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GUIDELINES
Viewpoints
Visual Impairment after Blepharoplasty and
after Depot Steroid Injection
Sir:
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Fig. 1. (Above) Intraoperative photograph shows the fatty hernia of the left lower eyelid before repair. (Below) The same lower
eyelid is shown after repair of the fatty hernia with approximation
of the capsulopalpebral fascia and the arcus marginalis with interrupted 5-0 monofilament sutures.
www.PRSJournal.com
REFERENCES
1. Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast
Reconstr Surg. 2010;125:10071017.
2. Parsa FD, Miyashiro MJ, Elahi E, Mirzai TM. Lower eyelid
hernia repair for palpebral bags: A comparative study. Plast
Reconstr Surg. 1998;102:24592465.
3. Parsa AA, Lye KD, Radcliffe N, Parsa FD. Lower blepharoplasty
with capsulopalpebral fascia hernia repair for palpebral bags:
A long-term prospective study. Plast Reconstr Surg. 2008;121:
13871397.
4. Muhlbauer W, Holm C. Orbital septorrhaphy for the correction of baggy upper and lower eyelids. Aesthetic Plast Surg.
2000;24:418423.
5. Yagci A, Palamar M, Egrilmez S, Sahbazov C, Ozbek SS. Anterior segment ischemia and retinochoroidal vascular occlu-
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Fig. 1. (Above, left) Preoperative planning. (Above, right) Deepithelialization of the upper eyelid.
(Below) The excised isolated orbicularis oculi muscle.
Fig. 2. (Above, left) Looseness of the septum and fat pad herniation in the lower eyelid. (Above, right) The stage
of inferior rim determination of the orbicularis oculi muscle graft. (Below, left) Adaptation of the orbicularis
oculi muscle on the herniated fat pad. (Below, right) Completely determined stage of the orbicularis oculi
muscle graft.
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unsutured to prevent the risk of ectropion. The remaining muscle graft was flapped according to the
defect size to develop a pad in patients with tear
trough deformity and the region of the sulcus was
dissected subperiosteally and fixed in the canal. Afterward, the excess material of the elevated musculocutaneous lower eyelid flap was excised and
adapted to its anatomical location.
Our results appear completely homogeneous and
natural and avoid the obviously-operated-on appearance. It is natural and youthful to have fat in the
eyelids; therefore, septo-orbitoperiosteoplasty more
naturally reverses the aging process of the eyelids
(Figs. 3 and 4).
In conclusion, it is an acceptable opinion that
prominent lower eyelid prolapse and fat pads are
caused not by excess fat but by herniation related to
the weakness of the anterior septum. To construct
the orbital septum, orbicularis oculi muscle, the excision material of upper blepharoplasty, was extended in front of the septum to support the septum
strongly. At the same time, in the presence of sufficient material, a subperiosteal pocket is generated
and muscle graft is folded and can be located in this
region for performing tear trough deformity correc-
REFERENCES
1. Mendelson BC. Herniated fat and the orbital septum of the
lower eyelid. Clin Plast Surg. 1993;20:323330.
2. Cook TA, Derebery J, Harrah ER. Reconsideration of fat pad
management in lower eyelid blepharoplasty surgery. Arch Otolaryngol. 1984;110:521524.
3. Bisaccia E, Scarborough DA, Swensen RD. A technique for
blepharoplasty without incising or puncturing orbital septum. J Dermatol Surg Oncol. 1990;16:360363.
4. Spira M. Lower blepharoplasty: A clinical study. Plast Reconstr
Surg. 1977;59:3538.
5. de la Plaza R, Arroyo JM. A new technique for the treatment
of palpebral bags. Plast Reconstr Surg. 1988;81:677687.
6. Lewis JM. Augmentation blepharoplasty. Ann Plast Surg. 1988;
21:434438.
139e
he question mark ear is a severe malformation involving a cleft between the helix and the earlobe. It
is usually accompanied by protrusion of the upper third
of the ear and unfurling of its antihelix.
This malformation was first reported by Vincent et
al.1 in 1961. Subsequently, Cosman et al.2,3 reported two
cases and named the deformity the question mark deformity. We designed and performed a new technique
that is very simple and effective for the treatment of this
deformity: a surgical plan to correct both the cleft and
the protrusion of the upper ear (Fig. 1). A skin flap was
designed on the postauricular fold based inferiorly.
One end of the base of the flap was connected to an
incision on the posterior surface of the ear extended
upward, parallel and close to the edge of the ear crossing the cleft area to reach the upper limit of the defect.
The postauricular skin flap was raised and the incision
on the posterior surface of the ear parallel and close to
the edge of the ear was performed. Undermining of the
edges of the incision created a defect to be filled with
the postauricular skin flap. Through the wound, expo-
Fig. 1. (Above, left) Design of the amount of skin and cartilage needed to be added (shaded
area) to correct the deformity. (Above, right) Design of the skin flap on the posterior side of the
ear. An incision near and parallel to the edge of the ear is made to receive the flap. (Below, left)
The skin flap is raised. The lateral incision is opened to create a recipient site for the skin graft.
A cartilage graft is taken from the antihelix to help restore a prominent antihelix edge. (Below,
right) Final posterior appearance after skin flap inset and the cartilage graft inside it and
primary donor-site closure correcting the protruding upper ear.
140e
2 Rd 18 Maadi
Cairo, Egypt
elsahyplasticsurgery@gmail.com
DISCLOSURE
The author has no financial interest to declare in relation
to the content of this article.
REFERENCES
1. Vincent RW, Ryan RF, Longenecker CG. Malformation of ear
associated with urogenital anomalies. Plast Reconstr Surg Transplant Bull. 1961;28:214220.
2. Cosman B, Bellin H, Crikelair GF. The question mark ear. Plast
Reconstr Surg. 1970;46:454457.
3. Cosman B. The question mark ear: An unappreciated major
anomaly of the auricle. Plast Reconstr Surg. 1984;73:572576.
4. Al-Qattan MM. Cosman (question mark) ear: Congenital auricular cleft between the fifth and sixth hillocks. Plast Reconstr
Surg. 1998;102:439441.
5. Vayvada H, Karaca C, Menderes A, Yilmaz M. Question mark
ear deformity and a modified surgical correction method: A
case report. Aesthetic Plast Surg. 2005;29:251254; discussion
255.
6. Elsahy NI. Reconstruction of the ear after skin and perichondrium loss. Clin Plast Surg. 2002;29:187200.
141e
Fig. 2. (Above) A 34-year-old woman is shown after augmentation of the upper and lower lips with temporalis fascia grafts. The
grafts remain supple and retain their augmentation at 1 year. (Below) A 28-year-old woman is shown after augmentation of the
upper and lower lips with temporalis fascia grafts. The grafts remain supple and retain their augmentation at 1 year.
142e
Ian Roy
Malcolm A. Lesavoy, M.D.
Division of Plastic and Reconstructive Surgery
University of California, Los Angeles School of Medicine
Los Angeles, Calif.
Correspondence to Dr. Lesavoy
16311 Ventura Boulevard, Suite 555
Encino, Calif. 91436-4314
drlesavoy@aol.com
Fig. 1. (Above) The triangular area of depression, identified between the nasolabial fold, the malar arch, and the line that
connects these two anatomical landmarks, presented by the
authors. (Below) The same area after a filling treatment.
143e
DISCLOSURE
The authors have no financial interest to declare in relation to
the content of this article. No outside funding was required.
REFERENCES
1. Paton NI, Yang Y, Tha NO, Sitoh YY. Changes in facial fat in
HIV-related lipoatrophy, wasting, and weight gain measured by
magnetic resonance imaging. HIV Clin Trials 2007;8:227234.
2. Davison SP, Timpone J Jr, Hannan CM. Surgical algorithm for
management of HIV lipodystrophy. Plast Reconstr Surg. 2007;120:
18431858.
3. Serra-Renom JM, Fontdevila J. Treatment of facial atrophy related to treatment with protease inhibitors by autologous fat
injection in patients with human immunodeficiency virus infection. Plast Reconstr Surg. 2004;114:551555; discussion 556557.
4. Mori A, Lo Russo G, Agostini T, Pattarino J, Vichi F, Dini M.
Treatment of human immunodeficiency virus-associated facial lipoatrophy with lipofilling and submalar silicone implants. J Plast Reconstr Aesthet Surg. 2006;59:12091216.
5. Claude O, Domergue Than Trong E, Blanc R, et al. Treatment of
HIV facial lipoatrophy with a submalar porous polyethylene implant
(Medpor) (in French). Ann Chir Plast Esthet. 2009;54:2128.
Fig. 1. Telangiectasia after (left) Mohs surgery for basal cell carcinoma of the nasal
bridge and (right) face lift.
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Fig. 2. Mohs surgery for basal cell carcinoma of the nasal bridge, before (left) and after
(right) two treatments with pulsed dye laser.
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the treated area. Skin samples were fixed in formaldehyde and embedded in paraffin. The biopsy specimens were dyed by elasticavan Gieson and hematoxylin stain. All samples were numerated by random
and, at the end of the study, were evaluated for
histologic characteristics by an independent dermatologist and pathologist in a blinded study. Slides
were analyzed for epidermal thickness, total collagen
staining area, and gross organization (Fig. 2). The
slides were analyzed by color measurement, and the
relative amount of black pixels corresponding to
the stained elastic fibers was calculated in a 2560
1920-pixel picture (24 bits per pixel at 20magnification). The epidermal thickness was also measured.
Ten patients underwent the two punch biopsies
and completed the protocol. All subjects were
pleased with the results and acknowledged that they
would undergo another Dermaroller treatment
(Fig. 1). The procedure was very well tolerated. No
side effects were reported. None had to interrupt his
or her daily routine or leave work. The needled areas
showed small bruising and mild redness for 1 or 2
days; occasionally, a slight hematoma was seen on
Fig. 2. Histologic sample before (above) and 6 weeks after (below) microneedling.
Before
After
Relative
Response
0.18
0.02
0.12
0.16
0.08
0.12
0.06
0.1
0.14
0.18
0.2
0.18
0.07
0.35
0.13
0.13
0.04
0.14
0.16
0.14
1.11
10
0.58
2.19
1.63
1.08
0.67
1.4
1.14
0.78
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DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Orentreich DS, Orentreich N. Subcutaneous incisionless
(subcision) surgery for the correction of depressed scars and
wrinkles. Dermatol Surg. 1995;21:543549.
2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast
Surg. 1997;21:4851.
3. Kitzmiller WJ, Visscher M, Page DA, Wicket RR, Kitzmiller
KW, Singer JL. A controlled evaluation of dermabrasion
versus CO2 laser resurfacing for the treatment of perioral
wrinkles. Plast Reconstr Surg. 2000;106:13661372; discussion
13731374.
4. Giese SY, McKinney P, Roth SI, Zukowski M. The effect of
chemosurgical peels and dermabrasion on dermal elastic
tissue. Plast Reconstr Surg. 1997;100:489498; discussion 499
500.
5. Grossman AR, Majidian AM, Grossman PH. Thermal injuries
as a result of CO2 laser resurfacing. Plast Reconstr Surg. 1998;
102:12471252.
6. Coimbra M, Rohrich RJ, Chao J, Brown SA. A prospective
controlled assessment of microdermabrasion for damaged
skin and fine rhytides. Plast Reconstr Surg. 2004;113:1438
1443; discussion 1444.
7. Rubino C, Farace F, Dessy LA, Sanna MP, Mazzarello V. A
prospective study of anti-aging topical therapies using a
quantitative method of assessment. Plast Reconstr Surg. 2005;
115:11561162; discussion 11631164.
8. Rosenberg GJ, Brito MA Jr, Aportella R, Kapoor S. Long-term
histologic effects of the CO2 laser. Plast Reconstr Surg. 1999;
104:22392244; discussion 22452246.
9. Kligman LH. Photoaging: Manifestation, prevention and
treatment. Dermatol Clin. 1986;4:517528.
10. Davis SP, Allen MG, Prausnitz MR. The mechanics of microneedles. Proceedings of the Second Joint EMBS Conference ;
October 2326, 2002; Houston, Texas.
11. Henry S, McAllister DV, Allen MG, Prausnitz MR. Microfabricated microneedles: A novel approach to transdermal drug
delivery. J Pharm Sci. 1998;87:922925.
148e
Fig. 1. Histologic evaluation at the time of nipple creation reveals positive immunohistochemical staining for CD31, a commonly used endothelial cell marker, demonstrating a vascular
supply in the SurgiMend sample approximately 4 months after
initial implantation.
edges. A piece of the SurgiMend was sent for histologic evaluation, revealing a vascularized matrix with
positive CD31 staining (Fig. 1). The augmented volume produced a nipple 8 mm in height. Projection
was 7 mm at 4-month follow-up and 6 mm at 7-month
follow up (Fig. 2).
Previous techniques have incorporated folded biological matrices placed within thinned dermal flaps
to augment projection.13 This introduces a large
volume of foreign material compared with the compromised native tissue. We hypothesized that subdermal placement of a matrix after expansion at the
site of future nipple reconstruction would allow for
dermal augmentation by vascularization of the matrix before nipple creation.
We chose SurgiMend because, in contrast to human-derived biologic matrices, histologic evaluation
in animal models has shown a diminished inflammatory response, with persistence of the implant at 12
weeks and no chronic inflammatory responses seen.4
In our study, the SurgiMend was found both clinically
and histologically to be vascularized (Fig. 1), augmenting the native dermis. This restored the lost
dermal volume, allowing thicker flaps to be raised
and maintaining the integrity of the capsule. Ultimately, this provided a well-vascularized substrate for
improved bulk and projection. Whether the evidence
of decreased inflammation and vascularization of biological matrices results in clinically improved outcomes remains to be determined and will be measured in years rather than months.
DOI: 10.1097/PRS.0b013e3182131e74
DISCLOSURE
Dr. May is a consultant for TEI Biosciences (Boston,
Mass.). There were no sources of funding for this work.
REFERENCES
1. Nahabedian MY. Secondary nipple reconstruction using
local flaps and AlloDerm. Plast Reconstr Surg. 2005;115:
20562061.
2. Garramone CE, Lam B. Use of AlloDerm in primary nipple
reconstruction to improve long-term nipple projection. Plast
Reconstr Surg. 2007;119:16631668.
3. Chen WF, Barounis D, Kalimuthu R. A novel cost-saving approach to the use of acellular dermal matrix (AlloDerm) in
postmastectomy breast and nipple reconstructions. Plast Reconstr Surg. 2010;125:479481.
4. Hwang K, Hwang JH, Park JH, Kim DJ, Shin YH. Experimental study of autologous cartilage, acellular cadaveric
dermis, lyophilized bovine pericardium, and irradiated bovine tendon: Applicability to nasal tip plasty. J Craniofac
Surg. 2007;18:551558.
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DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Hammond DC, Khuthaila D, Kim J. The skate flap purse-string
technique for nipple-areola complex reconstruction. Plast Reconstr Surg. 2007;120:399406.
2. Few JW, Marcus JR, Casas LA, Aitken ME, Redding J. Longterm predictable nipple projection following reconstruction.
Plast Reconstr Surg. 1999;104:13211324.
he traditional dictum for bilateral breast reconstruction is to use the same type of reconstruction
on both sides for optimal symmetry. This can sometimes prove difficult in patients electing to have autologous reconstruction. Challenges include patients
with (1) unilateral reconstruction who subsequently
need contralateral mastectomy, (2) bilateral reconstruction who suffer unilateral flap loss, and (3) a
paucity of donor-site tissue. In such patients, autologous tissue from two different donor sites should
theoretically provide a better match compared with
autologous tissue on one side and implant on the
other. Furthermore, as many of these patients undergo irradiation, reconstruction with an implant
carries an increased risk of capsular contracture and
asymmetry.1 The long-term effects of reconstructions
using different donor sites are unclear. We present
our experience with six patients who had bilateral
reconstruction with a deep inferior epigastric artery
perforator (DIEP) flap on one side and a superior
gluteal artery perforator (SGAP) flap on the other.
Although most patients achieved satisfactory results,
in one case, postoperative changes and weight gain
created persistent asymmetry.
Two patients had unilateral breast cancer and
DIEP flap reconstruction. Both developed a primary
cancer in the contralateral breast within 3 years and
chose mastectomy with SGAP flap reconstruction.
Two patients had bilateral mastectomy and bilateral
DIEP flap reconstruction. In both patients, venous
congestion led to unilateral flap loss and tissue expander placement. They both elected to subsequently undergo expander removal and SGAP flap
reconstruction. Two patients had staged reconstruction, as there was insufficient abdominal tissue for
bilateral reconstruction (Fig. 1). Both patients had a
DIEP flap on one side and an SGAP flap on the other.
One of the patients developed a 35-lb weight gain
over 4 years. The breast reconstructed with the DIEP
flap appeared much larger despite similar initial flap
weights (Fig. 2). Five of the six patients had acceptable postoperative results based on symmetry and
volume, with a mean follow-up of 2.1 years.
Our experience suggests that bilateral autologous
reconstruction from different donor sites can be sat-
151e
Fig. 1. A 35-year-old woman with unilateral breast cancer preoperatively (left) and 2 years after staged right SGAP and
left DIEP flap surgery (right). Note the increased projection of the SGAP flap despite the similar breast volume.
Fig. 2. A 47-year-old woman with bilateral breast cancer preoperatively (left) and 4 years after staged left DIEP and right
SGAP flap surgery (right). This patient gained 35 lb and developed a subsequent asymmetry with preferential volume
increase on the left.
isfactorily performed in rare instances where warranted. However, challenges remain to achieving a
good aesthetic outcome. We found that the higher
fat content and more pronounced septation in SGAP
flaps lead to increased projection and decreased superior pole fullness. This makes symmetry difficult,
even when the flaps are closely matched in weight.
Additional revision procedures, including autologous fat grafting, may be required to achieve maximal symmetry.
Our last case highlights the potential for long-term
asymmetry with weight gain. This is of particular concern in the breast cancer patient population, as chemotherapy, hormonal therapy, and menopause are
known contributors to weight gain.2,3 Fluctuations in
body weight have been associated with changes in graft
volume after fat grafting.4 It is possible that adipocytes
transferred as part of composite tissue grafts behave as
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they would in their site of origin because normal stromal support and tissue architecture are preserved.
Therefore, they may exhibit different responses to systemic weight gain, just as they do in situ. If different
donor sites must be used for reconstruction, patients
should be counseled about potential asymmetry that
can occur with weight gain.
DOI: 10.1097/PRS.0b013e318213a1ea
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Lee BT, Adesiyun TA, Colakoglu S, et al. Postmastectomy
radiation therapy and breast reconstruction: An analysis of
complications and patient satisfaction. Ann Plast Surg. 2010;
64:679683.
2. Demark-Wahnefried W, Winer EP, Rimer BK. Why women
gain weight with adjuvant chemotherapy for breast cancer.
J Clin Oncol. 1993;11:14181429.
3. Moore HC, Kim J, Rodriguez C, et al. Predictors of permanent
menopause after chemotherapy for early-stage breast cancer
in premenopausal women. J Clin Oncol. 2009;27:15s.
4. Delay E, Garson S, Tousson G, Sinna R. Fat injection to the
breast: Technique, results, and indications based on 880 procedures over 10 years. Aesthet Surg J. 2009;29:360376.
Age
(yr)
Type of
Reconstruction
Reason for
Single Recipient
Type of Arterial
Anastomosis
Type of Venous
Anastomosis
1
2
3
4
5
6
7
8
9
10
45
42
49
35
59
53
62
38
47
26
Bilateral immediate
Immediate and delayed
Immediate and delayed
Bilateral prophylactic
Bilateral delayed
Immediate and delayed
Bilateral delayed
Bilateral prophylactic
Bilateral immediate
Immediate and delayed
Monitoring purposes
Scarred vessels
Scarred vessels
Coronary lesions on CT scan
Previous CABG
Coronary lesions on CT scan
Cardiac patient
Iatrogenic
Cardiac patient
Iatrogenic
II
III
IV
II
III
II
III
III
III
III
IV
III
IV
III
IV
IV
IV
III
IV
I
153e
Fig. 1. Options for anastomosing the arteries of a bilateral free flap breast reconstruction. IMAp, internal mammary artery perforator, proximal; IMAd, internal mammary artery perforator, distal.
154e
De Pintelaan 185
Gent B-9000, Belgium
koenraad.vanlanduyt@ugent.be
REFERENCES
1. Masia J, Clavero JA, Larran
aga JR, Alomar X, Pons G, Serret P.
Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59:594
599.
2. Blondeel PN. One hundred free DIEP flap breast reconstructions: A personal experience. Br J Plast Surg. 1999;52:104111.
3. Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm
in choosing recipient vessels for perforator free flap in breast
reconstruction: The role of the internal mammary perforators. Br J Plast Surg. 2004;57:258265.
4. Tomizawa Y, Endo M, Nishida H, et al. Use of arterial grafts
for coronary revascularization: Experience of 2987 anastomoses. Jpn J Thorac Cardiovasc Surg. 1999;47:325329.
5. Gansera B, Schmidtler F, Angelis I, et al . Quality of internal
thoracic artery grafts after mediastinal irradiation. Ann Thorac
Surg. 2007;84:14791484.
Fig. 2. Options for anastomosing the veins of a bilateral free flap breast reconstruction. IMAp, internal mammary
vein, proximal; IMAd, internal mammary vein, distal.
In dissecting the plane below the superior retromuscular pocket of the 615 cases, 315 procedures
(51.2 percent) were performed using direct visualization dissection with complete electrocautery versus 300 procedures (48.8 percent) performed with a
Dingman blunt dissector for blind dissection. The
occurrence rate of capsular contracture with complete electrocautery dissection was two (0.64 percent) of 315 cases compared with 19 (6.4 percent) of
300 cases with blunt blind dissection (chi-square test,
13.5; p 0.001; Fishers exact test, p 0.0001). The
relative risk of capsular contracture with blunt blind
dissection compared with complete electrocautery
dissection is 10 (95 percent confidence interval, 2.5
to 38.5), indicating that procedures performed with
blunt, blind dissection are 10 times as likely to produce capsular contracture. It is therefore highly
likely that bleeding during blunt, blind dissection
promotes the higher rate of capsular contracture.
(Contingency table analysis was performed by John
155e
REFERENCE
1. Barnsley GP, Sigurdson LJ, Barnsley S. Textured surface
breast implants in the prevention of capsular contracture
among breast augmentation patients: A meta-analysis of
randomized controlled trials. Plast Reconstr Surg. 2006;117:
21822190.
156e
Fig. 1. Case 1. (Above, left) Oblique-lateral view of the patient, demonstrating markings for lateral intercostal
artery perforator (X marks the perforator imaged with the Doppler probe) and thoracoabdominal flap (TAF).
(Below) Intraoperative view of the lateral intercostal artery perforator (LICAP) flap being harvested. (Above,
right) The patient is shown 6 months postoperatively.
Fig. 2. Lower pole breast deformity and possible lateral intercostal artery perforator flap inset positions.
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Fig. 3. (Left) Corrected lower pole deformity of the breast. Dotted line shows preoperative trunk contour,
before dermal lipectomy (lateral intercostal artery perforator flap harvest). (Right) Correction of lower pole
breast deformity with lateral intercostal artery perforator and thoracoabdominal flaps.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Saint-Cyr M, Nagarkar P, Schaverien M, Dauwe P, Wong C,
Rohrich RJ. The pedicled descending branch muscle-sparing
latissimus dorsi flap for breast reconstruction. Plast Reconstr
Surg. 2009;123:1324.
2. Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel
P, Monstrey S. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg. 2006;59:
644652.
3. Hamdi M, Spano A, Van Landuyt K, DHerde K, Blondeel P,
Monstrey S. The lateral intercostal artery perforators: Anatomical study and clinical application in breast surgery. Plast
Reconstr Surg. 2008;121:389396.
4. Hamdi M, Van Landuyt K, Blondeel P, Hijjawi JB, Roche N,
Monstrey S. Autologous breast augmentation with the lateral
intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthet Surg. 2009;62:6570.
158e
REFERENCES
1. Denzer C, Webel A, Muche R, Karges B, Sorgo W, Wabitsch
M. Pubertal development in obese children and adolescents.
Int J Obes. 2007;31:15091519.
58-year-old white woman who had undergone bilateral cosmetic breast augmentation with Inamed
McGhan smooth silicone gel breast implants 19 years
previously presented with a painful right breast and
Baker grade III capsular contracture without evidence
of breast mass or lymphadenopathy. In 2006, her device
had already been replaced in a private clinical structure
for the same complication. At admission, she was otherwise in good health. Her blood count and serum
chemistry values were normal. No local mammary or
systemic cutaneous manifestations were observed.
Mammography was unremarkable. Both implants were
removed and the submuscular pouch was explored,
with drainage of a serous-hematic fluid surrounding
the right prosthesis. Capsulectomy was performed and
the removed fibrous tissue analyzed because of its altered aspect. The pathologic findings were consistent
with a diagnosis of null-type, anaplastic lymphoma ki-
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Fig. 1. ALCL slide showing large blastic cells with abundant cytoplasm and eccentric nuclei that are generally horseshoe
shaped or reniform with prominent nucleoli (hematoxylin and
eosin; original magnification, 400).
Fig. 2. Typical immunophenotype of null-type [no expression of T-cell marker CD3 (above, right) or the B-cell
marker CD20 (above, left)] ALCL [intense expression of CD30 (below, left)] and showing no expression of anaplastic
lymphoma kinase (below, right) (original magnification, 200).
160e
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Sahoo S, Rosen PP, Feddersen RM, Viswanatha DS, Clark DA,
Chadburn A. Anaplastic large cell lymphoma arising in a
silicone breast implant capsule: A case report and review of
the literature. Arch Pathol Lab Med. 2003;127:e115e118.
2. Kraemer DM, Tony HP, Gattenlohner S, Muller JG. Lymphoplasmacytic lymphoma in a patient with leaking silicone
implant. Haematologica 2004;89:ELT01.
3. Wong AK, Lopategui J, Clancy S, Kulber D, Bose S. Anaplastic
large cell lymphoma associated with a breast implant capsule:
A case report and review of the literature. Am J Surg Pathol.
2008;32:12651268.
4. Roden AC, Macon WR, Keeney GL, Myers JL, Feldman AL,
Dogan A. Seroma-associated primary anaplastic large-cell
lymphoma adjacent to breast implants: An indolent T-cell
lymphoproliferative disorder. Mod Pathol. 2008;21:455463.
5. Kim B, Roth C, Chung KC, et al. Anaplastic large cell lymphoma and breast implants: A systematic review. Plast Reconstr
Surg. 2011;127:21412150.
6. Lazzeri D, Agostini T, Bocci G, et al. ALK-1 negative anaplastic large cell lymphoma associated with breast implants:
A new clinical entity. Clin Breast Cancer (in press).
7. Lazzeri D, Agostini T, Pantaloni M, DAniello C. Further
information on anaplastic large cell lymphoma and breast
implants. Plast Reconstr Surg. (in press).
8. Mora P, Melo AC, Amorim GLS, Scheliga AA. Primary T-cell
anaplastic lymphoma associated to a breast implant: Case
report. Haematologica 2009;94:658659.
9. Popplewell L, Chang K, Olevsky O, Nademanee A, Forman S.
Primary anaplastic large cell lymphoma of the breast occurring
in patients with silicone breast implants (American Society of
Hematology: Abstract). Blood 2004;104:4563.
10. Brody G, Deapen D, Gill P, et al. T-cell non Hodgkins
anaplastic lymphoma associated with one style of breast implants. Presented at: 89th Annual Meeting of the American
Association of Plastic Surgeons, San Antonio, Texas; 2010.
161e
he actual criterion standard of distal digital reconstruction includes a convenient nail bed, with
length preservation and an almost normal nail lamina,
making the dorsal repair as important as the pulp
repair.1 Several techniques have been suggested and,
recently, adipofascial flaps, since the first descriptions
by Ozdemir et al.,2 have also been proposed.
In our previous article,3 we concentrated our research
on the homodigital adipofascial reverse flap, based on
distal dorsal perforators coming from the main volar vessels, and pointed out some key points for a safe dissection.
In particular, we recommended first that the skin flaps
on the ulnar side of the digits be raised to avoid
visible and tender scars and to avoid undermining
the distal part of the flap, preserving at least a 10-mm
cuff of tissue proximal to the eponychial fold.3
Afterward, we began to use the homodigital dorsal
adipofascial reverse flap to revascularize the damaged nail
bed in acute apical lesions; then, after getting acquainted
with technical pearls in flap performance, we have been
extending its indications to posttraumatic deformities. In
this viewpoint, we present our cases, 11 of them trauma
patients treated on an emergency basis, and seven apical
scars treated by elective surgery. Details are in listed Table 1.
After surgical debridement in the first group and
nail-bed scar removal in the latter, skin and adipofascial
flaps were designed, dissected, and elevated according
to the description of our anatomical article.3 The adi-
162e
*One patient suffered from venous congestion with partial flap necrosis (40 percent of the flap), requiring debridement and a subsequent local flap advancement. However, an almost normal regrowth
of nail lamina was documented. None of our patients complained of
cold intolerance or residual joint contracture.
DISCLAIMER
This article has been prepared and written conforming to the
Declaration of Helsinki; it is not a clinical trial.
REFERENCES
1. Momeni A, Zajonc H, Kalash Z, Stark GB, Bannasch H. Reconstruction of distal phalangeal injuries with the reverse
homodigital island flap. Injury 2008;39:14601463.
2. Ozdemir R, Kilinc H, Sensoz O, Unlu RE, Baran CN. Innervated dorsal adipofascial turnover flap for fingertip amputations. Ann Plast Surg. 2001;46:914.
3. Delia G, Casoli V, Sommario M, Risitano G, DAlcontres FS,
Colonna MR. Homodigital dorsal adipofascial reverse flap:
Anatomical study of distal perforators and key points for safe
dissection. J Hand Surg Eur Vol. 2010;35:454458
4. Hosnuter M, Kargi E, Babuccu O. Is nail germinal matrix
ablation always necessary in a dorsal reverse adipofascial flap
procedure for fingertip reconstruction? Plast Reconstr Surg.
2004;114:1678; author reply 16781679.
163e
polymyalgia rheumatica, heart disease, and hypothyroidism. Her medications included prednisone, Synthroid, estradiol, and multiple cardiac medications.
The patient also had long-standing right upper extremity lymphedema secondary to axillary lymph node dissection for breast cancer. There was no history of recent
travel, gardening, or other unusual hobbies. She did
not have any pets and could not recall any associated
trauma to her right arm.
On referral to a hand surgeon, the patient was afebrile, with several nontender erythematous nodules
over the dorsum of her right wrist and forearm. The
lesions were functionally nonlimiting; there was no
lymphadenopathy. Radiographs and basic laboratory
workup were normal. She subsequently underwent excision of the cutaneous lesions. Histologic evaluation
revealed dense neutrophilic collections within the deep
dermis and subcutaneous fat with abscess formation.
Acid-fast staining demonstrated large amounts of acidfast bacilli present throughout all the specimens obtained (Fig. 2, above). Additional Fites staining (a modified acid-fast stain, cross-reactive with M. chelonae)
corroborated these results (Fig. 2, below). The patient
continued on clarithromycin therapy for 6 months. All
wounds healed without incident.
M. chelonae is a rapidly growing acid-fast organism
that develops with an insidious course. It is most often
found in soil throughout the United States and is a rare
cause of mycobacterial cutaneous infection. Previous reports suggest that the most frequent areas of skin involvement are the extremities, which may correlate with areas
most often involved in minor traumatic injuries.1,2
Immunosuppression also appears to play a role in
the incidence and progression of the disease. Wallace
et al. identified 100 skin, soft-tissue, or bone isolates of
M. chelonae over a 10-year period.3 The most common
manifestation was disseminated cutaneous disease, followed by localized cellulitis, subcutaneous abscess, or
osteomyelitis. Among their patient population, 62 percent were receiving corticosteroids and 72 percent had
164e
Fig. 2. (Above) Photomicrograph showing multiple acid-fast bacilli, mostly in clusters. There are also bacilli scattered throughout
the specimen (acid-fast bacillus stain; original magnification,
40). (Below) Photomicrograph showing mycobacteria scattered throughout the cellular matrix. A cluster of bacilli is seen in
the specimen (Fites stain; original magnification, 40).
immunosuppressive conditions. In our patient, longterm prednisone therapy in addition to other comorbidities may have created chronic immunosuppression.
Diagnosis of M. chelonae cutaneous infection may
include chronic ulcerations, with expression of a caseous material. An antecedent penetrating traumatic injury may also be present, in addition to a history of
immunosuppressive conditions (e.g., acquired immunodeficiency syndrome) or drug therapy. Symptoms
may be vague, and there are no pathognomonic physical examination findings for M. chelonae. As a result,
diagnosis is often made late and usually follows other
empiric medical interventions that were unsuccessful.
M. chelonae infections of the upper extremity are rare.
Its incidence is associated with immunosuppression and
penetrating traumatic injuries. Surgical procedures may
also be associated. Early detection may be difficult, but
surgical excision is usually curative. In addition, the organism is largely sensitive to clarithromycin, and long-
REFERENCES
1. Mateo L, Rufi G, Nolla JM, Alcaide F. Mycobacterium chelonae tenosynovitis of the hand. Semin Arthritis Rheum. 2004;34:617622.
2. Kozin SH, Bishop AT. Atypical Mycobacterium infections of the
upper extremity. J Hand Surg Am. 1994;19:480487.
3. Wallace RJ Jr, Brown BA, Onyi GO. Skin, soft tissue, and bone
infections due to Mycobacterium chelonae chelonae: Importance
of prior corticosteroid therapy, frequency of disseminated
infections, and resistance to oral antimicrobials other than
clarithromycin. J Infect Dis. 1992;166:405412.
4. Franck N, Cabie A, Villette B, Amor B, Lessana-Leibowitch M, Escande JP. Treatment of Mycobacterium chelonae-induced skin infection with clarithromycin. J Am Acad Dermatol. 1993;28:10191021.
nerve structures. We propose a new technique to modify the shape of the needle, transforming it into a 90degree-angled needle and allowing the injector to stop
the needle insertion when it is introduced vertically
into firm palmar skin. This prevents the liquid from
penetrating into the deeper dermis, which may result
in muscle weakness (Figs. 1 and 2).
In the axilla, this technique allows for parallel introduction of the needle. It even allows the injector to
use the needle as a hook to raise the skin to make sure
that the injection is superficial, thereby minimizing the
subsequent loss of effect of the product.
To modify the needle, sterile clamps and sterile surgical gloves are used. The depth at which the injection
is intended is calculated (approximately 2.5 to 3 mm
for the palm of the hand and 5 mm for the armpit), and
the caudal end of the needle is bent without reducing
the caliber or damaging the cutting edge.
In our experience, this technique has simplified the
work significantly, resulting in reduced pain when the
Fig. 1. The needle is bent with a sterile clamp. The finished appearance of the modified needle is shown on the right.
165e
Guillermo Blugerman,
Diego Schavelzon,
Honorio Labaronnie,
Andrea Markowsky,
Jorge DAngelo,
M.D.
M.D.
M.D.
M.D.
M.D.
B & S Clinic
Buenos Aires, Argentina
Correspondence to Dr. Blugerman
B & S Clinic
Buenos Aires, Argentina
blugerman@clinicabys.com
REFERENCES
1. Glaser DA, Hebert AA, Pariser DM, Solish N. Palmar and
plantar hyperhidrosis: Best practice recommendations and
special considerations. Cutis 2007;79:1828.
2. Zaiac M, Weiss E, Elgart G. Botulinum toxin therapy for palmar hyperhidrosis with ADG needle. Dermatol Surg. 2000;26:
230.
3. de Almeida AR, Kadunc BV, de Oliveira EM. Improving botulinum toxin therapy for palmar hyperhidrosis: Wrist block
and technical considerations. Dermatol Surg. 2001;27:3436.
166e
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Siemionow M, Arslan E. Ischemia/reperfusion injury: A review in relation to free tissue transfers. Microsurgery 2004;24:
468475.
2. Smit JM, Zeebregts CJ, Acosta R, Werker PM. Advancements
in free flap monitoring in the last decade: A critical review.
Plast Reconstr Surg. 2010;125:177185.
3. Chiu ES, Altman A, Allen RJ Jr, Allen RJ Sr. Free flap
monitoring using skin temperature strip indicators: Adjunct to clinical examination. Plast Reconstr Surg. 2008;122:
144e145e.
4. Booi DI, Debats IB, Boeckx WD, van der Hulst RR. A study of
perfusion of the distal free-TRAM flap using laser Doppler
flowmetry. J Plast Reconstr Aesthet Surg. 2008;61:282288.
167e
168e
REFERENCES
1. Shaikh FM, Giri SK, Durrani S, Waldron D, Grace PA. Experience with porcine acellular dermal collagen implant in onestage tension-free reconstruction of acute and chronic abdominal wall defects. World J Surg. 2007;31:19661672;
discussion 16731674, 1675.
2. Hiles M, Record Ritchie RD, Altizer AM. Are biologic grafts
effective for hernia repair? A systematic review of the literature. Surg Innov. 2009;16:2637.
3. Hammond TM, Chin-Aleong J, Navsaria H, Williams NS. Human in vivo cellular response to a cross-linked acellular collagen implant. Br J Surg. 2008;95:438446.
4. Jarman-Smith ML, Bodamyali T, Stevens C, Howell JA, Horrocks M, Chaudhuri JB. Porcine collagen crosslinking, degradation and its capability for fibroblast adhesion and proliferation. J Mater Sci Mater Med. 2004;15:925932.
Panniculectomy as a PreBariatric
Surgery Procedure
Sir:
169e
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Igwe D Jr, Stanczyk M, Lee H, Felahy B, Tambi J, Fobi MA.
Panniculectomy adjuvant to obesity surgery. Obes Surg. 2000;
10:530539.
2. Reichenberger MA, Stoff A, Richter DF. Dealing with the mass:
A new approach to facilitate panniculectomy in patients with
very large abdominal aprons. Obes Surg. 2008;18:16051610.
3. Manahan MA, Shermak M. Massive panniculectomy after massive weight loss. Plast Reconstr Surg. 2006;17:21912197; discussion 21922193.
4. Daw JL, Mustoe TA. Use of tourniquet in panniculus resection. Plast Reconstr Surg. 1997;99:20822084.
5. Jensen PL, Sanger JR, Matloub HS, Yousif NJ. Use of portable
floor crane as an aid to resection of the massive panniculus.
Ann Plast Surg. 1990;25:234235.
170e
60
43
51
72
73
46
43
80
35
Initial
Operation
Crohn disease,
tobacco
abuse
None
Hepatitis C
Comorbidities
Sacral
chordoma
Sacral
chordoma
Sacral
chordoma
Sacral
chordoma
Sacral
chordoma
Sacrectomy
Sacrectomy
Sacrectomy
Sacrectomy
Sacrectomy
Concurrent
prostate
cancer (with
radiation of
79.2 Gy)
None
None
None
None
Underlying
Disease
Sex
Age
(yr)
19.8
(postoperative,
57.6 )
50.4
(postoperative,
19.8 )
50.4
(postoperative,
19.8 )
50.4
(postoperative
19.8 )
50.4
21.6
50.4
54
Radiation before
Dermal
Apposition (Gy)
Closure done at
50.4
time of primary
(postoperative,
resection
19.8)
Draining sinuses,
infection,
nonhealing
wound for 33
mo
Abscess, draining
sinuses,
nonhealing
wound for 23
mo
Abscesses, sinus
tracts, positive
margins, open
wound for 1
mo
Sacral wound
breakdown
with
nonhealing for
12 mo
Closure done at
time of primary
resection
Closure done at
time of primary
resection
Closure done at
time of primary
resection
Closure done at
time of primary
resection
Complications
from Cancer
Resection
Size of
Deepithelialization
(cm2)
100
40
64
24
36
60
160
90
60
Size of
Wound
(cm)
25 7
42
96
32
16 5
25 6
30 9
18 7
17 6
None
None
None
None
None
None
None
None
None
Complications
from Dermal
Apposition
11
11
33
33
56
18 (died with
healed
wound)
39
Follow-Up
(mo)
171e
Fig. 1. Posterior view of a typical patient in the series demonstrating original wound extending
into the peritoneal cavity (left). The deepithelialized dermis is advanced into the wound and
closedinlayers(right).Thesuperiorportionofthewoundwasclosedwithoutdeepithelialization.
Fig. 2. Preoperative (left) and 6-week postoperative (right) photographs after wound closure using the extended dermal
apposition technique. This patient received 50.4 Gy of preoperative and 19.8 Gy of postoperative irradiation. He also received 79.2 Gy directed to his prostate for concomitant prostate cancer before the dermal invagination closure.
172e
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
REFERENCES
1. Tibbs M. Wound healing following radiation therapy: A review. Radiother Oncol. 1997;42:99106.
2. Gorodetsky R, McBride WH, Withers HR, Miller GG. Effect of
fibroblast implants on wound healing of irradiated skin: Assay
of wound strength and quantitative immunohistology of collagen. Radiat Res. 1991;125:181186.
3. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary
perineal wound closure after preoperative radiotherapy and
abdominoperineal resection has a high incidence of wound
failure. Dis Colon Rectum 2005;48:438443.
4. Zileli M, Hoscoskun C, Brastianos P, Sabah D. Surgical treatment of primary sacral tumors: Complications associated with
sacrectomy. Neurosurg Focus 2003;15:18.
5. Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases perineal wound complications after pelvic
chemoradiation and surgery: A cohort study. Ann Surg Oncol.
2005;12:104110.
Fig. 1. (Above, left) A 7-cm distal tibia defect (filled with antibiotic bone spacer) had loss of overlying soft tissue following surgical
debridement. Intraoperative marking of the tunnel site for skin paddle was marked with a checkerboard pattern. (Above, left) A
retrograde osteocutaneous fibula flap was mobilized on the distal pedicle after ligation of the peroneal vessels at their takeoff.
(Below, left) After contouring osteotomy, a double-barreled vascularized fibula and a single strut of nonvascularized fibula were
cerclage-wired together to fill the distal tibial defect. (Below, right) After final inset, the skin paddle appeared viable.
173e
Fig. 2. (Left) Lateral radiograph shows the reconstructed tibia at 20-month follow-up.
(Right) At 12-month follow-up, the patient was able to bear weight and had stable
soft-tissue coverage and acceptable final contour.
174e
DISCLOSURE
The authors have no financial interests in or commercial
associations with any product or technique advocated in this
article.
REFERENCES
1. Khouri RK, Shaw WW. Reconstruction of the lower extremity
with microvascular free flaps: A 10-year experience with 304
consecutive cases. J Trauma 1989;29:10861094.
2. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004;114:14571466.
3. Mathes SJ, Nahai F. Fibula flap. In: Reconstructive Surgery: Principles, Anatomy, and Technique. Vol. 2, 1st ed. New York:
Churchill Livingstone; 1997:13531370.
4. Chen ZW, Chen LE, Zhang GJ, Yu HL. Treatment of tibial
defect with vascularized osteocutaneous pedicled transfer of
fibula. J Reconstr Microsurg. 1986;2:199203, 205.
5. Minami A, Itoga H, Suzuki K. Reverse-flow vascularized fibula
graft: A new method. Microsurgery 1990;11:278281.
parative analysis on the recent developments of randomized controlled trials in reconstructive, burn, aesthetic, and hand surgery. Furthermore, reporting
quality of randomized controlled trials was addressed
by the Consolidated Standards of Reporting Trials
group first in 1996, and was updated in 2001 and very
recently in 2010.3 The Consolidated Standards of Reporting Trials items aim to improve the reporting quality of randomized controlled trials in full article and in
abstract form.4 Using the Consolidated Standards of
Reporting Trials items, one can compare the reporting
quality of randomized controlled trial conference abstracts, which was a second aim of this analysis. To
analyze up to date, we decided to analyze various conferences rather than full articles, given the fact that not
all randomized controlled trials presented as abstracts
will find their way to a full article within the next 5 years.
We analyzed 65 oral abstracts and 94 poster abstracts from the 2008 meeting of the American Society of Plastic Surgeons by two independent researchers. In addition, 152 oral and 100 poster
presentations from the 2008 meeting of the American Burn Association were analyzed, as were102 abstracts from the American Society for Surgery of the
Hand annual meeting. We determined the evidencebased medicine level of evidence for study design.
Furthermore, the level of reporting quality according
to the Consolidated Standards of Reporting Trials
recommendations was determined with a maximum
score of 17 of 17 points.
We found that at the American Society of Plastic
Surgeons 2008 meeting, 9 percent (5 percent oral and
4 percent poster abstracts) of presentations were randomized controlled trials. Reporting quality at the
American Society of Plastic Surgeons meeting was 6.7
1.2 for oral randomized controlled trials and 7.3 1 for
poster randomized controlled trials (p 0.498; 95 percent confidence interval, 2.62 to 1.46) of 17 achievable
points according to Consolidated Standards of Reporting Trials criteria. At the American Burn Association
Annual Meeting, 7 percent randomized controlled trials were presented, with 5 percent oral and 2 percent
poster presentations. Reporting quality according to
Consolidated Standards of Reporting Trials criteria was
not significantly different for oral versus poster randomized controlled trials (7.2 1.4 versus 6.5 1 of
17 points, p 0.552; 95 percent confidence interval,
1.78 to 3.06). We identified 10 percent randomized
controlled trials at the American Society for Surgery of
the Hand meeting. Consolidated Standards of Reporting Trials reporting quality was 8.2 1.4 of 17, somewhat higher than for randomized controlled trials presented at the American Society of Plastic Surgeons
meeting.
Our results indicate that the amount of randomized controlled trials presented either in oral or
poster abstract form at American Society of Plastic
Surgeons, American Burn Association, and American
Society for Surgery of the Hand meetings is still below
10 percent of all presentations. Given the fact that
175e
REFERENCES
1. Chung KC, Swanson JA, Schmitz D, Sullivan D, Rohrich RJ.
Introducing evidence-based medicine to plastic and reconstructive surgery. Plast Reconstr Surg. 2009;123:13851389.
2. Hopewell S, Clarke M, Askie L. Reporting of trials presented
in conference abstracts needs to be improved. J Clin Epidemiol.
2006;59:681684.
3. Schulz KF, Altman DG, Moher D; CONSORT Group.
CONSORT 2010 statement: Updated guidelines for reporting
parallel group randomised trials. BMJ. 2010;340:c332.
4. Hopewell S, Clarke M, Moher D, et al. CONSORT for reporting randomised trials in journal and conference abstracts.
Lancet 2008;371:281283.
5. Amadio PC, Higgs P, Keith M. Prospective comparative clinical trials in The Journal of Hand Surgery (American). J Hand
Surg Am. 1996;21:925929.
6. Chang EY, Pannucci CJ, Wilkins EG. Quality of clinical studies
in aesthetic surgery journals: A 10-year review. Aesthetic Surg J.
2009;29:144147; discussion 147149.
7. Becker A, Blumle A, Antes G, et al. Controlled trials in aesthetic plastic surgery: A 16-year analysis. Aesthetic Plast Surg.
2008;32:359362.
176e
Fig. 1. Individuals characterized by high levels of both narcissism and perfectionism appear especially interested in cosmetic surgery.
Skye Fitzpatrick
Simon Sherry, Ph.D.
Nikola Hartling
REFERENCES
1. Twenge J, Campbell W. The Narcissism Epidemic. New York: Free
Press; 2009.
2. Goldwyn R. The Patient and the Plastic Surgeon. Boston: Little,
Brown; 1991.
3. Raskin R, Terry H. A principle-components analysis of the
Narcissistic Personality Inventory and further evidence of its
construct validity. J Pers Soc Psychol. 1988;54:890902.
4. Hewitt P, Flett GL. Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. J Pers Soc Psychol. 1991;60:456470.
5. Sherry S, Hewitt P, Lee-Baggley D, Flett G, Besser A. Perfectionism and thoughts about having cosmetic surgery performed. J Appl Biobehav Res. 2004;9:244257.
177e