The potential of the free supra-clavicular flap should be kept in mind, and we wouldlike to thank to authors for indicating that possibility;however, the indications for the free use of the flapshould be limited to selected cases.DOI: 10.1097/PRS.0b013e3181a65bfe

Cagri A. Uysal, M.D.Rei Ogawa, M.D., Ph.D.

Department of Plastic and Reconstructive SurgeryNippon Medical School

Tokyo, Japan

Vu Q. Vinh, M.D., Ph.D.Department of Plastic and Reconstructive Surgery

Vietnam National Institute of BurnsHanoi, Vietnam

Hiroshi Mizuno, M.D., Ph.D.Hiko Hyakusoku, M.D., Ph.D.

Department of Plastic and Reconstructive SurgeryNippon Medical School

Tokyo, Japan

Correspondence to Dr. UysalDepartment of Plastic and Reconstructive Surgery

Nippon Medical School

1-1-5 Sendagi, Bunkyo-kuTokyo 113-8603, Japan

cagriuysal@hotmail.com

REFERENCES1. Cordova A, Pirrello R, D’Arpa S, Jeschke J, Brenner E, Mos-

chella F. Vascular anatomy of the supraclavicular area revis-ited: Feasibility of the free supraclavicular perforator flap. PlastReconstr Surg. 2008;122:1399–1409.

2. Uysal AC, Alagoz MS, Tuccar E, Sensoz O, Tekdemir I. Thevascular anatomy of the abductor digiti minimi and the flexordigiti minimi brevis muscles. J Hand Surg (Am.) 2005;30:172–176.

3. Vinh VQ, Anh TV, Ogawa R, et al. Anatomical and clinicalstudies of the supraclavicular flap: Analysis of 103 flaps usedto reconstruct neck scar contractures. Plast Reconstr Surg. (Ac-cepted for publication).

4. Vinh VQ, Ogawa R, Van Anh T, Hyakusoku H. Reconstructionof neck scar contractures using supraclavicular flaps: Retrospec-tive study of 30 cases. Plast Reconstr Surg. 2007;119:130–135.

5. Ogawa R, Murakami M, Vinh VQ, Hyakusoku H. Clinical andanatomical study of superficial cervical artery flaps: Retro-spective study of reconstructions with 41 flaps and the feasibility ofharvesting them as perforator flaps. Plast Reconstr Surg. 2006;118:95–101.

ReplySir:

We have carefully read the comment of Dr. Uysal andcolleagues regarding our recently published article,“Vascular Anatomy of the Supraclavicular Area Revis-ited: Feasibility of the Free Supraclavicular PerforatorFlap.”1

First, we would like to thank the authors for theopportunity they give us to further discuss our work. Weare aware of (and have appropriately cited) their re-markable experience with the flap and are happy toshare our thoughts with them.

In their comment, they raise some concerns aboutthe dynamic part of the anatomical investigation. Theyare afraid that latex injection through the axillary arterymay have caused a retrograde flow through the trans-verse cervical artery and that this might have impairedthe efficacy of injection. The transverse cervical artery,as they correctly point out, is a branch of the subclavianartery. Injection through the axillary artery will cause—this is true—retrograde flow in the subclavian artery,but not in the transverse cervical artery, in which theinjected latex will enter with an anterograde directionin both cases. The reason why the axillary access waschosen is that it is far from the region to be investigated.Median access to the subclavian vein might have inter-fered with dissection of the supraclavicular area withoutany apparent benefit.

Second, the authors state that, after reading the ar-ticle, they still think that the external jugular vein issafer based on their clinical experience. Venous drain-age was the most significant weakness of this flap. Inour study, we observed that venous drainage is ac-complished through the superficial venous plexusand not through the transverse cervical artery venae

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comitantes and that the superficial cervical vein is thevenous pedicle of the flap (a more detailed anatom-ical description has been published elsewhere).2 Thesuperficial cervical vein eventually joins with the ex-ternal jugular vein to ultimately drain in the subcla-vian vein. For this reason, to use the external jugularvein as a venous pedicle would be acceptable too andwill create a venous turbocharging to the flap byjoining the superficial cervical vein and any drainagecoming through the external jugular vein. This is notneeded for three reasons:

1. Such a small flap does not need venous super-charging.

2. The superficial cervical vein is smaller than theexternal jugular vein and this may often avoidundesired and bothersome size discrepancies.

3. The primary drainage of the flap is through thesuperficial cervical vein.

We encourage the authors to trust the su-perficial cervical vein when they will use thisflap.

Accessory comments are made on the indica-tions of the flap. First, we would like to underscorethat this flap was never presented as a “flap for alloccasions.” Every case is different and reconstruc-tion must always be tailored to that specific case.Microsurgery gives us the opportunity of havingthe whole body as a flap donor site, and with thisflap we have another choice to further refine ouroutcome and minimize donor-site morbidity ac-cording to every single patient’s needs. Otherwise,we could very well cover every hole with only oneflap if coverage was our only goal.

The authors state that easier opportunities ex-ist for reconstructions in cases such as those pre-sented. This is true, without any doubt. However,ease is not a parameter that normally influencesour choices. We believe that safety, reliability, finaloutcome, donor-site morbidity and, last but notleast, the patient’s desires, among others, are thecriteria that must influence our choice. The eas-iest procedure is seldom the best.

Furthermore, this flap is not a difficult flap atall. As for any other anatomical region, the sur-geon should know it very well. Surgeons familiarwith head and neck surgery will find harvestingthis flap to be very easy.

Once again, we think that this flap can be auseful option in those cases in which:

• Tissue of such texture, color, and thinness isneeded.

• A huge flap is not required.• A long pedicle is not needed.• A pedicled supraclavicular flap will not reach

the defect.

• There is the wish to have a hidden, nonmorbiddonor site.

We think that the supraclavicular donor site,when primary closure is achieved, may be moreappealing than a radial forearm flap donor site oran anterolateral thigh donor site in women.

We also think that we should always seek im-provements in our practice. We believe that, eventhough we would not use this flap every day, tohave it as an alternative will help achieve betteroutcomes in selected cases.DOI: 10.1097/PRS.0b013e3181a65c11

Adriana Cordova, M.D.

Roberto Pirrello, M.D.

Salvatore D’Arpa, M.D.

Johannes Jeschke, M.D.Erich Brenner, M.D.

Francesco Moschella, M.D.Chirurgia Plastica e Ricostruttiva

Dipartimento di Discipline Chirurgiche ed OncologicheUniversita degli Studi di Palermo

Palermo, Italy

Correspondence to Dr. CordovaChirurgia Plastica e Ricostruttiva

Dipartimento di Discipline Chirurgiche ed OncologicheUniversita degli Studi di Palermo

Via del vespro n. 129 c.a.p.Palermo, Italy 90127

REFERENCES1. Cordova A, Pirrello R, D’Arpa S, Jeschke J, Brenner E, Mos-

chella F. Vascular anatomy of the supraclavicular area revis-ited: Feasibility of the free supraclavicular perforator flap. PlastReconstr Surg. 2008;122:1399–1409.

2. Cordova A, D’Arpa S, Pirrello R, Brenner E, Jeschke J, MoschellaF. Anatomic study on the transverse cervical vessels perforatorsin the lateral triangle of the neck and harvest of a new flap: Thefree supraclavicular transverse cervical artery perforator flap.Surg Radiol Anat. 2009;31:93–100.

Choice of Incision for Primary Repair ofUnilateral Cleft LipSir:

I am presuming it was a “slip of the pen” by Dr. Reddyet al. in their article “Choice of Incision for Primary

Repair of Unilateral Cleft Lip: A Comparative Study ofOutcomes in 796 Patients” (Plast Reconstr Surg. 2008;121:933-940) that accounts for the drawing of the Mil-lard incision to be incorrectly depicted. The way it isshown, the rotation flap extends all the way to the lowpoint of the Cupid’s bow, rather than to the high pointon the cleft side as it certainly should.

Performed in this fashion, the operation would ob-viously not give a good result.DOI: 10.1097/PRS.0b013e3181a65bec

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S. Anthony Wolfe, M.D.Division of Plastic SurgeryMiami Children’s Hospital

Miami, Fla.

Correspondence to Dr. Wolfe6280 Sunset Drive

Suite 400Miami, Fla. 33143

ReplySir:

We would like to thank Dr. Wolfe for his comments onour article and commend his attention to detail. Theincision line in Figure 1 does indeed appear to have beeninadvertently extended to the dot marking the low pointof the Cupid’s bow. This is, as he suggests, a “slip of thepen,” and we apologize for our graphical error.DOI: 10.1097/PRS.0b013e3181a65c73

Roger M. Webb, F.R.C.S.(Eng.)Goslar Reddy, B.D.S., M.D.S.

Anthony F. Markus, F.D.S. R.C.S., F.D.S. R.C.P.S.Maxillofacial Unit

Poole HospitalPoole, Dorset, United Kingdom

Correspondence to Dr. Webb1 Warditch Cottages

WhitsburyFordingbridge

Hampshire SP6 3QH, United Kingdomrogermwebb@hotmail.com

Arterial and Venous Anatomy of Deep InferiorEpigastric Perforator and Superficial InferiorEpigastric Artery FlapsSir:

We would like to thank Schaverien et al. for theirimpressive study (Plast Reconstr Surg. 2008;121:

1909–1919), which is very successful in our opinion,especially with regard to presentation and figures. Theauthors present us with very “difficult-to-express” re-sults through a nice investigative technique. We thinkthat discussing this subject a little further will contrib-ute to clinical applications of their findings.

The survival problem of transverse rectus abdominismusculocutaneous (TRAM) flaps in zone IV is a well-known issue. To augment the nourishment of a TRAMflap, the flap can be delayed by ligating the inferiorepigastric artery.1 Thus, the perforators of the deepinferior epigastric artery (DIEA) are induced to gainblood flow from the superficial inferior epigastric ar-tery (SIEA), resulting in an increased ability of the flapto survive. Here, when a delay mechanism for deepinferior epigastric artery perforator flaps is considered,one can determine the main perforator of widest di-ameter with a manual Doppler examination, and ligatethe others. Nourishment of zone IV may be increasedthrough this intervention. The authors also emphasize

the fat necrosis problem resulting from the limitedvascularization of fatty tissue. Can skin vascularizationand survival be increased by fatty tissue trimming, aswith the thin flap mechanism?

Another point is whether there is a correlation be-tween the diameter of the perforator and the skin areait can supply. It is known that distal necrosis of a ran-dom flap is attributable to the existing but unrecog-nized perforators. We think that this should have beeninvestigated in this study, but it was not. What we ad-vocate is that distal end necroses of perforator flaps canbe prevented by investigation of perforator diameters.We would like to discuss this idea with the authors.

SIEA flaps leave unpleasant scars, as the artery coursesperpendicular to the abdominal lines. For this reason,they should not be applied where they are not mandatory.Pudendal artery, gracilis, or groin flaps, which have lessdonor-site morbidity, are more favorable, instead of thisflap, which is preferably used for vagina and scrotumreconstruction. Also, application of SIEA flaps togetherwith DIEA flaps does not seem feasible to us.

As an epilogue, we would like to thank the authorsfor their important study, and kindly request fromthem disclosure of their opinions on the issues we men-tioned above.DOI: 10.1097/PRS.0b013e3181a3f16f

Muhammet Uraloglu, M.D.Department of Plastic and Reconstructive SurgeryAnkara Numune Research and Training Hospital

Ankara, Turkey

Metin Kerem, M.D.Sırnak State Hospital

Sırnak, Turkey

Enver Arpacı, M.D.Department of Plastic and Reconstructive SurgeryAnkara Numune Research and Training Hospital

Ankara, Turkey

Correspondence to Dr. UralogluDepartment of Plastic and Reconstructive SurgeryAnkara Numune Research and Training Hospital

Ovecler 2. cadde 185Sokak no 4/6

Ankara 06000, Turkeyuraloglu@hotmail.com

REFERENCE1. Jensen JA. TRAM flap delay: Two techniques and an unre-

solved question. Plast Reconstr Surg. 2003;111:2478–2479.

TRAM Flap Delay: New Data Addressing OldQuestionsSir:

Dr. Uraloglu et al. do a great service for those of usinterested in transverse rectus abdominis muscu-

locutaneous (TRAM) flap circulation and viability byrefocusing our attention on the elegant anatomicalstudy conducted at the University of Texas.1 In thisstudy, deep inferior epigastric artery perforator (DIEP)

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and superficial inferior epigastric artery (SIEA) flapswere harvested from cadavers and abdominoplastyspecimens and perfused with various dyes and/or ra-diopaque agents. Perfusion patterns were observed usingstatic and dynamic computed tomographic angiography.Several interesting conclusions were drawn: first, injec-tion of medial and lateral perforators produced dis-tinctly different patterns of perfusion, with the injec-tion of the medial perforator producing a larger areaof contralateral perfusion; second, injection of theSIEA produced a pattern resembling that produced byinjection of a lateral perforator but that failed to crossthe midline; and third, venous injection showed thatdrainage through the superficial system communicatedon the ipsilateral side with the deep system and thatcommunication with the opposite side was restricted tovessels in the subdermal plexus (to vessels in the su-perficial system on the opposite side).

As careful and elegant as this study is, however, wemust be careful with extrapolations of ex vivo experi-mental studies to in vivo surgical results. This studywould tend to confirm Dr. Blondeel’s observation thatzone IV of the TRAM flap cannot be adequately nour-ished using a lateral perforator.2 Uraloglu et al. raisethe interesting question of whether subjecting a DIEPflap to a surgical delay might increase the possibilitythat zone IV could be safely transferred (I presume)using a lateral perforator. This question cannot be re-solved without a clinical series.

Uraloglu et al. also suggest that the mechanism bywhich the surgical delay of a pedicle TRAM flap improvessurvival is because “the perforators of the deep inferiorepigastric artery. . .are induced to gain blood flow fromthe superficial inferior epigastric artery . . .” If the authorsmean that surgical delay improves the connections be-tween the DIEA and the SIEA in zone I of the flap, I woulddisagree with their statement. However, if they mean thatsurgical delay improves the vascular connections amongthe DIEA, the SIEA, the subdermal plexus, and the deepand superficial systems of the opposite side (zones II andIV), I completely agree and commend them for theirperceptiveness. This is an argument that I have waged formore than a decade.3

The question of what constitutes an adequate delayof a pedicle TRAM flap was raised by Hartrampf et al.4in their original report and was echoed when I pub-lished a series of delayed TRAM flaps in 1995.5 Is liga-tion of the deep inferior epigastric vessels (as proposedby Hartrampf et al., Boyd et al.,6 Hudson,7 Codner etal.,8 and others) sufficient to ensure the viability of thepedicle TRAM flap in high-risk patients? The “extendedskin island delay” elevates zones II and IV of the flap—thus necessitating increased flow through the subder-mal plexus across the midline. (Technique improve-ment: advancing zone IV of the flap medially as a V-Yclosure during the delay procedure improves the sur-vival of zone IV.9) It is on this flow that the survival ofzones II and IV depends when the flap is finally elevatedand transposed. This conclusion is supported by the exvivo data presented by Drs. Schaverien and Saint-Cyr

and their colleagues in Texas. Only by stratifying pa-tients according to risk in a clinical study can the ques-tion of what constitutes an adequate surgical delayfinally be resolved.10

Standing back for a moment and surveying thechoices of TRAM flap transfer discussed herein, it ispossible to appreciate a full spectrum. An extendedskin island delay of a unipedicle TRAM flap offers arelatively low-tech and low-skill but highly reliable so-lution to the problem of TRAM flap transfer, whereastransfer of the flap based only on perfusion from amedial perforator must be regarded as high-tech andhigh-skill and might not be as reliable in the high-risksetting. A delayed unipedicle flap can be performedconsistently by a single surgeon in less than 5 hours ofsurgical time (on two separate visits to the operatingroom), whereas a perforator flap requires the efforts ofat least two microsurgeons, sometimes working for ex-tended operating times. A delayed unipedicle flap re-quires routine postoperative care, whereas a perforatorflap requires intensive hourly flap checks. A delayedunipedicle flap requires the loss of function of a singlerectus abdominis muscle (thus relegating the bipedicleTRAM flap to the status of surgical anachronism11),whereas a perforator flap avoids the loss of a rectusmuscle. The functional consequences of this loss for aunilateral flap remain uncertain.12

The TRAM flap has emerged as a powerful tool for thetreatment of the mastectomy defect. Whether it should beperformed as a lower risk flap or as a higher risk flapdepends on many variables. Is it not interesting, though,that basic science studies such as the present one fromTexas add insight into both approaches?DOI: 10.1097/PRS.0b013e3181a3f185

J. Arthur Jensen, M.D.John Wayne Cancer Center

David Geffen School of Medicine at the University ofCalifornia, Los Angeles

2001 Santa Monica Boulevard, Suite 790WSanta Monica, Calif. 90404

dr.j.jensen@gmail.com

DISCLOSURESThe author has no financial conflict of interest to

disclose with regard to the content of this communicationor the article to which it relates.

REFERENCES1. Schaverien M, Saint-Cyr M, Arbique G, Brown SA. Arterial

and venous anatomies of the deep inferior epigastric perfo-rator and superficial inferior epigastric artery flaps. PlastReconstr Surg. 2008;121:1909–1919.

2. Blondeel PN. One hundred free DIEP flap breast reconstruc-tions: A personal experience. Br J Plast Surg. 1999;52:104–111.

3. Jensen JA. Re: The surgically delayed unipedicled TRAM flapfor breast reconstruction. Ann Plast Surg. 1996;37:342–343.

4. Hartrampf CR, Scheflan M, Black PW. Breast reconstructionwith a transverse abdominal island flap. Plast Reconstr Surg.1982;59:216–225.

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5. Jensen JA, Handel N, Silverstein MJ, Waisman JR, Gierson ED.Extended skin island delay of the unipedicle TRAM flap: Ex-perience in 35 cases. Plast Reconstr Surg. 1995;96:1341–1345.

6. Boyd JB, Taylor GI, Corlett R. The vascular territories of thesuperior epigastric and the deep inferior epigastric systems.Plast Reconstr Surg. 1984;73:1–16.

7. Hudson DA. The surgically delayed unipedicled TRAM flapfor breast reconstruction. Ann Plast Surg. 1996;36:238–242;discussion 242–245.

8. Codner MA, Bostwick J III, Nahai F, Bried JT, Eaves FF.TRAM flap vascular delay for high-risk breast reconstruction.Plast Reconstr Surg. 1995;96:1614–1622.

9. Jensen JA. Effect of tension on flap perfusion: Laboratory andclinical findings. Wound Repair Regen. 2003;11:405–410.

10. Jensen JA. TRAM flap delay: Two techniques and an unre-solved question. Plast Reconstr Surg. 2003;111:2478–2479.

11. Jensen JA. Is double pedicle TRAM flap reconstruction of asingle breast within the standard of care? Plast Reconstr Surg.1997;100:1592–1593.

12. Futter CM, Webster MH, Hagen S, Michell SL. A retrospec-tive comparison of abdominal muscle strength followingbreast reconstruction with a free TRAM or DIEP flap. Br JPlast Surg. 2000;53:578–583.

Diastasis Recti: Clinical AnatomySir:

We read with interest the article by Dr. Braumanregarding diastasis recti and the sources of ab-

dominal wall protrusions. We would like to commendthe author on addressing a subject that is frequentlyunder-evaluated with respect to abdominal contouring.Abdominal protrusion can be a result of multiple fac-tors including extraabdominal fat, intraabdominal fat,diastasis recti, abdominal wall hernia, as well as globalmyofascial laxity.

Traditional abdominoplasty techniques address extra-abdominal fat through liposuction and resection, andcorrection of diastasis recti and abdominal wall hernia(s)through direct fascial repair including plication of thelinea alba. Intraabdominal fat can be a significant sourceof abdominal protrusion, but it is not addressed in tra-ditional abdominoplasty techniques.

The last potential source of abdominal wall protru-sion is global myofascial laxity.

Abdominoplasty patients with significant abdominalprotrusion and relatively little intra- and extraabdomi-nal fat frequently have abdominal wall laxity that ismuch greater than the degree of diastasis recti present.Deferring plication or plicating only sufficiently to de-crease the width of the linea alba frequently results ininadequate correction of abdominal wall laxity and thepersistence of abdominal wall protrusion.

Based on these observations, we prefer to use theterm myofascial plication to better describe the processof global myofascial laxity correction.1 The techniqueis similar to standard diastasis recti plication; however,plication involves imbricating a wider portion of theanterior rectus sheath as determined by preoperativeassessment and intraoperative estimation with the pa-tient under muscular relaxation. The process of myo-

fascial plication shorthens the width of the anteriorrectus sheath and in turn pulls the paired linea semi-lunaris toward midline, resulting in reapproximation ofthe medial edges of the rectus muscles.1 This entireprocess results in overall tightening of the abdominalwall as a myofascial unit. The frequency and signifi-cance of global myofascial laxity are often under-ap-preciated in the process of abdominal wall tighteningfor the abdominoplasty patient.DOI: 10.1097/PRS.0b013e3181a84920

Remus Repta, M.D.Advanced Aesthetic Associates

Phoenix, Ariz.

Joseph P. Hunstad, M.D.The Hunstad Center

Charlotte, N.C.

Correspondence to Dr. ReptaAdvanced Aesthetic Associates

9225 N 3rd Street, Suite 103Phoenix, Ariz. 85020

drrepta@gmail.com

REFERENCE1. Hunstad JP, Repta R. The Atlas of Abdominoplasty. London:

Saunders;2008.

ReplySir:

I appreciate the letter by Drs. Repta and Hunstad.They point out that they have identified a group ofpatients whose abdominal wall laxity is so markedthat merely correcting their diastasis will lead to un-dercorrection of their abdominal protrusion. They referto this finding as “global myofascial laxity.” In doing so,they have perceptively addressed an important aspect ofabdominal wall reconstruction and diastasis recti repair:laxity. The authors proceed to describe their method ofdiastasis repair, which extends well lateral to the medialborders of the rectus muscles and is performed undermuscular relaxation.

The authors’ clinical findings lend support to my con-clusion in the article entitled “Diastasis Recti: ClinicalAnatomy”1 that, “contrary to current thought, abdominalwall protrusions are caused by the stretching of the entireabdominal wall and not only the linea alba.”

The issue of the laxity of the musculofascial abdom-inal wall has been addressed at some length in myprevious article on this subject, “Liposuction Abdomi-noplasty: An Evolving Concept.”2 In it, “the lax (oroverstretched) abdominal wall” was defined as an “en-velope that is larger than its contents and capable ofaccommodating more volume without additionalstretching.” In addition, in that article, a detailed de-scription was included of my approach to preoperativeand intraoperative assessment of laxity.

Because I continue to perform all my abdomino-plasty procedures under local anesthesia, I have theopportunity to evaluate the laxity of the muscular ab-

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dominal wall under conditions that are as close to phys-iologic as possible. During surgery, laxity is assessed asthe degree of tension required to approximate therectus fascia until the abdominal wall feels tight andappears flat. I have also determined for myself a scalefor laxity: grade I denotes minimal laxity, grade IIIdenotes a very lax abdomen, and grade II is somewherein-between.

My opinion about the intraoperative assessment oflaxity differs from that of Drs. Repta and Hunstad. Inmy opinion, the intraoperative assessment and repairof diastasis under muscle relaxation may tend toovercorrect fascial laxity. Therefore, I had devised asegmental approach to diastasis repair, in which onlythe most protruding segment of the abdominal wallis repaired. I believe that this segmental approachsatisfies the requirements for musculofascial repairand prevents unnecessary recurrences of abdominalprotrusions.

My technique for diastasis repair is similar to that ofDrs. Repta and Hunstad in that the fascial plicationis confined to the anterior fascia and extends beyondthe medial edges of the recti muscles. In addition,interrupted, figure-of-eight sutures (no. 1 Vicryl; Ethicon,Inc., Somerville, N.J.) in one or two layers add a verticaltightening component to the otherwise horizontal repair.DOI: 10.1097/PRS.0b013e3181a3f1fe

Daniel Brauman, M.D., M.B., B.S.Weill Medical College of Cornell University

White Plains, N.Y.

Correspondence to Dr. Brauman222 Westchester Avenue, Suite 102

White Plains, N.Y. 10604dbrauman@dbraumanmd.com

DISCLOSURESThe author has no financial interest in any of the

products, devices, or drugs mentioned in this reply or inthe article being discussed.

REFERENCES1. Brauman D. Diastasis recti: Clinical anatomy. Plast Reconstr

Surg. 2008;112:1564–1569.2. Brauman D. Liposuction abdominoplasty: An evolving concept.

Plast Reconstr Surg. 2003;112:288–298; discussion 299–301.

Maximizing the Aesthetic Result inPanniculectomy after Massive Weight LossSir:

W ith great interest, I read the article entitled “Max-imizing the Aesthetic Result in Panniculectomy

after Massive Weight Loss” by Dr. Leahy et al. in theOctober issue of the Journal. According to the mostrecent 2008 Current Procedural Coding manual, apanniculectomy is clearly defined as “Excision, ex-cessive skin and subcutaneous tissue (includes lipec-tomy); abdomen, infraumbilical panniculectomy”(15830). I do not believe that the authors in their

presented cases strictly remained infraumbilical. Infact, the authors rather present a series of modifiedabdominoplasties, as defined as “Excision, excessiveskin and subcutaneous tissue (includes lipectomy),abdomen (e.g., abdominoplasty) (includes umbilicaltransposition and fascial plication)” (15830/15847).

As we have recently discussed in the Journal,1 thequality of pictures with partial underwear in the areaof interest do not meet the criteria for scientificpublications and we should pay more attention tothis detail (Figs. 1 and 2).DOI: 10.1097/PRS.0b013e3181a65b32

Detlev Erdmann, M.D., Ph.D., M.H.Sc.Division of Plastic, Reconstructive,

Maxillofacial, and Oral SurgeryDuke University Medical Center

Box 3181Durham, N.C. 27710

detlev.erdmann@duke.edu

REFERENCE1. Erdmann D. Resection of panniculus morbidus: A salvage

procedure with a steep learning curve (Letter). Plast ReconstrSurg. 2008;122:1290; author reply 1290–1292.

Minimizing Donor-Site Morbidity afterOsteocutaneous Radial Forearm Flap Harvest:How, When, and WhySir:

We read and reread the article entitled “PatientSelf-Report of Disability of the Upper Extremity

following Osteocutaneous Radial Forearm Free FlapHarvest” (Plast Reconstr Surg. 2008;122:1479-1484) by De-leyiannis et al. The authors describe very interesting re-sults derived from a questionnaire regarding arm, shoul-der, and hand disability on a sample of 12 patients whounderwent composite forearm flap harvest, available atthe time of investigation. One of these had a pathologicfracture of the radius. We carefully read the section re-garding the harvesting technique and the results; fromwhere it emerges, they harvest the flap under tourniquetcompression, without preoperative echo color Doppler.They use a skin graft for donor-site closure and a bolsterdressing for 2 weeks. In light of these practices, severalconsiderations and suggestions for improving donor-sitemorbidity emerge on the basis of personal experiencethat includes 198 forearm flaps. Of these patients, 38underwent composite radial forearm flap surgery, five fortotal nasal reconstruction and the remaining 33 for man-dibular defects. We usually perform Doppler evaluationto identify vascular anomalies such as a double humeralartery or a superficial ulnar artery (both occurred). Weprefer to close the donor site with the V-Y ulnar flap,reserving skin grafting for larger defects.1–3 With partic-ular regard to composite flaps, we harvest the bone in akeel-shaped fashion, with care taken to remain withinone-third of the bone diameter,4 and secure both the graftand the radius with a plaster cast until the half-arm

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dressing is applied at 4 weeks. After this, patientsbegin passive and active motion under physiothera-pist supervision for 1 month. Our indication for man-dible reconstruction is represented by defects of 4 to5 cm, saving the fibula for emergency. In our expe-rience, we do not report pathologic fractures or ten-don exposure because the evidence indicates thatimmobilization plays a key role in wound healing, and

this is especially true for bone. Nevertheless, whenmore bone is needed or in case of harvesting mistakes,we suggest that radial defects be repaired with bonegrafts from the iliac crest, tibia, metacarpal, olecranon,or skull, choosing the most convenient bone at themoment, and then fixing the graft with miniplates,with care taken to immobilize the upper limb untilhalf of the arm, just to contrast the activity of the

Fig. 1. Inverted T-shape abdominoplasty in a 67-year-old female patient after a gastric bypassprocedure with a consecutive weight loss of 52 kg over 18 months. The patient’s body massindex at the time of surgery was 24.

Fig. 2. Panniculectomy including removal of umbilicus in a 56-year-old female patient afterdiet-induced weight loss of 45 kg. The patient’s body mass index at the time of surgerywas 58.

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pronator teres, which is the main muscle responsible forfractures of the weakened radius. Because of these expe-dients, the donor-site morbidity following forearm flapharvest is reduced, achieving at least good aesthetic andfunctional outcome on both soft tissue and bone.DOI: 10.1097/PRS.0b013e3181a3f197

Tommaso Agostini, M.D.Vittorugo Agostini, M.D.

Department of Plastic and Reconstructive SurgeryFaculty of Medicine and Surgery

University of FlorenceFlorence, Italy

Correspondence to Dr. Tommaso AgostiniDepartment of Plastic and Reconstructive Surgery

CTO-AOUCLargo Palagi 1

University of FlorenceFaculty of Medicine and Surgery

50100 Florence, Italytommasoagostini@ymail.com

DISCLOSURENeither of the authors has any commercial associa-

tions that may pose or create a conflict of interest withinformation presented in this communication.

REFERENCES1. Shoaib T, Van Niekerk WJ, Morley S, Ellabban MA, Soutar DS.

The ulnar artery perforator based islanded V-Y flap closure ofthe radial forearm flap donor site. J Plast Reconstr Aesthet Surg.2008;62:421–423.

2. Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducingmorbidity in the radial forearm flap donor site. Plast ReconstrSurg. 1990;86:287–292; discussion 293–294.

3. Elliot D, Bardsley AF, Batchelor AG, Soutar DS. Direct closureof the radial forearm flap donor defect. Br J Plast Surg. 1988;41:358–360.

4. Soutar DS, Widdowson WP. Immediate reconstruction of themandible using a vascularized segment of radius. Head NeckSurg. 1986;8:232–246.

Anatomical Study of the Ulnar Dorsal Arteryand Design of a New Retrograde Ulnar DorsalFlapSir:

We have read with great interest the article entitled“Anatomical Study of the Ulnar Dorsal Artery

and Design of a New Retrograde Ulnar Dorsal Flap”(Plast Reconstr Surg. 2008;121:1716–1723) by EnriqueVergara-Amador. We would like to congratulate theauthor for this outstanding study.

As mentioned in the original study, complex forearmdefects that include exposition or injury of tendons,bones, or neurovascular structures require a secure flapcoverage. In this article, the flap introduced by theauthor offers a feasible, single-step solution withoutsacrificing the major arteries. With the courage we ob-tained from this article, we decided to use this flap forone of our patients. The patient was a 42-year-old man,

who had zone 6 extensor tendon defects of the second,third, fourth, and fifth digits resulting from a trafficaccident. The dorsum of the hand had been skingrafted in another center. We planned to implant sil-icone rods for the tendon defects and to cover themwith the retrograde ulnar dorsal flap introduced in theoriginal article. After removal of the skin-grafted areaon the dorsum of the hand and implantation of thesilicone rods, we designed a 12 ! 5-cm retrograde ulnardorsal artery flap as described by the authors, andadapted it to the defect. The flap, which did not showany circulatory problems during the intraoperative and

Fig. 1. Photograph of the hand on the second postoperativeday. Obvious venous congestion progressing proximally is ob-served.

Fig. 2. Intraoperative view of the base of the flap during explo-ration. The arrow indicates a thrombosed venous structure orig-inating from the base of the flap.

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early postoperative periods, started to suffer fromvenous insufficiency on the second postoperativeday, which proceeded in a distal-to-proximal direc-tion (Fig. 1). We removed the sutures that werethought to apply tension on the flap and started leechtherapy. However, the flap did not respond to theseconservative interventions, and the patient had toundergo reoperation for debridement and soft-tissuereconstruction. In the second operation, the distaltwo-thirds of the flap was necrotic, and a thrombosedvein coursing toward the base of the flap, which wasapproximately 3 mm in diameter, was noted (Fig. 2).After removal of the necrotic flap, the defect wascovered with a groin flap.

For reverse flaps, venous inflow has been previouslyblamed as a factor that increases the risk of venousinsufficiency.1,2 In the original article, the author statesthat none of his 10 patients faced venous congestionand necrosis, which seems quite admirable to us. Wewonder how the author protected the flaps from venouscongestion and what precautions were taken. In ouropinion, if the venous congestion is caused by venousinflow, dissection and ligation of the superficial veinnear the flap base will contribute to flap survival. Incontrast, such a dissection may endanger the anasto-mosis of the ulnar artery with its deep branch.

We would kindly like to learn the author’s ideasregarding the issues mentioned above, and thank himfor his contribution to the literature.DOI: 10.1097/PRS.0b013e3181a3f4b2

Serdar Altun, M.D.Muhammet Uraloglu, M.D.

Plastic and Reconstructive SurgeryAnkara Numune Hospital

Ankara, Turkey

Metin Kerem, M.D.Sirnak State Hospital

Sirnak, Turkey

Burak Alhan, M.D.Plastic and Reconstructive Surgery

Ankara Numune HospitalAnkara, Turkey

Correspondence to Dr. AltunPlastic and Reconstructive Surgery

Ankara Numune HospitalAta Mahallesi

2. Cadde, 176. Sokak6/15, Ovecler

Ankara 06460, Turkey

REFERENCES1. Chang SM, Gu YD, Li JF. The role of the large superficial vein

in survival of proximally based versus distally based sural veno-neuro-fasciocutaneous flaps in a rabbit model. Plast ReconstrSurg. 2005;115:213–218.

2. Chang SM, Chen ZW. Can superficial veins reverse flowthrough valves in distally based fasciocutaneous flaps? PlastReconstr Surg. 1991;87:995–996.

ReplySir:

The flap congestion caused by inadequate venousdrainage is the most frequent complication in retro-grade flaps.

Studies have been performed regarding venousdrainage in the distally based peroneal flap and dis-tally based superficial sural flap, and communicatingchannels and bypasses between the concomitantveins around the arteries have been demonstratedwith venous drainage through these channels.1–3 Ithink that this concept can be adopted for the ret-rograde ulnar dorsal flap. In my experience, for thebest result, one must leave a wide adipofascial pedicleto ensure the connections between arteries and veins(Figs. 1 and 2).

A large vein inclusion into the flap, like that de-scribed by Dr. Altun et al. is not recommended by me.Xu and Lai-Jin observed that the lesser saphenous veinincluded in the pedicle of the distally based sural neu-

Fig. 1. Intraoperative view of the island retrograde ulnar dorsalflap. No large vein is included in the wide adipofascial pedicle.

Fig. 2. Photograph obtained on the third postoperative day.Good perfusion without venous insufficiency can be observed.

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rocutaneous flap is the cause of venous congestion, andthey recommend ligating the lesser saphenous vein4:

Based on our experience, we suggest the lesser saphe-nous vein cannot provide venous drainage to the distallybased sural neurocutaneous flap; in contrast, the lessersaphenous vein is the direct cause of the postoperativevenous congestion. In addition, this venous congestiondue to preservation of the lesser saphenous vein is diffi-cult to release. Due to its competent function in mostcases, we consider the lesser saphenous vein is resistantto reverse flow.4

Probably the cause of flap congestion that is de-scribed by Altun et al. could have the same explanation.

I do not have studies about the venous drainage in theretrograde ulnar dorsal flap, so I adopted the same con-cept for the distally based peroneal flap and distally basedsuperficial sural flap.DOI: 10.1097/PRS.0b013e3181a3f4fa

Enrique Vergara, M.D.Universidad Nacional de Colombia

Ciudad UniversitariaCarrera 30, Calle 45

Bogota 11001000, Colombia

REFERENCES1. Hasegawa M, Torii S, Katoh H, Esaki S. The distally based

superficial sural artery flap. Plast Reconstr Surg. 1994;93:1012–1020.

2. Oberlin C, Azoulay B, Bhatia A. The posterolateral malleolarflap of the ankle: A distally based sural neurocutaneous flap.A report of 14 cases. Plast Reconstr Surg. 1995;96:400–405.

3. Imanishi N, Nakajima H, Fukuzumi S, Aiso S. Venous drainageof the distally based lesser saphenous-sural veno-neuroadipo-fascial pedicled fasciocutaneous flap: A radiographic perfu-sion study. Plast Reconstr Surg. 1999;103:494–498.

4. Xu G, Lai-Jin L. The coverage of skin defects over the foot andankle using the distally based sural neurocutaneous flaps:Experience of 21 cases. J Plast Reconstr Aesthet Surg. 2008;61:575–577.

Splinting after Carpal Tunnel Release: CurrentPractice, Scientific Evidence, and TrendsSir:

We read with great interest the article by Henry etal. entitled “Splinting after Carpal Tunnel Release:

Current Practice, Scientific Evidence, and Trends” (PlastReconstr Surg. 2008;122:1095–1099) and were pleased tosee this good article addressing this important issue.

As mentioned in the article, there is wide variabilityin the use and duration of postoperative splinting aftercarpal tunnel release. The authors decided that noscientific evidence existed to support the use of splintsafter carpal tunnel release.

We have over 500 cases and 10 years of clinical ex-perience in carpal tunnel release surgery. We thinkproper splinting with short duration is important forboth wound healing and reduction of edema forma-tion1,2; splinting is a part of hand rehabilitation. Earlypostoperative static splinting that is applied for a short

time provides support, maintains position, and reducespain during the healing process.

The use of a dorsal splint for the first 3 days aftersurgery is a helpful measure and prevents the mediannerve from prolapsing forward and becoming adherentto or trapped by the edges of the severed transverse carpalligament.3 Thus, it is hard to say that postoperative splint-ing after carpal tunnel release is of no benefit.

We agree that long-duration splinting may causesome problems, especially in older patients. However,this does not totally eliminate the necessary use ofsplinting.

We conclude that the best policy would be short-termpostoperative splinting followed by early active motion.DOI: 10.1097/PRS.0b013e3181a3f1c3

Ramazan E. UnluSerdar Altun, M.D.Emre Inozu, M.D.

Enver Arpacı, M.D.Plastic and Reconstructive Surgery,

Ankara Numune HospitalAnkara, Turkey

Correspondence to Dr. AltunPlastic and Reconstructive Surgery

Ankara Numune HospitalAta Mahallesi

2. Cadde, 176. Sokak6/15, Ovecler

Ankara 06460, Turkey

REFERENCES1. Sailer SM. The role of splinting and rehabilitation in the

treatment of carpal and cubital tunnel syndromes. Hand Clin.1996;12:223–241.

2. Nobuta S, Sato K, Nagakawa T, Hatori M, Itoi E. Effects of wristsplinting for Carpal Tunnel syndrome and motor nerve con-duction measurements. Ups J Med Sci. 2008;113:181–192.

3. Laws ER Jr. Referral guidelines: Carpal tunnel syndrome. Neu-rosurg Focus 1997;15:e11.

ReplySir:

I thank Dr. Altun et al. for taking an interest in myarticle regarding splinting after carpal tunnel release.Although they disagree with the article, I think thearguments in their letter indirectly illustrate its funda-mental point, which was to encourage readers to prac-tice evidence-based medicine.

Altun et al. state that postoperative splinting is im-portant for wound healing and reduction of edema.The first reference cited to support this assertion is ageneral review article covering the hand therapist’s rolein the treatment and rehabilitation of carpal tunnelsyndrome (“expert opinion,” or level 5 evidence), andthe second is, curiously, a report of the effects of splint-ing on nerve conduction studies in patients who havenot undergone carpal tunnel release (completely un-related). In contrast, the five randomized controlled

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trials (level 1 evidence) discussed in my article, and anadditional trial published after it was written,1 all foundno effect of postoperative splinting on wound healingor edema.

It was further stated that postoperative splinting re-duces pain. No reference was offered to support thisassertion, and for good reason—there is none—be-cause this assertion is classic dogma. Every one of theaforementioned trials showed that splinting after car-pal tunnel release does not reduce pain. In fact, two ofthem found that postoperative discomfort was worsewhen a splint was used.

Finally, it was stated that splinting “prevents the me-dian nerve from prolapsing forward and becoming ad-herent to or trapped by the edges of the severed trans-verse carpal ligament.” The reference cited is a brief(one-page) opinion piece that provides no scientificevidence to support this assertion. Although I am awareof this potential complication of carpal tunnel release,I could not find any scientific evidence of any levellinking it to a lack of postoperative splinting. Althoughit may be impossible to disprove this possibility (i.e.,“prove the negative”), consider the following: with over400,000 carpal tunnel releases performed in the UnitedStates annually,2 it follows from my survey results that overthe past 10 years—the time frame of the 500-case expe-rience of Dr. Altun et al.—there have been roughly 2million “splintless” carpal tunnel releases performed inthe United States alone, yet there has not been a singlestudy associating median nerve entrapment with a lack ofpostoperative splinting. Admittedly, this extrapolationdoes not qualify as scientific evidence, but it does providecompelling testimony that median nerve entrapment (orany other complication) is almost certainly not a functionof whether a splint is used.

I fully recognize that much of what we do in plasticsurgery is not and cannot be based on level 1 evidence, asmany of the problems we face are simply not amenable torandomized controlled investigations. Expert opinionand theoretical concerns therefore still do and shouldhave a very important influence on how we practice. How-ever, in a few instances—such as splinting after carpaltunnel release—good scientific evidence exists to directus. Although I certainly do not believe that a brief periodof postoperative splinting does any significant harm, I dofeel that it may be a nuisance to patients and is an un-necessary expenditure of time and materials. I again urgeDr. Altun et al.—and all surgeons—to look critically at theevidence and adjust their practice accordingly.DOI: 10.1097/PRS.0b013e3181a3f1e8

Steven L. Henry, M.D.Chang Gung Memorial Hoptial

Taipei, Taiwansteve7973@gmail.com

DISCLOSUREThe author has no commercial associations with or

financial interests in any of the drugs, products, orinstruments used in this study.

REFERENCES1. Cebesoy O, Kose KC, Kuru I, et al. Use of a splint following

open carpal tunnel release: A comparative study. Adv Ther.2007;24:478–484.

2. Palmer DH, Hanrahan LP. Social and economic costs of carpaltunnel surgery. Instr Course Lect. 1995;44:167–172.

Calf Augmentation with Autologous TissueInjectionSir:

Erol, Gurlek, and Agaoglu published an originalmethod of using autologous fat and tissue cocktail

injection for the correction of hypoplastic calves (PlastReconstr Surg. 2008;121:2127–2133). The senior authorhas vast experience with the use of autologous dicedcartilage, dermis, and fat for improving facial form ingeneral and particularly the nasal dorsum.1 Similartechniques were applied during the years 1992 to 2003in 77 patients with the aim of restoring the deficientmedial contour of their calves.

The authors presented a good historic review of calfaugmentation techniques and a well-illustrated descrip-tion of their method. They listed possible complicationsand disadvantages associated with the use of the siliconeimplants, but the most dreadful complication—compart-ment syndrome—was omitted (Fig. 1).2,3 They reportedthat “the planned shape was achieved in all patients afterone to four injections.” This included good improvementin 67 (87 percent) and moderate improvement in 10

Fig. 1. Photograph demonstrating compartment syndrome in28-year-old body builder after calf augmentation with two im-plants, 165 cc on the medial side and 90 cc on the lateral side. Thepatient is shown 1 year later, after fasciotomies and multiple de-bridements in the anterior tibiofibular compartment.

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patients. “None of the patients showed minimal or noclinical improvement.”

The problem is that the three—presumably thebest—cases in Figures 2 through 4, illustrating the vir-tues of their method, did not support the aforemen-tioned favorable statistics of clinical outcomes. I see nochange in the preoperative and postoperative photo-graphs in Figures 3 and 5 and minimal but aestheticallyinsufficient improvement in the case in Figure 4.

Reported results were calculated on the basis of as-sessment of the preoperative and postoperative pho-tographs by the three independent physicians. An eval-uation would have been more objective if insteadpatients were assessed and the preoperative and post-operative calf circumferences was compared.4,5 Threepatients depicted in Figures 1, 3, and 4 are bow-legged(genu varum). In such cases, insertion of an implantwith the larger height (projection) will counterbalancebow deformity by creation of the convex medial con-tour (Fig. 2). Frequently, liposuction in the lower thirdof the crus, lateral to the Achilles tendon, will furtherimprove the total aesthetic impression.4,5 After readingthis article, I do not think that “fat injection is veryeffective” for improvement of the calf contour. Thedescribed method is biologically correct, attractive intheory, and opportune, but in my opinion the authorsfailed to prove that it actually works in calves.DOI: 10.1097/PRS.0b013e3181a3f4d0

Igor Niechajev, M.D., D.Sc.Lidingo-clinicTorsvagen 30

181 32 Lidingo-Stockholm, Swedeninfo@lidingokliniken.se

REFERENCES1. Erol OO. Facial autologous soft-tissue contouring by adjunc-

tion of tissue cocktail injection (micrograft and minigraftmixture of dermis, fascia, and fat). Plast Reconstr Surg. 2000;106:1375–1387; discussion 1388–1389.

2. Haeck P. On legal grounds: Part two. $1 million and up. Case9. Plast Surg News 2006;December:11.

3. Medical malpractice in plastic surgery cases: Part I and II. YouTube, 2008. Available at: http://www.youtube.com/watch?v"1DPaqGLVv2I http://www.youtube.com/watch?v"xtGc_N9RvZM&feature"related.

4. Niechajev I. Calf augmentation and restoration. Plast ReconstrSurg. 2005;116:296–305; discussion 306–307.

5. Niechajev I. Calf implant techniques. Body Language 2005;16:12–14.

ReplySir:

We would like to thank Dr. Niechajev for his interestin reading our article “Calf Augmentation with Autol-ogous Tissue Injection” (Plast Reconstr Surg. 2008;121:2127-2133). We know that Dr. Niechajev has significantexperience with calf silicone implants. Calf augmenta-tion with silicone implants has been improved over theyears. However, calf implants have many drawbacks,including infection, capsular contracture, extrusion,displacement, visualization, rupture of the implant,and erosion of the bone surface. Dr. Niechajev hasadded the most dreadful complication, the compart-ment syndrome, to the list of the calf implant draw-backs, which we had failed to mention. We have seenmany patients who had calf implants in another insti-tution with at least one or two of the complicationsmentioned above. Dr. Niechajev has criticized our re-sults by mentioning that he cannot see any change inthe postoperative photographs. Evaluation of the pa-tients was performed by taking photographs at the samedistance and angle, as we think it is the most valuablemethod for assessing the results. The preoperative andpostoperative photographs of the patients were evalu-ated by three independent physicians and the peerreviewers of this Journal and were accepted as satis-factory. Repeated injection of autologous tissue (atleast two sessions) was performed in all of the pa-tients to achieve the desired result, and patient sat-isfaction was the key criterion in ending the treat-ment. We present another patient treated with thesame method who asked for exaggerated augmenta-tion of her calves; we hope this will convince, and beacceptable to, Dr. Niechajev (Fig. 1).

We believe that calf augmentation with autologoustissue injection has many advantages and we recom-mend it to those surgeons who consider calf augmen-tation and approach silicone implants cautiously.DOI: 10.1097/PRS.0b013e3181a43d8e

Fig. 2. Photograph of a 25-year-old woman with thin bow legs 3years after calf augmentation with 220-cc symmetric implantswith 30-mm projection, placed medially and camouflaging thebow deformity. The arrow indicates the convex medial contour.(Modified with permission from Niechajev I. Calf implant tech-niques. Body Language 2005;16:12–14.)

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O. Onur Erol, M.D.ONEP Plastic Surgery Science Institute, and

Istanbul Bilim UniversityIstanbul, Turkey

Galip Agaoglu, M.D.Istanbul Bilim University

Istanbul, Turkey

Correspondence to Dr. ErolONEP Plastic Surgery Science Institute

Manolyalı Sokak No: 15 Levent34330 Istanbul, Turkey

onurerolmd@onep.com.tr

Redefining Reoperations: Ducks andLow-Mileage LoveliesSir:

The editorial entitled “Redefining Reoperations” inthe October of 2008 issue of this Journal fails to

make a logical case for “redefining reoperations,” muchless renaming reoperations as “revisions.”

The author’s solution to increased risks and costs forpatients of reoperations is a nomenclature smoke-screen—a classification with 30 categories and an as-tounding suggestion that the term “revision” is an ap-propriate substitute for all reoperations. Solutions that

Fig. 1. Photographs obtained preoperatively (left) and 2 years after two sessions of micro fatinjection into each leg (right).

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really deliver better for patients are not opinions—theyare scientifically verifiable improvements in every as-pect of patient care. I am not aware of any classificationsystem or renaming scheme that has ever been shownby objective data to lower patient risks and costs.

The tone of the editorial implies that most reopera-tions are simply revisions, that patient discretionaryreoperations somehow do not count, that surgeonswith low reoperation rates may be “gaming” the system,and that categorizing changes reality. Logic and datasuggest otherwise.

First I will discuss logic. Using the author’s proposedcategory system, only four of 30 causes of reoperation(13 percent) are clearly events where surgeon and pa-tient decisions and actions do not impact the rate ofoccurrence. Seven of 30 causes of reoperation (23 per-cent) relate directly to patient education and informedconsent processes; thirteen of 30 (43 percent) relatedirectly to surgeon and patient decision processes; andthree of 30 (10 percent) are patient discretionary. Amaximum of 13 percent of causes of reoperation arenot directly affected in some way by patient and sur-geon decisions and actions—87 percent of reopera-tions the author would like to call revisions (or 77percent if one subtracts patient discretionary procedures)might have occurred at a much lower rate if decisions andprocesses had been optimal during the first augmenta-tion. Events that can occur in any operation, such asinfection, seroma, hematoma, and capsular contracture,are not exempt, because each relates directly to surgeondecisions and actions. Patient discretion is a right. Ensur-ing that patients recognize the consequences of choicesand decisions is a surgeon responsibility. Reducing un-necessary reoperations requires that surgeons recognizeand change decision processes and actions, not definecategories and change names.

Now I will discuss data. In the most recent averageddata from premarket approval studies by Mentor andAllergan,1,2 the reoperation rate for the four of 30causes of reoperation (13 percent) that were not di-rectly related to surgeon and patient decisions andactions constituted a total of 7.8 percent of reopera-tions (biopsy/lumpectomy, 5.8 percent; nipple proce-dure, 1.4 percent; and mastectomy/diagnosis of can-cer, 0.6 percent); 92.2 percent of all reoperations wererelated directly or indirectly to patient and surgeondecisions and actions. Peer-reviewed and publisheddata clearly prove that those numbers can be reduceddramatically by straightforward, proven processes.3 Sev-enteen percent of all reoperations in Allergan’s latestpremarket approval study data2 were for size exchange,the most common reason for reoperation. Patient dis-cretion rights acknowledged, this number is totally un-acceptable. Inadequate education, decisions based onsubjective opinions and requests instead of totally ob-jective patient tissue measurements, failure to prioritizedecisions, unwillingness to say “no” to a patient to pre-vent damage to their tissues, and manufacturer unwill-

ingness to address the issue because of revenue con-cerns are root causes of this ridiculously highreoperation rate for size exchange.

Optimally educated patients seek elective reopera-tions at a much lower rate compared with U.S. Foodand Drug Administration data.1–5 Patients request sizechange less, because they were taught and understandpreoperatively that systems exist that accurately andpredictably fill their breast maximally based on breastwidth and skin stretch.3,4 Once filled, additional volumecreates unnatural upper breast shape distortion andrisks of longer term, irreversible tissue compromisesthat include parenchymal atrophy, skin and subcuta-neous tissue thinning, and visible rippling. Optimallyeducated patients seek fewer reoperations for minorshape differences and asymmetries because they weretaught preoperatively that no two breasts ever matchbefore or after augmentation (despite some surgeons’claims) and that all breasts are different postopera-tively, and that revisions, instead of making breastsmatch, only deliver a different set of differences.

Veiled assertions such as surgeons gaming the systemand “women [being denied] legitimate revisions orreasonable discretionary changes simply to keep agiven surgeon’s operation rate artificially low” are in-appropriate from the Breast section editor of this Jour-nal, even in an editorial. More appropriate alternativesare to provide proof, reject the articles, or match thepeer-reviewed results.

The ancient mariner with a massive, dead bird hang-ing around his neck, with feathers, a bill, and wings, cancall it a duck, but it remains an albatross. Renaming itdoes not make it go away. A used-car salesman trying tounload on an unwary buyer can call it a low-mileagelovely, but it remains a worn machine that could usesome maintenance. Renaming it does not fix what iswrong. Call it what you may, but it is what it is. At-tempting to rename reoperations to revisions is not inthe best interests of patients. Redefining reoperationsis not about renaming. Redefining reoperations isabout improving patient education and implementa-tion of processes that lower reoperation rates.

From the lyrics of a song by Toby Keith, “a little lesstalk and a lot more action” is what patients need.DOI: 10.1097/PRS.0b013e3181a3f144

John B. Tebbetts, M.D.2801 Lemmon AvenueWest, Suite 300

Dallas, Texas 75204jbt@plastic-surgery.com

REFERENCES1. Cunningham B. The Mentor Study on Contour Profile Gel

Silicone MemoryGel Breast Implants. Plast Reconstr Surg. 2007;120(Suppl 1):33S–39S.

2. Allergan, Inc. Important information for women about breastaugmentation with Natrelle silicone-filled breast implants.Available at: http://www.allergan.com/assets/pdf/11174_Aug_Labeling_7308.pdf. Accessed October 29, 2008.

3. Tebbetts JB. Achieving a zero percent reoperation rate at3 years in a 50 consecutive case augmentation mamma-

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plasty PMA study. Plast Reconstr Surg. 2006;118:1453–1457.

4. Tebbetts JB, Adams WP. Five critical decisions in breast aug-mentation using 5 measurements in 5 minutes: The high fivesystem. Plast Reconstr Surg. 2005;116:2005–2016.

5. Tebbetts JB. An approach that integrates patient educationand informed consent in breast augmentation. Plast ReconstrSurg. 2002;110:971–978.

External Skin ExpansionSir:

I was delighted to read the article by Daya and Nairconfirming the concept of external skin expansion.1

I have been working on this principle for 8 years withengineers from Canica Design, Inc. (Almonte, Ontario,Canada), developing products to accomplish woundclosure and presurgical external skin expansion in asafe and reliable way.

There are two complications one may encounter inthe skin with tape application under tension. The firstis blistering from the shear forces at the skin adhesivejunction.2 These blisters are painful and can causescarring. Reinforced strips do not stretch, whichmeans that when they are adhered under tension, allof the force on the tape is transferred to the skinbeneath the strip. The skin is no longer compliant,as it is bonded to the reinforced fabric. The skin rightat the end of the strip suffers the highest load. Thesecond problem is pain.

Dr. Dal Cin describes expanding the skin to close an8-cm skin graft on a scalp with dynamic external forcesover a period of 149 days. The patient lost enthusiasmat several points along the way because of discomfort.However, with the adjustable features of dynamic trac-tion, gently stretching the scalp, the graft was excisedand primary closure achieved.2,3

The Canica Design solution has been to simply usean elastomer between two strips of Micropore tape (3M,St. Paul, Minn.). This provides gentle relentless tractionon the skin. The level of tension is set initially by alimiter controlling the stretch of the elastomer, whichprotects even the most easily damaged skin (e.g., legulcers in diabetics and in irradiated skin). Similarly, thismechanism of controlled tensioning reduces pain. It isnoninvasive, repeatable, and very easily applied. Theproduct is called DynaClose. It is licensed for woundclosure and is currently being reviewed by the U.S.Food and Drug Administration for surgical skin expan-sion. It is approved in Canada for both uses.

We believe this product offers benefits similar to thetechnique described by Daya and Nair in prestretchingskin but will avoid the problems of skin irritation, break-down, and pain. This is achieved by controlled elasticforces.

As Daya and Nair state, the use of the external trac-tion principle has many potential applications4–6: pre-stretching skin before surgical reconstruction, pain re-lief, and scar reduction. The Canica DynaClose tapecan also be used in open wounds, which can be viewed

directly through the transparent silicone sheeting, sothat any infectious process would be directly evident(Fig. 1). This principle of dynamic closure is invaluablein closing unclosable wounds nonsurgically. DynaCloseis the latest and simplest of the Canica family of Dy-

Fig. 1. This fasciotomy was primarily controlled by DynaClosetape to prevent excessive retraction. The tapes were changedweekly to achieve delayed primary closure by 5 weeks, with nosecondary intervention required. (Above) Photograph obtainedon July 9, 2007. (Center and below) Photographs obtained onApril 23, 2008.

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namic Wound Closure devices, which are well docu-mented in the literature.7–10

With my evident conflict of interest as a paid designconsultant for Canica Design, I cannot participate in avalid study of these products, but I would encourageothers to assess the benefits of this newly available tech-nology in an objective fashion.DOI: 10.1097/PRS.0b013e3181a3f4e7

Michael S. G. Bell, M.D.Plastic, Reconstructive, Cosmetic Surgery

and Laser Resurfacing1919 Riverside Drive, Suite 402

Ottawa, Ontario K1H 1A2, Canadamsgbell@cyberus.ca

REFERENCES1. Daya M, Nair V. Traction-assisted dermatogenesis by serial

intermittent skin tape application. Plast Reconstr Surg. 2008;122:1047–1054.

2. Pushpakumar SB, Hanson RP, Carroll S. The application ofSteri-Strips. Plast Reconstr Surg. 2004;113:1106–1107.

3. Dal Cin A, Seal SK. Scalp expansion with the Canica WoundClosure System: First case report. Can J Plast Surg. 2006;14:233–235.

4. Taylor RC, Reitsma BJ, Sarazin S, Bell MSG. Early resultsusing a dynamic method for delayed primary closure of fas-ciotomy wounds. J Am Coll Surg. 2003;197:872–878.

5. Price J, Rubens F, Bell MSG. Elastic device facilitating delayedprimary closure of sternal wound infection. Ann Thorac Surg.2007;83:1162–1165.

6. Berg R, Hristov H, George R. Pre-operative use of a noveladhesive expanding device for primary closure of compli-cated wide local excisions. Poster presented at: CanadianAssociation of General Surgeons Forum; September 7–8,2007; Toronto, Ontario, Canada.

7. Bluman E, Foley R, Singh N, Albrecht M. Application of adynamic closure device to four compartment leg fasciotomywounds caused by high energy combat injuries obviated theneed for skin grafting. Poster presented at: Society of MilitaryOrthopedic Surgeons Conference; December 10–13, 2007;Vail, Col.

8. Singh N, Starnes B, Andersen C. Dynamic wound closure fordecompressive fasciotomy. Paper presented at: 2007 Com-bined Annual Meeting of the Washington and Oregon Chap-ters of the American College of Surgeons; June 14–17, 2007;Chelan, Wash.

9. Urbaniak RM, Khuthaila DK, Dhaili AJ, Hammond DC. Clo-sure of massive abdominal wall defects: A case report usingthe abdominal reapproximation anchor (ABRA) system. AnnPlast Surg. 2006;57:573–577.

10. Reimer MW, Yelle YD, Reitsma B, Doumit G, Allen MA, BellMSG. Management of open abdominal wounds using a dy-namic fascial closure system. Can J Plast Surg. 2008;51:209–214.

ReplySir:

I am most appreciative of the compliment extended tous by Dr. Bell. The technique that both of us describe hasclear advantages. I have applied this technique only toscars and not open wounds. I am most encouraged by thedescribed technique with the DynaClose product, with aclear advantage of its application in open wounds.

The complications of erythema, folliculitis, and blis-tering are noted in our article.1 The use of the skinbarrier cream may be invaluable because these com-plications were not seen after careful skin preparationand the use of skin protectant. We also thought that itwas important to control the amount of traction on theskin on application of the tape to avoid the shearingforces, which are powerful enough to blister the skin.None of our patients experienced pain. Perhaps theexperience of pain is related more to the use in openwounds and invasive external devices.

We find that the described Canica DynaClose tech-nique has a long period of expansion: 149 days for thecase report of the 8-cm skin graft scalp resurfacing2 and5 weeks for the open fasciotomy case as described in theletter. It is my opinion that the latter case is a combi-nation of traction and open wound secondary healing,and the contribution of each cannot be clearly eluci-dated. The DynaClose device is demonstrated to beapplied over a wide area of the adjacent skin. Theattached skin directly under the device or the tape isrendered noncompliant and is not available for theprocess of expansion. Only the unattached skin outsidethe zone of attachment is available for both mechanicaland biological creep. The relatively long interval ofexpansion may also be an indicator that the amount oftraction generated by the DynaClose device is not op-timized for the potential extensibility and creep in thesurrounding skin. The controlled elastic forcesachieved by this device may prevent the noted compli-cations, but the limit of the skin to withstand the trac-tion forces without sequelae needs to be further studiedin the interest of decreasing tissue expansion time.

I would also like to encourage clinicians and re-searchers alike to further explore the potential of thistechnique of tissue expansion.DOI: 10.1097/PRS.0b013e3181a3f1b1

Mahendra Daya, F.C.S.(S.A.)Department of Plastic and Reconstructive Surgery

Inkosi Albert Luthuli Central Hospital800 Bellair Road

Cato ManorDurban, Kwazulu-Natal 4091, South Africa

REFERENCES1. Daya M, Nair V. Traction-assisted dermatogenesis by serial

intermittent skin tape application. Plast Reconstr Surg. 2008;122:1047–1054.

2. Dal Cin A, Seal SKF. Scalp expansion with the Canica WoundClosure System: First case report. Can J Plast Surg. 2006;14:233–235.

Assaying Fat Cell Viability: A Focus on Clinicalover Experimental TechniqueSir:

We read with great interest the article by Pu et al.assessing the clinical viability of fat grafting using

two different harvesting techniques and concludingsuperior fat graft viability using manually aspirated fat

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in comparison with conventional liposuction.1 We wishto bring to your attention the fact that several protocoldifferences have the potential to undermine these con-clusions. The fat, harvested with two different techniques,was subsequently centrifuged with different machines atdifferent settings and with different centrifugation tubesizes. This combination of variables makes it difficult todistinguish which, if any, components of the Colemantechnique result in superior fat graft viability.

The assays for viability, appropriate as they may be,would benefit from controlling for fat cell concentra-tion, which is not addressed in the text. Because thecentrifuge presumably exerts different relative centrif-ugal forces over the different time settings (3 versus 10minutes), equivalent volumes aspirated from the cen-tral fat layer should not be presumed to have the sameconcentration of graftable cells. A simple assay for totalcell number aspirated after centrifugation, irrespec-tive of viability, with subsequent results expressed aspercentage viable or, ideally, additional centrifuga-tion control groups, would resolve this issue. It isunfortunate that the divergent methods for collect-ing and processing the fat in this study do not allowfor an equitable comparison and for a clinicallysound conclusion regarding best practices.DOI: 10.1097/PRS.0b013e3181a3f15c

Jonathan D. McCue, M.D.Bruce L. Cunningham, M.D., M.S.

Department of Plastic and Reconstructive SurgeryUniversity of Minnesota

Minneapolis, Minn.

Correspondence to Dr. McCueDepartment of Plastic and Reconstructive Surgery

University of Minnesota420 Delaware Street, SE

Minneapolis, Minn. 55455

REFERENCE1. Pu LL, Coleman SR, Cui X, Ferguson RE Jr, Vasconez HC.

Autologous fat grafts harvested and refined by the Colemantechnique: A comparative study. Plast Reconstr Surg. 2008;122:932–937.

ReplySir:

On behalf of the authors of our recent article pub-lished in Plastic and Reconstructive Surgery,1 we appreciatevery much the thoughtful comments on our article byDrs. McCue and Cunningham. We totally agree withtheir concerns regarding the differences in terms ofhow fat grafts were harvested and processed with theColeman technique and conventional liposuction. Inour study, we attempted to compare two different tech-niques that have commonly been used clinically to har-vest and process the fat grafts.2 One was the Colemantechnique using a syringe for manual aspiration of fatthat was then put into a 10-cc syringe and centrifugedwith a standard centrifuge (Byron Medical, Inc., Tuc-

son, Ariz.) at 3000 rpm for 3 minutes. The middle layerwithin the syringe after centrifugation, although it mayhave different concentrations of adipocytes, was ana-lyzed. Fat harvested by conventional liposuction wasprocessed by our modified method based on the studyby Boschert et al.,3 also published in this Journal. In ourmethod, adipose aspirates from conventional liposuc-tion were collected in a 50-cc tube and then centrifugedat 500 rpm for 10 minutes. After centrifugation, theresulting middle layer of adipose aspirates that con-tained the most viable adipocytes was studied. We be-lieve our modified method may represent the best wayof processing fat grafts harvested with conventionalliposuction if these fat grafts were used clinically. Ourstudy was designed to possibly compare the viability ofthe fat grafts harvested and processed by these twodifferent techniques (fat grafts from the Coleman tech-nique versus fat grafts from conventional liposuctionand processed with our modified method). Our inten-tion was to compare the end products from each tech-nique, even though the size of the tube used for cen-trifugation, the force of centrifugation, and also theduration of the centrifugation were different. We agreewith Drs. McCue and Cunningham that this may resultin different concentrations of viable adipocytes withinthe fat grafts harvested and processed by each tech-nique. Nevertheless, we felt we provided the best pos-sible comparison of the fat grafts as end products fromeach technique, just like another study we conducted.4Interestingly, the fat grafts harvested and processed bythese two different techniques seem to appear grosslysimilar, even though the concentration of viable adi-pocytes may not be the same.

With acknowledgment of the limitations of the study,including the two techniques described in our article,our study focused on comparison of the viability of thefat grafts harvested and processed by these two tech-niques regardless of the differences between the twotechniques. Perhaps in the future we should conductanother study to provide a truly equivalent comparisonin which fat grafts are harvested by conventional lipo-suction but processed by the exact Coleman technique.DOI: 10.1097/PRS.0b013e3181a3f1d6

Lee L. Q. Pu, M.D., Ph.D.Division of Plastic Surgery

University of California, Davis2221 Stockton Boulevard, Suite 2123

Sacramento, Calif. 95817lee.pu@ucdmc.ucdavis.edu

DISCLOSUREThe author has no commercial associations or fi-

nancial interests in any of the drugs, products, or in-struments used in this study.

REFERENCES1. Pu LL, Coleman SR, Cui X, Ferguson RE Jr, Vasconez HC.

Autologous fat grafts harvested and refined by the Colemantechnique: A comparative study. Plast Reconstr Surg. 2008;122:932–937.

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2. Kaufman MR, Bradley JP, Dickinson B, et al. Autologous fattransfer national consensus survey: Trends in techniques forharvest, preparation, and application, and perception of short-and long-term results. Plast Reconstr Surg. 2007;119:323–331.

3. Boschert MT, Beckert BW, Puckett CL, Concannon MJ. Anal-ysis of lipocyte viability after liposuction. Plast Reconstr Surg.2002;109:761–765; discussion 766–767.

4. Pu LL, Cui X, Fink BF, Cibull ML, Gao D. The viability of fattytissues within adipose aspirates after conventional liposuction.Ann Plast Surg. 2005;54:288–292; discussion 292.

Correction: Treatment of a Postburn KeloidScar with Topical Captopril: Report of theFirst Case

In the Viewpoint entitled “Treatment of a PostburnKeloid Scar with Topical Captopril: Report of the

First Case,” by Ardekani et al. (Plast Reconstr Surg. 2009;123:112e–113e), the last name of the second author wasmisspelled. The author’s name should have appearedas Shahin Aghaei, M.D. This error has been noted inthe online version of the article, which is available at theJournal’s website (www.PRSJournal.com). The pub-lisher regrets this error.DOI: 10.1097/PRS.0b013e3181abc4b4

REFERENCEArdekani GS, Aghaei S, Nemati MH, Handjani F, Kasraee B.Treatment of a postburn keloid scar with topical captopril:Report of the first case. Plast Reconstr Surg. 2009;123:112e–113e.

Correction: Accelerating Stem Cell Proliferationby Down-Regulation of Cell Cycle Regulator p21

In the February 2009 Plastic Surgery Research CouncilSupplement article entitled “Accelerating Stem Cell

Proliferation by Down-Regulation of Cell Cycle Regu-

lator p21,” by Plasilova et al. (Plast Reconstr Surg. 2009;123(Suppl.):149S–157S), the last name of the secondauthor was misspelled. The author’s name should haveappeared as Bjorn Schonmeyr, M.D. This error hasbeen noted in the online version of the article, whichis available at the Journal’s website (www.PRSJournal.com). The publisher regrets this error.DOI: 10.1097/PRS.0b013e3181abc517

REFERENCEPlasilova M, Schonmeyr B, Fernandez J, Clavin N, Soares M,Mehrara BJ. Accelerating stem cell proliferation by down-regula-tion of cell cycle regulator p21. Plast Reconstr Surg. 2009;123(Suppl.):149S–157S.

Correction: Histologic Analysis of Angiogenesisand Lymphangiogenesis in AcellularHuman Dermis

In the April 2008 article entitled “Histologic Analysisof Angiogenesis and Lymphangiogenesis in Acellular

Human Dermis,” by Wong et al. (Plast Reconstr Surg.2008;121:1144–1152), the last name of the second au-thor was misspelled. The author’s name should haveappeared as Bjorn H. Schonmeyr, M.D. This error hasbeen noted in the online version of the article, whichis available at the Journal’s website (www.PRSJournal.com). The publisher regrets this error.DOI: 10.1097/PRS.0b013e3181abd4d5

REFERENCEWong AK, Schonmeyr BH, Singh P, Carlson DL, Li S, Mehrara BJ.Histologic analysis of angiogenesis and lymphangiogenesis in acel-lular human dermis. Plast Reconstr Surg. 2008;121:1144–1152.

Future Meetings of the American Society of Plastic SurgeonsThe following are the planned sites and dates for future annual meetings of the American Society of PlasticSurgeons:

2009 Seattle, Wash. October 23 to 28

2010 Toronto, Canada October 1 to 6

2011 Denver, Colo. September 23 to 28

2012 Washington, D.C. November 1 to 7

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