VIEWPOINTS

GUIDELINES

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tiful female subjects, and measurements between facial landmarks were obtained and depicted in charts
(Figs. 1 and 2).
The criteria for being beautiful were based on the
research committees opinion. Charts were constructed
on the basis of information regarding North American
Caucasians.1 Findings were compared with those of
Caucasians by using SPSS (SPSS, Inc., Chicago, Ill.)
(one-sample t test, p 0.05; 95 percent confidence
interval). The results are listed in Table 1.
All parameters regarding anterior and lateral views
of face height were smaller compared with those of

Fig. 1. Standard landmarks, frontal view.

Viewpoints
Facial Aesthetic Analysis in Beautiful Persian
Female Subjects Aged 13 to 30 Years by Means
of Photogrammetry
Sir:

acial analysis is of great importance for evaluation

and planning in aesthetic surgery.1 Numerous studies have resulted in the vast array of reports available,
the majority of which have been gathered from American Caucasians, and there are few regarding the Persian population.2 4 Porter reported the significant differences among various ethnicities and cited the need
for ethnic data.
Standard photogrammetry, using both anteroposterior and lateral views, incorporating a ruler or grid for
adjustments, was performed (focal length, 95 cm; object distance to camera, 125 cm; zooming by means of
Tele; real size printing).
Standard facial landmarks were represented by
points on printed photographs of 197 Persian beauCopyright 2010 by the American Society of Plastic Surgeons

Fig. 2. Standard landmarks, lateral view.

www.PRSJournal.com

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Plastic and Reconstructive Surgery June 2010

Table 1. Results and Basic Data Compared
Measurements
Facial heights for female subjects, mm
Upper tr-n
Middle n-sn
Lower sn-gn
Upper tr-,gn
Middle g-sn
Lower sn-me
sn-st
st-gn
Forehead
Forehead height, cm
Eyebrow, mm
Brow-pupil
Brow-crease
Eyes, mm
Intercanthal
Eye fissure
Upper lid limbus
Scleral show
Nose, mm
Alar base width
Ala-medial canthus
Lips, mm
Commissure medial limbus
Upper lip length
Upper lip vermillion
Lower lip vermillion
Lip strain
Tooth, mm
Incisor show
Lateral view
Lateral upper tr-n
Lateral middle n-sn
Lateral lower sn-gn
Lateral upper tr-gn
Lateral middle g-sn
Lateral lower sn-me
sn-st
st-gn
Forehead, degrees
Inclination
Nasofrontal angle
Eyes, mm
SOR-cornea
IOR-cornea
LOR-cornea
Nose
n-g (negative), mm
Nasofacial angle, degrees
Ala-sn, mm
Nasolabial angle, degrees
Lips, mm
Upper lip length
st-sl
sl-gn
Chin
g-sn sn-pg, degrees
Perp to FH through sn, mm
Perp to FH through n, mm
Facial convexity
Inclination of Lieber line, degrees

Basic Data
Measurements

Test Data
Measurements

Comments

63 6
51 3
64 4
53 6
63 4
64 4
20 2
43 3

59 2
59 2
58 2
50 3
65 5
55 2
20 1
38 2

Decreased
Increased
Decreased
Decreased
Increased
Decreased
Within
Decreased

56

5.7 3

No change

25
15

24 1.5
14 1.5

Within
Within

3034
2931
12
0

32 2
32 1
1.7 0.4
0.6 0.4

No change
Increased
Increased
Increased

32 1
0.6 0.7

No change

12
Within limbus width
20 2
9 1.3
9 1.5
Absent

Within limbus width

20 1
10 1
11 0.7
Absent

No change
Within
Increased
Increased
No change

14

21

63 6
51 3
64 4
53 6
63 4
64 4
20 2
43 3

59 2
59 2
58 2
50 3
65 5
55 2
20 1
38 2

Decreased
Increased
Decreased
Decreased
Increased
Decreased
Decreased
Decreased

65
134 7

72
135 3

Increased
Within

() 812
() 23
() 1216

() 9.6 1.5
() 2 0.5
() 15 1

Decreased
Decreased
Within

() 46
34
() 2
105108

() 4.5 0.7
34 0.5
() 1.5 0.5
106 1

Decreased
No change

20 2
18 5
27 3
11 4
() 3 3
02
1.6 2.5

Caucasians (statistically significant), except for n-sn

(n-sn 59 mm versus 51 mm) and g-sn (g-sn 65
5 mm versus 63 4 mm), which were longer (statistically
significant). Therefore, the midface was a few millimeters

246e

Within

No change

20 1
15 2
23 1.5

Decreased
Decreased
Decreased

15 1
0.4 2
0.4 1

Increased
Within
No change

51

Increased

longer in the study group, and the lower third of the face
was a bit shorter (sn-st and st-gn); however, the canons
still rule the face. The height of the forehead was the
same, but the inclination and nasofrontal angle were

Volume 125, Number 6 Viewpoints

higher. Surveying eyebrow and eye parameters showed
reduced figures for eyebrow-pupil, eyebrow-crease, SOR,
and IOR, and an increase for LOR, eye fissure, and upper
lid-limbus. Although a statistical difference was reported,
the standard deviations and means were within the values
for Caucasians. However, clinically, eyes seemed to be
more prominent (Table 1).
In contrast, there was minimal scleral show, yet the
overall beautiful appearance of the study group was not
detrimentally affected (yet it is possible that otherwise
they would appear prettier). The sum of these factors led
to more prominent eyes in the study group. A review of
nasal parameters showed statistical differences, but again,
mean values and SD were within those of Caucasians.
Generally, lips were somewhat shorter but more prominent in the study group (vermilion parameters and lip
length, sn-st, st-sl). Overall, chin height was a bit shorter,
clinically justifiable and regarding sn-st and st-gn values
(statistically significant). Facial convexity was greater in
the study group (g-sn sn-pg, perp to FH through sn,
inclination of the Lieber line) (statistically significant).
The inclination of the Lieber line was 5 1 degrees
compared with 1.6 2.5 degrees in Caucasians.
In summary, the overall facies of the study group
were as follows: small lower third of the face and chin,
prominent eyes, prominent lips, and a more convex
facial profile, all denoting a baby face appearance. It
is obvious that for a reasonable deduction, we are still
short of data, but according to the presented information, it seems that although some figures of Caucasians
were still applicable to the Persian population, many of
them might be changed for Persians if optimal operative
results are to be achieved (Table 1).
DOI: 10.1097/PRS.0b013e3181cb6486

Mohammad Reza Farahvash, M.D.

Jamshid Khak, M.D.
Department of Plastic Surgery
Medical School of Tehran University of Medical Sciences

Maryam Jafari Horestani, D.D.S.

Aesthetic and Operative Dentistry
Qazvin University of Medical Sciences
Faculty of Dentistry
Qazvin, Iran

Yashar Farahvash
Massachusetts College of Pharmacy
Boston, Mass.

Benyamin Farahvash
Department of Dermatology
Medical School of Boston University
Boston, Mass.
Correspondence to Dr. Farahvash
B-10-1, Hafez Building, Hormozan Avenue, Shahrak Gharb
Tehran 14667, Islamic Republic of Iran
drfarahvash@yahoo.com

PATIENT CONSENT
The patient provided written consent for the use of her image.

REFERENCES
1. Mathes SJ. The head and neck: Part 1. In: Plastic Surgery. Vol.
2, 2nd ed. Philadelphia: Saunders Elsevier; 2006:45.
2. Farkas LG, Bryson W, Klotz J. Is photogrammetry of the face
reliable? Plast Reconstr Surg. 1980;66:346355.
3. Chatrath P, De Cordova J, Nouraei SA, Ahmed J, Saleh HA.
Objective assessment of facial asymmetry in rhinoplasty patients. Arch Facial Plast Surg. 2007;9:184187.
4. Choe KS, Sclafani AP, Litner JA, Yu GP, Romo T III. The
Korean American womans face: Anthropometric measurements and quantitative analysis of facial aesthetics. Arch Facial
Plast Surg. 2004;6:244252.

Direct Excision of Glabellar Furrows:

An Alternative Treatment for Severe
Glabellar Rhytides
Sir:

reatment options for severe glabellar rhytides include brow lifts with open resection of the corrugator muscle, botulinum toxin type A (Botox; Allergan,
Inc., Irvine, Calif.) injections, intradermal fillers, topical creams, and endoscopic resection of the corrugator
muscle.1,2 For a select group of motivated patients with
glabellar rhytides that are more severe than the potential postoperative scarring, we believe that the direct
excision of severe glabellar furrows is an effective surgical alternative to traditional approaches. It offers the
advantage of reduced downtime postoperatively, decreased price, and potential permanency.
This prospective study, conducted over a 4-year period,
included 10 patients who met criteria for open or endoscopic treatment of severe glabellar rhytides. Each patient
underwent direct excision of glabellar rhytides, with the
incision length, method of handling skin and soft tissue,
and time of surgery kept as similar as possible between
patients. Patients underwent evaluation, along with photodocumentation, at 3 days, 1 week, 3 weeks, and 6 weeks
postoperatively. Complications and revision rates were
noted. Outcome measures included brow ptosis, incisional erythema, suture marks, suture extrusion, wound
infections, hematoma, seroma, unacceptable scarring
(hypertrophic scarring and scar unevenness), dehiscence, and numbness. Patient satisfaction was assessed
during the 6-month postoperative visit.
In 10 patients, there were no cases of brow ptosis,
infections, hematomas, seromas, or wound dehiscences
observed. Two patients had suture extrusion, and one
had mild hypertrophic scarring, requiring scar resurfacing. There were no cases of brow ptosis. All patients
complained of numbness lasting for several weeks to
months, and none reported numbness at the 6-month
follow-up visit. At the 6-month follow-up visit, all patients reported being very satisfied with their results.
There are significant data to suggest that the endoscopic
brow lift with corrugator resection is very effective.3,4 However, our experience has been that many surgeons remain
cautious during endoscopic and open brow lifts because
of the potential risk for damage to the supratrochlear
neurovascular bundle. As a result, we have seen patients

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Plastic and Reconstructive Surgery June 2010

require multiple treatments (nonsurgical and surgical)
for persistent glabellar frown lines (Fig. 1).
Direct excision is an excellent alternative to other traditional procedures. The surgical effect is usually permanent after the initial treatment, and patients notice the
results instantly (Figs. 1 and 2). Direct excision is not
performed as frequently as other operations for glabellar
furrowing, and for this reason, few data are currently
available. Disadvantages of this procedure include minor
scarring that is typically unnoticeable in most cases.
Numbness can affect initial patient satisfaction in our
study; however, all cases of numbness in this series of
patients resolved within 6 months after surgery.
Decreased postoperative downtime, decreased price,
and potential permanency all are important reasons to
consider direct excision as a useful and effective option
for the treatment of glabellar furrows. We do not purport that direct excision should be a universal treatment
but suggest that direct excision should be considered as

a viable option for suitable patients. In our experience,

the results are as effective as other approaches, and scarring is typically minimal, creating favorable results for
patients with severe glabellar furrows.
DOI: 10.1097/PRS.0b013e3181cb649e

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

Arjun S. Joshi, M.D.
Division of OtolaryngologyHead and Neck Surgery
George Washington University
Washington, D.C.

Darshni Vira, M.D.

Division of Head and Neck Surgery
David Geffen School of Medicine
University of California, Los Angeles
Los Angeles, Calif.

William H. Lindsey, M.D.

Division of OtolaryngologyHead and Neck Surgery
George Washington University
Washington, D.C.
Correspondence to Dr. Tanna
Department of Surgery
George Washington University
2475 Virginia Avenue NW, Apt. 907
Washington, D.C. 20037
ntanna@gwu.edu

DISCLOSURE
The authors have no commercial or financial interests to
disclose.
REFERENCES

Fig. 1. In this preoperative view, the patient has a history of

previous direct brow lift by another physician. Note the deep
glabellar furrows.

1. Frampton JE, Easthope SE. Botulinum toxin A (Botox Cosmetic): A review of its use in the treatment of glabellar frown
lines. Am J Clin Dermatol. 2003;4:709725.
2. Patel MP, Talmor M, Nolan WB. Botox and collagen for glabellar furrows: Advantages of combination therapy. Ann Plast
Surg. 2004;52:442447; discussion 447.
3. Matarasso A, Matarasso SL. Endoscopic surgical correction of
glabellar creases. Dermatol Surg. 1995;21:695700.
4. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Endoscopic
forehead lift: Review of technique, cases, and complications. Plast
Reconstr Surg. 2002;110:15581568; discussion 15691570.

A Simplified Lateral Canthopexy Technique

Sir:

Fig. 2. In a 3-year postoperative image, the longevity of direct

excision of glabellar furrows is visible.

248e

ateral canthopexy has become a routine part of cosmetic lower blepharoplasty to prevent lower lid malposition, especially in those patients with laxity of the
lower lid and negative vector anatomy.1 All canthopexy
techniques involve securing the lateral retinaculum to the
periosteum of the superolateral orbital rim with a suture.
However, the surgical approach to identify the lateral
retinaculum varies, with some techniques requiring more
surgical expertise than others. Perhaps the most challenging technique is that of Jelks et al.,2 who dissect the lateral
retinaculum from above through an upper blepharoplasty incision. Dissection of the lateral retinaculum
through the lateral extension of a lower blepharoplasty
incision is advocated by others.3,4 In this article, we describe

Volume 125, Number 6 Viewpoints

a technical modification of the Hamra5 transcanthal canthopexy that involves percutaneous placement of the canthopexy suture through the confluence of the superior and
inferior gray lines at the lateral canthal angle.
An upper blepharoplasty is completed, but the lateral
extent of the incision is not closed or, in the case in which
upper blepharoplasty is not performed, a small incision is
made in the upper eyelid crease laterally. An 18-gauge
needle (Fig. 1) is used to create a puncture wound at the
confluence of the superior and inferior gray lines at the
lateral commissure of the eye. One arm of a double-armed
5-0 Prolene suture (Ethicon, Inc., Somerville, N.J.) is
placed through the puncture wound, capturing the lateral retinaculum, and directed into the upper blepharoplasty incision, below the orbicularis oculi muscle. The
second arm is subsequently placed through the same
puncture wound but on a slightly different path into the
upper lid incision. These two sutures are secured to the
periosteum on the undersurface of the superolateral orbital
rim at a level just above the pupil or superior limbus, thus
tightening the tarsoligamentous sling. The suture is tied and

tension of the lower lid is checked. (See Video, Supplemental Digital Content 1, which demonstrates the lateral canthopexy technique, http://links.lww.com/PRS/A164.)
The lateral canthopexy described here is a modification of the Hamra transcanthal canthopexy. In our
modification, a needle is used to access the lateral retinaculum and direct canthopexy suture placement. It
is a minimally invasive technique that is simple to perform, especially in the hands of a novice blepharoplasty
surgeon. An advantage of this technique is absolute
assurance of capturing the lateral canthal tendon. Extensive dissection to identify the tendon is not required,
which limits operative time and postoperative edema. Furthermore, recreation of the lateral retinaculum and canthal angle as in canthoplasty (cantholysis) techniques is
obviated. With this minimally invasive technique, results
have been excellent, with few complications.
DOI: 10.1097/PRS.0b013e3181d45d19

Mort Rizvi, M.D.

Michael Lypka, M.D., D.M.D.
Mark Gaon, M.D.
Bradley Eisemann, B.A.
Michael Eisemann, M.D.
Department of Plastic and Reconstructive Surgery
Methodist Hospital and Weill Cornell Medical College
Houston, Texas

Michael Lypka, M.D., D.M.D.

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

DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
Fig. 1. Needle placement.

1. Glat PM, Jelks GW, Jelks EB, Wood M, Gadangi P, Longaker MT.
Evolution of the lateral canthoplasty: Techniques and indications.
Plast Reconstr Surg. 1997;100:13961405; discussion 14061408.
2. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior
retinacular lateral canthoplasty: A new technique. Plast Reconstr Surg. 1997;100:12621270; discussion 12711275.
3. Fagien S. Algorithm for canthoplasty: The lateral retinacular
suspension. A simplified suture canthopexy. Plast Reconstr
Surg. 1999;103:20422053; discussion 20542058.
4. Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous lower
blepharoplasty with routine canthal support: A comprehensive
10 year review. Plast Reconstr Surg. 2008;121:241250.
5. Hamra ST. The zygorbicular dissection in composite rhytidectomy: An ideal midface plane. Plast Reconstr Surg. 1998;
102:16461657.

Successful Replantation of an AlmostAmputated Nose

Sir:
Video. Supplemental Digital Content 1 demonstrates the lateral canthopexy technique, http://links.lww.com/PRS/A164.

econstructive methods to replace the nasal units

demand many surgical steps, sometimes with suboptimal results. A case report of a 19-year-old patient
with a posttraumatic nearly complete amputation of the

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Plastic and Reconstructive Surgery June 2010

nasal dorsum after falling during a seizure is presented,
causing an avulsion of the dorsum, the tip, and the right
ala subunits. The flap remained connected to the nasal
structure by only a small left ala pedicle.
First, we considered completing the amputation and
repairing the receptor site with a conventional mediofrontalis flap. Because of the presence of incipient capillary bleeding at the cranial part of the flap after dermal
prick, and a cyanotic nuance when the nasal flap was set
in place, we decided to preserve the pseudoavulsed tissue.
Anesthesia was accomplished with propofol and dormonid. The anesthesiologist also infiltrated the receptor
site with 1% lidocaine without epinephrine and administered an infraorbitalis nerve block with 0.5% bupivacaine without epinephrine to improve the vascular supply
by sympathetic blockade of the ala pedicle region. The
flap was then reattached over its original bed with 6-0
vertical mattress suture, despite the discrepancy between
the pedicle pattern and flap size (Fig. 1). The patient
rested with their head at a 45-degree angle, in a warm
room (28 to 30C), for 5 days. A nurse cleaned the reattached flap with warm saline every 4 hours, and the flaps
cranial segment was pin-pricked followed by a smooth
massage to facilitate venous drainage. Cefazolin (1 g three

times per day), acetylsalicylic acid (100 mg two times per

day), and the patients regular anticonvulsive drugs were
prescribed. On the fifth postoperative day, the flap had
satisfactory vitality and the patient was discharged for ambulatory follow-up (Figs. 2 and 3).
Facial angiosomes demonstrated abundant nutrition
around the neck, the face, and the nasal subunits.1 In our
patient, the ala lateral nasal artery was responsible for the

Fig. 2. The flap on postoperative day 5.

Fig. 1. The nearly avulsed flap and the cyanosis after immediate reattachment.

250e

Fig. 3. The flap on postoperative day 25, showing complete tissue integration.

Volume 125, Number 6 Viewpoints

arterial supply of the avulsed flap. Most successful replanted noses have been reported to be possible without
venous anastomosis.25 Easing the venous drainage can be
effective in difficult situations as demonstrated in our case
report. Finally, the synchrony between the medical and
paramedical staff made a difference in flap survival in our
patient despite the minimal flap arterial pedicle supply
without venous anastomosis.
DOI: 10.1097/PRS.0b013e3181d45d87

Osvaldo Pereira, M.D.

Universidade Federal de Santa Catarina

Jorge Bins-Ely, M.D., Ph.D.

Giovanni S. Lobo, M.D.
Kuang H. Lee, M.D.
Dante Eickhoff, M.D.
Clnica Jane
Universidade de Santa
Florianopolis, Santa Catarina, Brazil
Correspondence to Dr. Pereira
Federal University of Santa Catarina
R. Dep. Antonio Edu Vieira, 1414
Pantanal
Florianopolis, Santa Catarina 88040 001, Brazil
osvaldojpf@hotmail.com

PATIENT CONSENT
The patient provided written consent for the use of his
image.
REFERENCES
1. Houseman ND, Taylor GI, Pan WR. The angiosomes of the
head and neck: Anatomic study and clinical applications. Plast
Reconstr Surg. 2000;105;22872313.
2. Niazi Z, Lee TC, Eadie P, Lawlor D. Successful replantation of
nose by microsurgical technique and review of literature. Br J
Plast Surg. 1990;43:617620.
3. Sanchez-Olaso A. Replantation of an amputated nasal tip with
open venous drainage. Microsurgery 1993;14:380383.
4. Kayikciouglu A, Karamursel S, Keicik A. Replantation of nearly
total nose amputation without venous anastomosis. Plast Reconstr Surg. 2001;108:702704.
5. Yao JM, Yan S, Xu JH, Li JB, Ye P. Replantation of amputated
nose by microvascular anastomosis. Plast Reconstr Surg. 1998;
102:171173.

most frequent bite sites (14 cases), followed by the

extremities (eight cases) and the trunk (two cases).
All patients were operated on within 24 hours after
admission. Wounds were first cleansed with only saline in
all patients, because irrigation with antibiotic or iodine
solution may increase tissue irritation. Although half of
the patients wounds were closed with primary suture after
surgical debridement of crushed wound edges, the other
half required surgical treatment (Table 1). Besides the
patient transferred from another clinic on the seventh day
after the event, in whose hand there was tissue necrosis
and infection (Fig. 1), no other patient had infection. On
subsequent follow-up, three patients developed minor
scar complications on the cheek and the chin.
Our initial therapy in all animal bites includes copious irrigation with saline by means of a syringe with
a 19-gauge needle, careful debridement of devitalized
tissues, antibiotic prophylaxis with amoxicillin and clavulanic acid, tetanus and rabies prophylaxis, and early
repair.
Antimicrobial therapy is indicated for bite wound
infections, but the role of antibiotics in the treatment
of uninfected animal bite wounds is still a subject of
debate. Controversy exists regarding the use of antibi-

Table 1. Reconstructive Procedures in Patients with

Tissue Loss
Procedures
Debridement and suturing
Debridement and SSG
Debridement and FTSG
Debridement and chondrocutaneous
advancement flap
Debridement, chondrocutaneous advancement
flap, and FTSG
Debridement and reverse radial
forearm flap
Debridement and pedicled groin flap
Total ear reconstructions

No.
of Patients
12
3
2
2
1
2
1
1

SSG, split skin graft; FTSG, full-thickness skin graft.

Management of Horse and Donkey Bite

Wounds: A Series of 24 Cases
Sir:

lthough horses are the animals most commonly involved with fatalities,1 reports about horse bites are
very rare. Comparing animal bite wounds, cat bites result
in punctured deep wounds, dog bites cause rather superficial abrasion and laceration type wounds,2 and horse and
donkey bites provoke tissue loss wounds.3
We have performed a retrospective evaluation of 24
patients presenting with animal bites (19 horse and five
donkey bites) and treated at the department of plastic
surgery from 2003 to 2009. The head and neck were the

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

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Plastic and Reconstructive Surgery June 2010

Correspondence to Dr. Kose
Department of Plastic and Reconstructive Surgery
Harran University Hospital
63300 Sanliurfa, Turkey
rkose@harran.edu.tr

REFERENCES
1. Lathrop SL. Animal-caused fatalities in New Mexico, 1993
2004. Wilderness Environ Med. 2007;18:288292.
2. Stefanopoulos PK, Tarantzopoulou AD. Facial bite wounds: Management update. Int J Oral Maxillofac Surg. 2005;34:464472.
3. Shipkov CD. Nasal amputation due to donkey bite: Immediate and
late reconstruction with a forehead flap. Injury Extra 2004;35:8590.
4. Guida G, Nebiolo F, Heffler E, Bergia R, Rolla G. Anaphylaxis
after a horse bite. Allergy 2005;60:10881089.
5. Vidal S, Barcala L, Tovar JA. Horse bite injury. Eur J Dermatol.
1998;8:437438.

Contact Dermatitis from Dermabond

Sir:
Fig. 2. Crush injury of the right ear.

otic prophylaxis in avoiding infections after an animal

bite. The indications for antibiotic prophylaxis depend on the time between the bite and its medical
treatment, the type of animal, the anatomical structures involved, and the extent of the bite.2 Although
wounds on hands with exposed cartilage or delayed
therapy are considered at high risk for infection in
animal bites and delayed primary closure is recommended, we preferred early repair by immediate primary closure in horse and donkey bites, and no infection developed (Fig. 2).
A case of anaphylaxis after a horse bite is reported.4
A deep lesion (crush injury) producing severe hematoma, fat necrosis, and muscle rupture, without an external wound, in a woman bitten on her thigh by a horse
could be diagnosed only through ultrasound examination,
which can be useful for evaluating the extent of crush injuries after horse bites.5 We have not seen such cases in our
series.
Our experience shows the safety of primary closure
for horse and donkey bite wounds, provided that careful debridement and good cleansing with antibiotic
prophylaxis are also performed. An acceptable aesthetic outcome can be achieved only with early primary
repair and reconstructive procedures.
DOI: 10.1097/PRS.0b013e3181d515dd

Rustu Kose, M.D.

Department of Plastic and Reconstructive Surgery

zgur Sogut, M.D.

O
Department of Emergency Medicine

Cengiz Mordeniz, M.D.

Department of Anesthesiology and Intensive Care
Harran University
Medical School
Sanliurfa, Turkey

252e

-Octylcyanoacrylate, commonly known as Dermabond (Ethicon, Inc., Somerville, N.J.), was approved by the U.S. Food and Drug Administration
for human use in 1998 as a topical skin adhesive. There
have been few surgery reports on allergic phenomena
related to the product.1 We report two cases of contact
dermatitis secondary to Dermabond application. A 47year-old woman with no known drug allergies underwent uncomplicated bilateral breast reduction. Dermabond was applied after her subcuticular suture closure.
On day 6, the patient noted an enlarging nonpainful
but significantly pruritic rash along the incision lines.
She was afebrile. Physical examination at that time revealed a contiguous, nonblanching, and nonindurated
exanthem extending approximately 6 cm on either side
of all incisions. It was neither warm nor tender to palpation. The remainder of the breast tissue showed no
abnormalities. The Dermabond was removed with dilute acetone, and within 72 hours the pruritic rash
resolved with no additional treatment. The second patient is a 55-year-old woman with no known drug allergies who underwent scar revision of an abdominoplasty. The final layer of closure included Dermabond.
She re-presented on postoperative day 7 with pruritic
erythema extending along the surgical scars bilaterally
(Figs. 1 and 2). There was no pain, swelling, or warmth
on examination of the areas. She was afebrile. The
Dermabond was removed and the rash was treated with
topical steroids only. Her symptoms dissipated within
several days. Three weeks after resolution of the erythema, she underwent a test patch application of
Dermabond to her left forearm that resulted in a localized erythematous pruritic reaction.
The presenting differential diagnosis of these patients would include cellulitis, but the presentation
of the patients was not consistent with an infectious
cause with, specifically, the lack of fever, induration,
local discomfort, or increased warmth. Neither patient had a sense of malaise. Of significance in both

Volume 125, Number 6 Viewpoints

Fig. 1. Focal rash at 7 days postoperatively.

Fig. 2. Focal rash at 7 days postoperatively.

patients was the painless intense pruritic nature of

the erythema, which is also not consistent with cellulitis.
2-Octylcyanoacrylate is a monomer in liquid form.
On contact with tissue anions (e.g., tissue, blood, fluid),
there is rapid polymerization and binding to epidermal
keratin in an exothermic reaction.2,3 It is touted that the
speed of polymerization and high reactivity of the cyanoacrylate compound should prevent the molecule
from being a strong immunosensitizer.1,3
The long-term treatment of contact dermatitis ideally is avoidance of the contact allergen. Short-term
treatment includes removal of the offending material
and possibly brief use of a topical steroid.1 Application
of 2-octylcyanoacrylate should be avoided on open
wounds or incompletely closed surgical incisions to
avoid immunosensitization and subsequent development of allergy to cyanoacrylates.
Although contact dermatitis secondary to Dermabond is seemingly rare, plastic surgeons should be prepared to recognize the presence of 2-octylcyanoacrylate
allergy and treat accordingly. The exanthem is hallmarked by intense painless pruritus. Treatment consists of removal of the Dermabond and consideration
of short-term use of topical steroids.
DOI: 10.1097/PRS.0b013e3181d62a56

Brian K. Howard, M.D.

North Fulton Plastic Surgery
Roswell, Ga.

Susan E. Downey, M.D.

Department of Plastic Surgery
University of Southern California
Los Angeles, Calif.
Correspondence to Dr. Howard
North Fulton Plastic Surgery
1357 Hembree Road, Suite 200
Roswell, Ga. 30076

DISCLOSURE
Dr. Howard has not received any financial support from
and has no financial interest in Ethicon, Inc. Dr. Downey has
been a paid consultant for Ethicon, Inc., in the past.
REFERENCES
1. Hivnor CM, Hudkins ML. Allergic contact dermatitis after
postsurgical repair with 2-octylcyanoacrylate. Arch Dermatol.
2008;144:814815.
2. Ethicon, Inc. Dermabond package insert. Somerville, NJ: Ethicon, Inc.
3. Tomb RR, Lepoittevin JP, Durepaire F, Grosshans E. Ectopic
contact dermatitis from ethyl cyanoacrylate instant adhesives.
Contact Dermatitis 1993;28:206208.

253e

Plastic and Reconstructive Surgery June 2010

Internal Mammary Artery Perforators for the
Salvage of a Superficially Dominant Free Flap
Breast Reconstruction
Sir:

he deep inferior epigastric perforator (DIEP) flap

is becoming widely popular for autologous breast
reconstruction because preservation of the rectus abdominis musculature can lead to less abdominal wall
morbidity and postoperative pain. Alternatively, a
muscle-sparing free transverse rectus abdominis musculocutaneous flap offers many similar advantages.
In both cases, deep inferior epigastric vessels are
usually anastomosed to the recipient internal mammary vessels in the third intercostal space. However,
perforating vessels from the internal mammary circulation have also proven to be reliable recipients for
anastomosis.1,2 Using the internal mammary perforators primarily obviates the need for partial rib resection and allows the internal mammary vessels to be
preserved for potential future use as coronary revascularization grafts. To our knowledge, use of internal
mammary perforators for salvage of a congested flap
with patent internal mammary anastomoses has not
been previously described.
In a recent case of a bilateral free flap breast reconstruction, we noted mild congestion in half of the
flap, shortly after dividing the superficial inferior
epigastric vein (SIEV). The congestion improved
slightly with time while the flap remained connected
to the deep circulation, and the decision was made
to complete the procedure as a muscle-sparing free
transverse rectus abdominis musculocutaneous flap
with one arterial anastomosis from the deep inferior
epigastric artery to the internal mammary artery, and
two venous anastomoses from the inferior epigastric
venae comitantes to the two internal mammary veins
that were present. The other half of the flap had a
normal appearance, and a DIEP flap was performed
to reconstruct the left breast. However, the right
breast flap appeared mildly congested at the completion of the operation, initially improved, and then
worsened over the first postoperative day, necessitating operative exploration.
At the time of exploration, all arterial and venous
anastomoses were found to be widely patent but, once
the SIEV was opened, a continuous jet of venous flow
was seen, indicating venous congestion despite the two
venous anastomoses (Fig. 1). We augmented the venous outflow by coupling a saphenous vein graft between the SIEV and a perforating vein of the internal
mammary circulation in the second intercostal space
that had been left intact during the mastectomy (Fig.
2). After placement of the interposition graft, the abnormal tissue turgor and congested color of the flap
improved immediately and remained normal throughout the postoperative course.
This case demonstrates the importance of preserving
alternative vessels in cases of microvascular breast reconstruction. It also shows that a superficially dominant

254e

Fig. 1. A continuous jet of venous blood from the SIEV after

venotomy in preparation for salvage vein grafting.

Fig. 2. A saphenous vein graft interposed between the SIEV

of the flap and a perforating vein of the internal mammary
circulation.

hemiflap can become congested, even when harvested

as a non-DIEP flap with most of the normal deep circulation preserved. The senior author has previously
reported a technique for venous augmentation in a
DIEP flap by draining the SIEV to one of the venae
comitantes.3 Other options for venous augmentation
include an interposition vein graft from the SIEV, superficial circumflex iliac vein, or contralateral pedicle
to the cephalic vein4 or to recipient thoracodorsal,
lateral thoracic, or intercostal veins.5
Internal mammary perforators should be added to
the list of venous augmentation recipient vessels. We
recommend routine dissection and preservation of
the superficial inferior epigastric vessels during flap
harvest, and close communication with the breast
surgeons to preserve any sizable internal mammary
perforators found during the mastectomy. No addi-

Volume 125, Number 6 Viewpoints

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

Brian D. Cohen, M.D.

Nicholas Vendemia, M.D.
Division of Plastic and Reconstructive Surgery
New York-Presbyterian Hospital
New York, N.Y.

Jason A. Spector, M.D.

Division of Plastic and Reconstructive Surgery
Weill-Cornell Medical Center/New York-Presbyterian
Hospital
New York, N.Y.

Christine H. Rohde, M.D.

Division of Plastic and Reconstructive Surgery
Columbia University Medical Center/New York-Presbyterian
Hospital
New York, N.Y.
Correspondence to Dr. Rohde
161 Fort Washington Avenue, Suite 607
New York, N.Y. 10032
chj_hsu@yahoo.com

DISCLOSURE
No financial support or benefits have been received by any
of the authors, by any member of their immediate families, or
by any individual or entity with whom or with which the
authors have a relationship from any commercial source that
is related directly or indirectly to the scientific work reported in
this article.
REFERENCES
1. Park MC, Lee JH, Chung J, Lee SH. Use of internal mammary
vessel perforator as a recipient vessel for free TRAM breast
reconstruction. Ann Plast Surg. 2003;50:132137.
2. Saint-Cyr M, Chang DW, Robb GL, Chevray PM. Internal
mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr
Surg. 2007;120:17691763.
3. Rohde C, Keller A. Novel technique for venous augmentation
in a free inferior epigastric perforator flap. Ann Plast Surg.
2005;55:528530.
4. Niranjan NS, Khandwala AR, Mackenzie DM. Venous augmentation of the free TRAM flap. Br J Plast Surg. 2001;54:
335337.
5. Wechselberger G, Schoeller T, Bauer T, Ninkovic M, Otto A,
Ninkovic M. Venous superdrainage in deep inferior epigastric
perforator flap breast reconstruction. Plast Reconstr Surg. 2001;
1083:162166.

Hyperbaric Oxygen and Reduction

Mammaplasty in the Previously
Irradiated Breast
Sir:

ith expanding use of radiation therapy in treating malignancy, managing complications of radiation therapy becomes more important. A princi-

pal clinical manifestation of delayed radiation injury

is impaired wound healing. With the known risk of
poor wound healing, elective surgery is relatively contraindicated in areas of previous irradiation. With
lumpectomy/adjuvant radiation therapy becoming
the treatment of choice for early-stage breast cancer, there is an increasing population of postradiation therapy women who have difficulty obtaining
breast reduction. There are few case reports describing reduction mammaplasty after radiation therapy.
Handel et al.1 reported one case, with delayed healing and an inferior cosmetic result. Spear et al.2
reported three cases using modified surgical technique, with acceptable but again cosmetically inferior results. Hyperbaric oxygen therapy induces angiogenesis and increases tissue oxygen content in
irradiated tissue.3 Previous studies have shown benefits of hyperbaric oxygen therapy in patients with
delayed radiation injury, including as a surgical adjuvant in multiple irradiated areas.4
We conducted a retrospective chart review of five
patients undergoing reduction mammaplasty in previously irradiated breasts along with adjuvant hyperbaric oxygen therapy at Virginia Mason Medical Center in Seattle. All were scheduled to receive 20
preoperative hyperbaric oxygen therapy treatments,
each consisting of 90 minutes of 100% oxygen at 2.36
atm, followed by 10 similar postoperative treatments.
Study approval and waiver of informed consent was
obtained from the Institutional Review Board of the
Virginia Mason Medical Center/Benaroya Research
Institute. Initial Late Effects on Normal Tissue/Subjective, Objective, Management and Analytic breast
symptom scores5 measuring late effects of radiation
were calculated based on clinical notes before initiation of preoperative hyperbaric oxygen therapy,
and final Late Effects on Normal Tissue/Subjective,
Objective, Management and Analytic scores were
based on the last recorded plastic surgery follow-up.
Case data are outlined in Table 1. To summarize,
five women underwent bilateral reduction mammaplasty 2 to 6 years after unilateral lumpectomy and
postoperative radiation therapy. Wound healing in
all irradiated breasts was complete, with delayed healing in two patients of 4 and 11 weeks. In the nonirradiated breasts, delayed healing of 5 and 6 weeks
also occurred in two patients. In all cases, surgeon
evaluation of the final cosmetic result was good. All
patients expressed satisfaction with the final cosmetic
results. Representative preoperative and postoperative images for case 5 are included as Figures 1 and
2. No significant complications of hyperbaric oxygen
therapy occurred. One patient terminated postoperative hyperbaric oxygen therapy treatment after 8
of 10 planned treatments, because healing was already complete.
These cases illustrate that with adjuvant hyperbaric
oxygen therapy, elective reduction mammaplasty is a
safe option for some patients who have previously
undergone breast irradiation. Our patients ranged in

255e

256e

38

54

53

57

57

Irradiation

Left lumpectomy 5 Yes; dose unknown

yr previously
(radiation therapy
performed outside
our system)
Right lumpectomy 5040 cGy whole right
with excision of
breast, 1000 cGy
nipple-areola
boost lumpectomy
complex and
site
sentinel node
dissection 2 yr
previously
Left lumpectomy
4680 cGy whole left
with excision of
breast, 540 cGy
nipple-areola
boost lumpectomy
complex 4 yr
site
previously
Left lumpectomy
5040 cGy whole left
with axillary
breast, 1000 cGy
node dissection
boost lumpectomy
6 yr previously
site
Left lumpectomy 5 6640 cGY whole left
yr previously
breast

Cancer Surgery

No

No

No

Yes

Yes

Chemotherapy

39.5

23.6

30.9

32.7

26.7

BMI

20 yr
previously,
for 10 yr

Never

Remote for
5 yr

Never

Never

Smoker

20

20

20

20

20

Pre

10

10

10

10

Post

HBO2

10

Pre

Post

SOMA/
LENT

Delayed healing 6 wk,

complete wound
closure

Nonirradiated Breast

Delayed healing
11 wk,
complete
wound closure

Primary healing,
complete
wound closure

Primary healing,
complete
wound closure

Primary healing,
complete wound
closure

Primary healing,
complete wound
closure

Delayed healing 5 wk,

complete wound
closure

Delayed healing Primary healing,

4 wk, complete
complete wound
wound closure
closure

Primary healing,
complete
wound closure

Irradiated Breast

Outcomes

HBO2, hyperbaric oxygen therapy; LENT, Late Effects on Normal Tissue; SOMA, Subjective, Objective, Management and Analytic; BMI, body mass index; Pre, preoperatively; Post,
postoperatively.

Age
(yr)

Case

Table 1. Summary of Case Data

Plastic and Reconstructive Surgery June 2010

Volume 125, Number 3 Viewpoints

Neil B. Hampson, M.D.
Center for Hyperbaric Medicine
Virginia Mason Medical Center
Seattle, Wash.
Correspondence to Dr. Snyder
806 NW 83rd Street
Seattle, Wash. 98117
sean.snyder.md@gmail.com
Presented at the Northwest Society of Plastic Surgeons
Meeting, February of 2009.

DISCLOSURE
This was an author-initiated chart review study. Neither
the study nor its authors received any financial support. No
author has any conflict of interest to disclose.
REFERENCES

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

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

following radiation therapy for breast cancer. Plast Reconstr
Surg. 1992;89:953955.
2. Spear SL, Burke JB, Forman D, Zuurbier RA, Berg CD. Experience with reduction mammaplasty following breast conservation surgery and radiation therapy. Plast Reconstr Surg.
1998;102:19131917.
3. Marx RE, Ehler WJ, Tayapongsak P, Pierce LW. Relationship
of oxygen dose to angiogenesis induction in irradiated tissue.
Am J Surg. 1990;160:519524.
4. Feldmeier JJ, Hampson NB. A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: An evidence
based approach. Undersea Hyperb Med. 2002;29:430.
5. Pavy JJ, Denekamp J, Letschert J, et al. EORTC Late Effects
Working Group: Late effects toxicity scoring. The SOMA
scale. Radiother Oncol. 1995;35:1115.

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

Lipid Rescue in Resuscitation of Local

AnestheticInduced Cardiac Arrest in
Aesthetic Surgery
Sir:

age from 38 to 57 years. All but one patient we treated

showed improvement in their Late Effects on Normal
Tissue/Subjective, Objective, Management and Analytic symptom scales for late effects of radiation.
This series benefits from internal controls, as all patients underwent surgery on one previously irradiated and one nonirradiated breast. Complication
rates were equal, with two each of the irradiated and
nonirradiated breasts demonstrating delayed wound
healing. In conclusion, it is our hope that awareness
of these positive results will make the combination of
hyperbaric oxygen and reduction mammaplasty
more widely available to an appropriate population.
DOI: 10.1097/PRS.0b013e3181cb67d0

Sean M. Snyder, M.D.

General Internal Medicine

Kevin M. Beshlian, M.D.

Section of Plastic and Reconstructive Surgery

ardiac toxicity with local anesthetics such as bupivacaine and ropivacaine has long been recognized
by anesthesiologists and surgeons. Despite published
reports in the literature, the exact mechanism of action
of lipid emulsion for prompt reversal of bupivacaine
toxicity remains unexplained.1,2 Of all the amide local
anesthetics, bupivacaine exhibits the most cardiotoxicity, which is often the result of a sudden increase of
its concentration in the plasma. There is increasing
evidence in the anesthesia literature supporting the use
of lipid therapy to treat bupivacaine- and ropivacaineinduced toxicity after failure of established resuscitation measures.3 However, published reports regarding
the use of intravenous lipid emulsion in successful resuscitation of local anestheticinduced cardiac collapse
in aesthetic surgery are rare. We draw attention to the
efficacy of lipid rescue therapy in reversing local anestheticinduced cardiac arrest and set the stage for an
intriguing and emerging topic in the aesthetic surgery
literature.

257e

Plastic and Reconstructive Surgery June 2010

Incremental injections (30 ml) of bupivacaine 0.5%
are conventionally administered to achieve sciatic
nerve block in surgical patients. The amphipathic characteristic of local anesthetics such as bupivacaine allow
them to cross plasma and intracellular membranes
quickly and to interact with structural proteins, producing a variety of toxic effects in several tissue types,
mainly brain, heart, and skeletal muscle. Notably,
among the most potent toxic local anesthetics, bupivacaine has been shown to disrupt biochemical enzymatic cycles affecting oxidative phosphorylation. This
observation suggests that the pattern of tissues affected
includes those with the highest aerobic demand and
least tolerance for hypoxia. Thus, patients with local
anesthetic toxicity typically present with seizures followed by cardiac arrhythmias and hypotension. This is
a standard clinical picture in bupivacaine-induced toxicity, and a presumptive diagnosis can be made. Under
such circumstances, anesthetic injection should be
stopped immediately, cardiopulmonary resuscitation
initiated, and lipid emulsion administered within 30
seconds as 100-ml immediate and continuous infusion.

Appropriate cardiac resuscitative measures should be

adopted with necessary electrocardiographic watch
and intensive care monitoring until all vital signs are
stabilized. An almost complete recovery of the patient
can be expected with this intervention.
Local anestheticinduced cardiac arrest is an example of a rare and potentially fatal complication of local
anesthesia. Recent reports in the literature have reinforced the clinical utility of lipid emulsion and rescue
from local anestheticinduced toxicity in human
subjects.4 Continuing education and contemporary updates on important topics such as lipid rescue in anesthetic toxicity are critical to practice in aesthetic surgery. Cardiac and central nervous system toxicity as a
result of bupivacaine use requires urgent action with a
three-step approach: (1) rapid problem detection, (2)
prompt initiation of advanced cardiac life resuscitative
measures, and (3) timely administration of lipid emulsion with monitoring. It is important to note that
thresholds for the onset of local anestheticinduced
toxicity are subject to a wide range of patient variables.
Nonetheless, lipids should be readily available in the

Fig. 1. Lipid rescue protocol in resuscitation of local anestheticinduced cardiac arrest in aesthetic surgery. OR, operating
room; CPR, cardiopulmonary resuscitation.

258e

Volume 125, Number 6 Viewpoints

operating room for all aesthetic procedures as a precautionary plan.
This awareness and availability of a protocol (Fig.
1) in resuscitation is of utmost importance. This protocol presents significant knowledge of the clinical
effectiveness of lipid emulsion infusion on reversal of
cardiac arrest in an aesthetic surgical procedure. As
in the case with other clinical scenarios, lipid rescue
resuscitation should be used as soon as signs of local
anestheticinduced toxicity manifest, to attenuate
progression of anesthetic-induced toxic conditions.
The communication of this topic provides not only
a clear understanding of intraoperative emergencies
in aesthetic surgery but also a learning curve for
scientific education.

DISCLOSURE
The authors have no financial interests to disclose.
REFERENCES
1. Albright GA. Cardiac arrest following regional anesthesia with
etidocaine or bupivacaine. Anesthesiology 1979;51:285287.
2. Weinberg GL. Current concepts in resuscitation of patients
with local anesthetic cardiac toxicity. Reg Anesth Pain Med.
2002;27:568575.
3. Corcoran W, Butterworth J, Weller RS, et al. Local anestheticinduced cardiac toxicity: A survey of contemporary practice
strategies among academic anesthesiology departments.
Anesth Analg. 2006;103:13221326.
4. Groban L, Butterworth J. Lipid reversal of bupivacaine toxicity: Has the silver bullet been identified? Reg Anesth Pain Med.
2003;28:167169.

DOI: 10.1097/PRS.0b013e3181cb671b

Daniel Man, M.D.

Vinod K. Podichetty, M.D., M.S.
Dr. Man Aesthetic Plastic Surgery Center
Boca Raton, Fla.
Correspondence to Dr. Podichetty
Dr. Man Aesthetic Plastic Surgery Center
851 Meadows Road, Suite 222
Boca Raton, Fla. 33486
vinodpodichetty@yahoo.com

Hand Rejuvenation Using Radiesse

Sir:

outhful hands are easier to create, as advances in

the reduction of skin laxity, wrinkling, and masks
for underlying bone structure become more available
and less painful. Hand augmentation can add volume
and increase the youthful appearance of the hand without disrupting hand function. These qualities, along

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

259e

Plastic and Reconstructive Surgery June 2010

with other intrinsic properties, make soft-tissue fillers a
useful method for the rejuvenation of the hand.15 The
purpose of this article is to demonstrate our technique
and the results of using calcium hydroxylapatite
(Radiesse; BioForm Medical, San Mateo, Calif.) for
hand rejuvenation.
The patient extends and flexes the digits to identify hypotrophic areas (Fig. 1). Next, 0.5 cc of lidocaine is injected in the areas of the dorsal hand in two
places where the filler will be placed. The Radiesse
is injected just above the fascia plane and below the
subcutaneous tissue (Fig. 1). Usually, a second injection is given between the second and third metacarpals for easier distribution of the filler. Limiting
injections to one or two decreases the chance of
irritation to subcutaneous nerves.
The filler is introduced into the hand using a bolus
technique (0.5 to 1.3 ml per injection), with one or
two injections to each hand. The bolus is then digitally manipulated throughout the dorsal hand until
even distribution of the hydroxylapatite occurs while
the patient makes a tight fist. Pinching and tenting
the dorsal skin during injection will help avoid intramuscular injections. The filler remains in the subdermal and subfascial plane but dorsal to the muscle
fascia, where it can be moved in the subcutaneous
plane through gentle pressure.
Patients may return to normal activities of daily living
as soon as they feel comfortable. There may be mild
swelling and bruising in the injected area that usually
recedes in 1 to 2 weeks. A follow-up appointment is
scheduled for 14 days after the original injections for
rechecks and more volume if needed.
This article displays a method for hand rejuvenation. The Radiesse filler provides the patient with a
more youthful physical appearance without affecting
function. Although some bruising and swelling may
occur, the effect of the filler provides the patient with
quick recovery time and immediate results.

3. Jacovella PF, Peiretti CB, Cunille D, Salzamendi M, Schechtel SA. Long-lasting results with hydroxylapatite (Radiesse) facial filler. Plast Reconstr Surg. 2006;118(3 Suppl.):
15S21S.
4. Mann J, Rao J, Goldman M. A double-blind, comparative study
of nonanimal-stabilized hyaluronic acid versus human collagen for tissue augmentation of the dorsal hands. Dermatol Surg.
2008;34:10261034.
5. Bergeret-Galley C, Latouche X, Illouz YG. The value of new
filler material in corrective and cosmetic surgery: DermaLive
and DermaDeep. Aesthetic Plast Surg. 1994;18:1317.

Lessons from the Mexican Axolotl: Amphibian

Limb Regeneration and Its Impact on
Plastic Surgery
Sir:

major task of plastic surgery is the improvement

of extensive scars and problematic wounds. With the
exception of fetal scar-free healing, the possibilities for
regeneration within humans are limited. A wound that
exceeds the basement membrane results in scar formation, which means a rapid and firm but often unsatisfying
wound closure. Scar tissue is less resilient and functional,
keeping it questionable whether human wound healing is
an evolutionarily optimized process.
Among amphibians, regeneration in the sense of
neoplasm of identical tissue is a common event. The
Mexican axolotl (Ambystoma mexicanum) is able to regenerate whole limbs after amputation (Fig. 1) and
shows scar-free healing throughout its life. Dedifferentiation of resident cells, initiated and maintained by a limb
blastema, leads to a perfect restoration of lost tissue. This
process, called epimorphic regeneration, uses mechanisms similar to developmental limb formation.1
What leads to these regenerative processes? On
closer examination, the similarities between fetal and
amphibian wound healing seem to concern adaptive
immunity. The axolotl lacks adaptive immunity and

DOI: 10.1097/PRS.0b013e3181d45d9e

Scott S. Gargasz, M.D., J.D.

Michael C. Carbone
Advanced Hand and Plastic Surgery Center
Tampa, Fla.
Correspondence to Mr. Carbone
Advanced Hand and Plastic Surgery Center, Suite 251
Tampa, Fla. 33613
advancedsurgery@yahoo.com

DISCLOSURE
Neither of the authors has any financial interest, including but not limited to patent licensing arrangements, consultancies, or stock ownership, in Radiesse.
REFERENCES
1. Busso M, Appelbaum D. Hand augmentation with Radiesse
(calcium hydroxylapatite). Dermatol Ther. 2007;20: 385387.
2. Butterwick KJ. Rejuvenation of the aging hand. Dermatol Clin.
2005;23:515527.

260e

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

Volume 125, Number 6 Viewpoints

therefore shows minimal inflammatory response to injury, which also applies to the fetus, whereas adult human skin tends to undergo a rapid restoration by rigid
connective tissue accompanied by a strong inflammatory reaction. Recent studies showed the ambivalent
role of the immune system in healing processes.2
An interesting consideration would be about which
type of wound was liable to evolutionary selection at all.
Definitely, it was more the small and medium contaminated wound, because larger injuries surely resulted in
death presently. This was a demand for a strong immunologic response and firm closure of wounds. The modern wound (e.g., generated by surgical incision or debridement) often suffers from inflammation, scarring,
and fibrosis, as it heals under molecular mechanisms initially selected for the environment of our ancestors.
The deprivation of regenerative competence caused
by evolutionary demands was presumably accompanied
by major variances concerning adaptive immunity. Is
this reversible? Consolidated findings suggest that modern wound healing is a conserved, evolutionarily
adapted rather than an optimized program. The studies of Odelberg et al.3 showed that dedifferentiation of
adult mammalian cells is possible and therefore may be
initiated in humans. A similar composition of mediators and signaling pathways raises the hope of using
regenerative mechanisms to the good of our patients.
Actually, the process of wound healing can be influenced by even minor changes of the composition of
growth factors, as the reduced scar formation after
experimental use of transforming growth factor- isoforms has already displayed.4
We can assume that further characterization of the
molecular mechanisms underlying amphibian limb regeneration might facilitate the development of therapeutic concepts in wound therapy. The lesson taught by
the Mexican axolotl potentially gives direction to compelling advances in plastic and reconstructive surgery.
DOI: 10.1097/PRS.0b013e3181d45e16

Bjoern Menger, Cand.med., M.D.

Kerstin Reimers, Dr.rer.nat., Ph.D.
Joern W. Kuhbier, Cand.Med, M.D.
Peter M. Vogt, Prof. Dr. med., M.D.
Clinic for Plastic, Hand, and Reconstructive Surgery
Replantation and Burn Center of Lower Saxony
Hannover Medical School
Hannover, Germany
Correspondence to Dr. Menger
Laboratory of Experimental Plastic Surgery
Hannover Medical School
Podbielskistrae 380
30659 Hannover, Germany
bjoernmenger@web.de

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

REFERENCES
1. Gardiner DM, Endo T, Bryant SV. The molecular basis of limb
regeneration: Integrating the old with the new. Cell Dev Biol.
2002;13:345352.
2. Martin P, Leibovich SJ. Inflammatory cells during wound repair: The good, the bad and the ugly. Trends Cell Biol. 2005;
15:599607.
3. Odelberg SJ, Kollhof A, Keating MT. Dedifferentiation of
mammalian myotubes induced by msx1. Cell 2000;103:1099
1109.
4. Shah M, Foreman DM, Ferguson MW. Neutralisation of TGFbeta 1 and TGF-beta 2 or exogenous addition of TGF-beta 3
to cutaneous rat wound reduces scarring. J Cell Sci. 1995;108:
9851002.

A Modified Lead Oxide Cadaveric Injection

Technique for Embalmed Contrast Radiography
Sir:
n the past four decades, plastic surgery has enjoyed
an anatomical renaissance in which old techniques
have been revived and refined and new procedures
evolved. The two most detailed studies of the cutaneous
circulation were performed by Manchot in 18991 and
Salmon in 1936.2 In 1986, Rees and Taylor developed
an improved protocol.3 There have been many attempts to use the Rees-Taylor technique on embalmed
cadaveric tissue but, until recently, without success.4
Four upper limbs were harvested. The cadavers had
been treated with Genelyn Solution (Anatomical Series
nonflammable S6; Genelyn Pty. Ltd., South Australia,
Australia) and stored in vacuum plastic bags in the cool
room (4C) for up to 1 year.
A suitable sized cannula was inserted directly into
the subclavian or axillary vessels at the disarticulated
level. Heavy silk or linen was used to tie the cannulae
in place. Then, 50 ml of 6% hydrogen peroxide
(Orion Laboratories Pty. Ltd., Western Australia,
Australia) was injected. The cannula was closed using
surgical forceps to leave the solution in the vessels for
up to 3 hours. Leaks were checked and secured on
the cut surfaces.
During this time, the lead oxide mixture was prepared: 36 g of milk powder (Nuture, Toddlers; Heinz
Ltd., Victoria, Australia) and 200 g of lead oxide (P3O4
Red lead; Ajax Chemicals, Australia) mixed with 40 ml
of tap water and ground into a fine, smooth paste with
a pestle and mortar. Finally, 80 ml of boiling water was
added to the paste and stirred thoroughly.
A 50-cc syringe with 35 to 55 ml of mixture was injected
in a pulsatile fashion and stopped when greatest resistance occurred. The limbs were stored in the cool room.
The mixture solidified in the small vessels after 24 hours
and in large vessels (brachial artery) after up to 10 days.
Whole limbs were radiographed at a distance of 150 cm
between digital cassette (Fuji FCR IP CC; Fiji Film Corp.,
Tokyo, Japan) and x-ray source (Linear x-ray Collimator
MC 200C; Progeny, Inc., Buffalo Grove, Ill.). We used 100
kV, 0.32 second, and 85 mA for the shoulder; 75 mA for
the upper arm; and 65 mA for the forearm (Fig. 1).

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Plastic and Reconstructive Surgery June 2010

The integument and muscle were removed and radiographed (55 mA, 100 kV, 0.32 second; and 60 mA,
100 kV, 0.32 second, respectively) (Fig. 2).
This study was successful because (1) the cadavers
had been embalmed using the Genelyn solution,
leaving the tissue more pliable; (2) hydrogen peroxide
was used before the lead oxide injection; and (3) the lead
oxide injectant had been modified.5 It is thought that we
can apply more pressure during injection, as the vessel
walls in embalmed cadavers are tougher than in fresh
cadavers. There were no vessel ruptures in our four upper
arm injections. Smaller syringes (5 or 10 ml) contribute
to higher pressure. With limited access to fresh cadaveric
tissue, this technique broadens the application of cadaveric radiography to unembalmed tissue.
We have reported an embalmed cadaveric injection
using a modified lead oxide mixture. It provides results
equal to those obtained from the unembalmed (fresh)
cadaveric injection.
DOI: 10.1097/PRS.0b013e3181d45eb4

Wei-Ren Pan, M.D.

Nicholas M. Cheng
Fatima Vally
The Jack Brockhoff Reconstructive Plastic Surgery
Research Unit
Department of Anatomy and Cell Biology
University of Melbourne
Parkville, Victoria, Australia

Fig. 1. Inverted radiograph of a right upper arm (embalmed) injected with lead oxide mixture showing the details of the vascular
anatomy.

Correspondence to Dr. Pan

Jack Brockhoff Reconstructive Plastic Surgery Research
Unit
Room E533
Department of Anatomy and Cell Biology
University of Melbourne
Grattan Street
Parkville, Victoria 3050, Australia
w.pan@unimelb.edu.au
The second and third authors are equivalent second
authors; their names are listed in alphabetical order.

ACKNOWLEDGMENTS

The authors thank Prue Dodwell, G. Ian Taylor,

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

Fig. 2. Inverted radiograph showing the details of the blood

supply of the deltoid.

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

of the Human Body. New York: Springer-Verlag; 1983:149.
2. Salmon M. In: Taylor GI, Tempest M, eds. Arteries of the Skin.
London: Churchill Livingstone; 1988.
3. Rees MJ, Taylor GI. A simplified lead oxide cadaver injection
technique. Plast Reconstr Surg. 1986;77:141145.
4. Taylor GI, Palmer JP. The vascular territories (angiosomes) of
the body: Experimental study and clinical applications. Br J
Plast Surg. 1987;40:113141.
5. Suami H, Taylor GI, Pan W-R. A new radiographic cadaver
injection technique for investigating the lymphatic system.
Plast Reconstr Surg. 2005;115:20072013.

Volume 125, Number 6 Viewpoints

Umbilicoplasty for Types of Umbilical
Deformities
Sir:

any methods have been reported for umbilicoplasty. However, although umbilical deformities
have many variations, no report has described the selection of umbilicoplasty method for each umbilical
deformity. In this article, we report the most suitable
umbilicoplasty method for each type of umbilical deformity. Three methods of umbilicoplasty were used for
various types of umbilical deformities.
In method 1, we elevated a pair of long flaps opposing
obliquely and having their bases at the left and right sides

Fig. 1. Schematic depiction of the three methods for umbilicoplasty. In method 1, a pair of long flaps with lateral bases is elevated
from the cranial and caudal sides of a umbilical position (left). In
method 2, a pair of fan-style flaps is elevated from bilateral sides of
a large umbilical protrusion (center). In method 3, a pair of skin flaps
is created by vertical division of a umbilical protrusion (right).

of the umbilical position1,2 (Fig. 1, left). After closing the

hernia orifice, the right and left skin flaps were sutured
together to make a skin pouch. The pouch was turned
inside out and the median line of the dermal side was
sutured to the median line of the abdominal wall. Finally,
the cranial and caudal ends of the flap donor sites were
closed. This method was adapted to umbilical defects and
low-grade umbilical protrusions.
In method 2, we elevated a pair of fan-style flaps on
bilateral sides of the umbilical protrusion and excised excessive tissue on the cranial and caudal sides (Fig. 1, center).
After closing the hernia orifice, a skin pouch was created,
turned inside out, and fixed the same as in method 1. This
method was adapted to large umbilical protrusions.
In method 3, we divided the umbilical protrusion
vertically to create a pair of skin flaps based laterally
(Fig. 1, right). After closing the hernia orifice, the flaps
were sutured together and fixed on the median line of
the abdominal wall in manner similar to that used in
methods 1 and 2. This method was adapted to tall and
narrow umbilical protrusions and small umbilical protrusions in the umbilical depression.
We performed umbilicoplasty for 31 patients between 1998 and 2006: five umbilical defects, 20 lowgrade umbilical protrusions, three large umbilical protrusions, one tall and narrow umbilical protrusion, and
two small umbilical protrusions in depression. All types
of umbilical deformities were well corrected, and natural vertically long and deep umbilical depressions
without conspicuous scars were shown.
A 3-year-old boy presented with a low-grade 5-mm
umbilical protrusion, which was round and 15 mm in
diameter. A small hernia orifice, 5 mm in diameter, was
palpable in the umbilicus (Fig. 2, left). The umbilical
protrusion was corrected using method 1 (Fig. 2, cen-

Fig. 2. Method 1 was used in a 3-year-old boy with a low-grade umbilical protrusion (left). The patient underwent umbilicoplasty
using our method 1 (center). The natural vertically long and deep umbilicus without conspicuous scar is shown 2 years postoperatively (right).

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Plastic and Reconstructive Surgery June 2010

ter). A natural vertically long and deep umbilical depression facing forward without conspicuous scars is
shown at 2 years postoperatively (Fig. 2, right).
Many surgical methods of umbilicoplasty using suture
fixation methods and local flaps have been reported.3 8
However, the conventional methods often result in an
unnatural, wide, and shallow umbilical depression with
conspicuous scarring. To resolve these problems and
form a cosmetically pleasing umbilicus, we devised a new
umbilicoplasty method with an S-shaped skin incision.1,2
This method enables us to create a vertically long and
deep umbilical depression facing forward at the correct
umbilical position without conspicuous scars. However,
there are many variations of umbilical deformities, and
some cases do not need this method. Therefore, we devised two more methods of umbilicoplasty to correct all
types of umbilical deformities.
Method 1 is suited to the umbilicoplasty for umbilical
defects and low-grade umbilical protrusions that do not
have enough surplus skin for umbilicoplasty. In this
method, we elevate a pair of long flaps from the cranial
and caudal sides of the umbilical position to create a skin
pocket without waste of skin. The skin closure of the donor
sites and the lateral location of the flap bases enable us to
form a longitudinal umbilical depression.1,2 Method 2 is
better adapted to large umbilical protrusions that have surplus skin for umbilicoplasty. In this method, it is easy to create
a longitudinal deep umbilicus with a pair of fan-style flaps,
which is laterally based and distally wide. Method 3 is best for
tall and narrow umbilical protrusions and small protrusions
in the umbilical depression. These umbilical deformities
have just size of skin for umbilicoplasty. This method is a type
of suture fixation method, but in selected cases, it can create
a vertically long and deep umbilical depression the same as
the other methods. We called this method method 3 as a
matter of convenience.
Although our three methods have different designs,
they have the common policy of making a pair of skin flaps
laterally based. Using the best choice of the three methods, a natural vertically long and deep umbilical depression can be created in any type of umbilical deformity.
We studied the best method of umbilicoplasty for
each type of umbilical deformity. Using the best choice
of our three methods, it is easy to create a natural,
vertically long and deep umbilical depression without
conspicuous scars in any type of umbilical deformity.

Fukushima Medical University

1, Hikarigaoka
Fukushima 960-1295, Japan
kajikawa@fmu.ac.jp

DISCLOSURE
None of the authors has a financial interest to declare in
relation to the content of this article.
REFERENCES
1. Kajikawa A, Ueda K, Suzuki Y, Ohkouchi M. A new umbilicoplasty for children: Creating a longitudinal deep umbilical
depression. Br J Plast Surg. 2004;57:741748.
2. Kajikawa A, Ueda K, Narushima M, et al. Umbilicoplasty for
children: Creating a longitudinal deep umbilical depression
facing forward at the correct position. J Jpn Plast Reconstr Surg.
2005;25:788796.
3. Onizuka T, Kojima K. Reconstruction of the navel. Jpn J Plast
Surg. 1970;13:248254.
4. Hodgkinson DJ. Umbilicoplasty: Conversion of outie to innie. Aesthetic Plast Surg. 1983;7:221222.
5. Itoh Y, Arai K. Umbilical reconstruction using a cone-shaped
flap. Ann Plast Surg. 1992;28:335338.
6. de Lacerda DJ, Martins DM, Marques A, Brenda E, de Moura
Andrews J. Umbilicoplasty for the abdomen with a thin adipose layer. Br J Plast Surg. 1994;47:386387.
7. Onishi K, Yang YL, Maruyama Y. A new lunch box-type method
in umbilical reconstruction. Ann Plast Surg. 1995;35:654656.
8. Yotsuyanagi T, Nihei Y, Sawada Y. A simple technique for
reconstruction of the umbilicus, using two twisted flaps. Plast
Reconstr Surg. 1998;102:24442446.

Triangulation for Abdominoplasty

Sir:

he symmetry of an abdominoplasty scar is essential,

and if it is not achieved, it is something often commented on by patients postoperatively. It can be difficult

DOI: 10.1097/PRS.0b013e3181d62a6a

Akiyoshi Kajikawa, M.D., Ph.D.

Kazuki Ueda, M.D., Ph.D.
Takao Sakaba, M.D.
Masaki Momiyama, M.D.
Yoko Katsuragi, M.D.
Department of Plastic and Reconstructive Surgery
Fukushima Medical University
Fukushima, Japan
Correspondence to Dr. Kajikawa
Department of Plastic and Reconstructive Surgery

264e

Fig. 1. With the patient lying squarely on the table (or preoperatively), an approximate incision marking is drawn. In this case, a
previous cesarean delivery scar formed the initial marking of the
central part. Long sutures are placed at the symphysis pubis and
xiphisternum. The abdominal meridian may be marked.

Volume 125, Number 6 Viewpoints

Fig. 2. The two marking sutures are aligned so that they meet at
an identified point on the marked incision line. They are held
together with artery forceps.

Fig. 3. Keeping the forceps holding the marking sutures together, they are moved across to the opposite side of the abdomen, and the point where the forceps reach is marked. This process is repeated for several points along the original marked
incision line, until the corresponding marked points can be
joined to form the symmetrical incision line on the other side.

to achieve, however, especially early in ones practice, and

may only come with experience. Presented here is a
method that simplifies the marking of abdominoplasty
incisions and that should ensure symmetry.
As for all abdominoplasties, the patient should be
assessed lying and standing. Crude assessment of overall body habitus/body symmetry should be performed,
including relative heights of the anterior superior iliac
spines and symmetry of the chest. This is important
because these will be points of reference for marking
the incision when the patient is lying down, and asymmetry when standing may not then be apparent. Discussion about length and height of the scar is of course
appropriate at this stage.
With the patient on the operating table, care is taken
to ensure they are lying squarely. An approximate incision

Fig. 4. The same process may also be used for contoured/geometric incisions.

line is marked on the lower abdomen before draping.

Once the patient has had skin preparation and the drapes
have been laid in place, the point of the xiphisternum and
the center of the symphysis pubis are identified. A 2-0 silk
(75 cm) stitch is placed at each of these points. This stitch
is also useful for securing drapes, particularly if nonadherent drapes are used. The sutures are cut long to allow
them to be used for the triangulation.
Using the sutures to join the two points of attachment
allows marking of the meridian or central line of the abdomen. This should pass through the umbilicus and allow
marking of the position of the new umbilicus (Fig. 1).
Altering the relative lengths of the two sutures and
holding them together with an artery clip allows accurate measurement on each side of the midline. A point
on the previously marked incision line is chosen, and
the sutures are aligned to that point. Holding the sutures together, they are then transferred to the opposite side of the abdomen and a mark is made. This is
repeated with several points along the line until the
marks can be joined to create an even, symmetrical scar.
The silk sutures are removed at the end of the procedure (Figs. 2 through 4).
This is a simple but reliable method of marking and
checking markings for abdominoplasty to ensure symmetry of the resulting scar.
DOI: 10.1097/PRS.0b013e3181d62a7e

J. Alexa Potter, M.R.C.S.

Philip A. Griffin, F.R.A.C.S.
Flinders Medical Center
Bedford Park
Adelaide, South Australia, Australia
Correspondence to Dr. Potter
Suite 605
Flinders Private Hospital
Bedford Park
Adelaide, South Australia 5042, Australia
alexajpotter@hotmail.com

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Plastic and Reconstructive Surgery June 2010

DISCLOSURE
Neither of the authors has a financial interest to declare
in relation to the content of this article.

How We Teach Tendon Repairs Outside the

Operating Room
Sir:

t our institution, we have been successful in teaching residents how to repair a tendon using a simple, efficient, and inexpensive simulation. Developing
the fine motor skills needed to repair a tendon by
means of surgical simulation while removed from the
stress of the operating room is ideal and should enhance the trainees ability to focus on and combine
those other aspects of being a well-rounded surgeon
when in the operating room.
The simulated tendon is a white, round, flexible, synthetic bait worm 10 mm in diameter and 6 cm long (Gary
Yamamoto Custom Baits, Page, Ariz.). This is pinned to a
foam board taped securely to the underlying table, and
the model is transected at its midpoint (Fig. 1). Residents
are first taught how to perform a four-strand cruciate
flexor tendon repair1 by watching a 5-minute instructional
video created by the authors in which the repair is drawn
in a stepwise fashion and then demonstrated on the
model. The residents are then free to practice and improve on repairs with the simulator. A diagram is made
available for reference during the repairs. We have found
that surgical residents from all levels benefit from this
approach and that 10 repairs is a reasonable initial goal.
Should assessment of resident progress be desired, the
repairs can be timed and also graded using a global rating
scale (Fig. 2) that is similar to a previously validated grad-

ing system.2 Standard surgical instruments and 4-0 monofilament suture are used.
The importance of simulation in todays surgical
residencies is well recognized.2 4 To our knowledge, we
are the first to report a surgical simulator designed to
teach flexor tendon repairs.5 A rubber bait worm serves
as a good tendon simulator in its general appearance
and feel. It is inexpensive and simple to set up. The
model tendon readily shows damage from heavy handling; this is advantageous in assessing for unnecessary
or improper use of forceps, for example. Our goal was
to provide a safer, more productive, and more efficient
interface between the surgical resident and their first
flexor tendon repair on a real patient. Indeed, residents who trained with the simulated tendon have subsequently reported good confidence and less anxiety in
performing their first true operative repair.
DOI: 10.1097/PRS.0b013e3181d5172d

John M. Ingraham, M.D.

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

Robert A. Weber, III

Temple High School

Robert A. Weber, M.D.

Scott & White Memorial Hospital
Texas A&M Health Science Center College of Medicine
Temple, Texas
Correspondence to Dr. Ingraham
Division of Plastic Surgery
Scott & White Memorial Hospital
2401 South 31st Street
Temple, Texas 76508
Portions of this article have previously been published in
Hand (DOI no. 10.1007/s11552-009-9184-9).

DISCLOSURE
The authors have no conflicts of interest to disclose.
REFERENCES

Fig. 1. Simulated tendon repair setup with transected bait

worm pinned to the foam base.

266e

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

of the cruciate four-strand flexor tendon repair. J Hand Surg
(Am.) 1999;24:295301.
2. Wanzel KR, Matsumoto ED, Hamstra SJ, Anastakis DJ. Teaching technical skills: Training on a simple, inexpensive, and
portable model. Plast Reconstr Surg. 2002;109:258264.
3. Leach DC. Simulation and rehearsal. In: Philibert I, ed.
ACGME Bull. 2005;December:110.
4. Grober ED, Hamstra SJ, Wanzel KR, et al. Laboratory based
training in urological microsurgery with bench model simulators: A randomized controlled trial evaluating the durability
of technical skill. J Urol. 2004;172:378381.
5. Ingraham JM, Weber RA III, Weber RA. Utilizing a simulated
tendon to teach tendon repair technique. Hand (NY.) 2009;
4:150155.

Volume 125, Number 6 Viewpoints

Fig. 2. Simulated tendon repair global rating scale.

267e