- Email: [email protected]
The V-V flap – A simple modification of the C-V flap for nipple reconstruction
Correspondence and communications
Results Of the 135 volume discrepancy questions, participants were correct 95 times, and incorrect 40 times. Consultants were correct 37 times, and incorrect 17 times whereas the registrars were correct 58 times and incorrect 23 times. No correlation was found between correct estimation of volume discrepancy and the training grade of the participant (c2 Z 0.148, p Z 0.700). Table 1 shows the results of the binomial analysis.
Discussion The volumes used were decided upon as they have been found to roughly reflect average breast volumes on MRI scan.3 When surgeons are visually assessing the patient at the end of the procedure, looking from the end of the table with the patient sat slightly head up is the normal method of assessment. However, during resection of tissue, assessing volume by feel is easier than visual estimation as the tissue may not all be in a skin envelope and thus difficult to compare. Stark defined breast asymmetry by differences in volume and form. He stated that the differences in volume should be at least 30% to diagnose asymmetry.4 Even with a small volume of breast tissue (here, equivalent to 20 ml), these results suggest that the surgeon estimating by feel would be able to easily distinguish this volume discrepancy between sides (p Z 0.017).
Conclusion Although this is a non-living model, these results show that surgeons of varying surgical experience are capable of reliably detecting even relatively small differences in volume. This suggests that tactile volume estimation of the breasts during breast reduction can be a surprisingly accurate aid for achieving better breast symmetry.
Conflict of interest statement None.
Funding None.
References 1. Giacalone PL, Bricout N, Dantas M, Daure ´s J, Laffargue F. Achieving symmetry in unilateral breast reconstruction: 17 years experience with 683 patients. Aesthetic Plast Surg 2002; 26(4):299e302. 2. Hudson DA. Factors determining shape and symmetry in immediate breast reconstruction. Ann Plast Surg 2004;52(1):15e21. 3. Hussain Z, Roberts N, Whitehouse GH, Garcia-Finana M, Percy D. Estimation of breast volume and its variation during the menstrual cycle using MRI and stereology. Br J Radiol 1999;72: 236e45. 4. Stark B. Author’s reply. Eur J Plast Surg 1992;15:205.
1009 Thomas A. Reekie Plastic Surgery CT2, University Hospital North Durham, Durham, England, UK E-mail address: [email protected] Elizabeth Wharton Paul Sugden Plastic Surgery Department, University Hospital North Durham, Durham, England, UK ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.005
The V-V flap e A simple modification of the C-V flap for nipple reconstruction Dear Sir, We have been following the discussion of various modifications of the C-V flap for nipple reconstruction in your journal over the last years with great interest. The C-V flap as described by Bostwick in 19941 is a standard flap in nipple reconstruction, but as every local flap creating a three dimensional structure out of two dimensional design, prone to loss of projection due to scarring and tissue shrinkage. According to the literature published to date the loss of intra-operative achieved volume averages 30e40%2 and therefore several modifications have been developed to limit the loss of volume and to improve the postoperative outcome. The original flap design is a trefoil, two V flaps in the horizontal axis with a central C flap in the vertical axis. The previously described modifications include deepithelisation and integration of the tips of the V flaps into the nipple core to achieve more volume3,4 or raising the C flap in a deep dermal layer to create a supporting base under the nipple itself.5 We would like to use the opportunity to introduce our simple modification, best described as a VV-flap. This flap design provides more substantial volume to the neo-nipple by introducing dermis rather than fat into its core and allowed the senior author to achieve very satisfying results since its introduction 14 years ago. In our modification, the C flap is designed as a further V and the tip de-epithelialised to provide more substance in the core of the nipple corpus, when enveloped by the V flaps. The design of our V-V flap is shown in Figure 1, slightly larger than the contralateral nipple to anticipate the postoperative shrinkage. The tip of the vertical V flap is deepithelialised (marked in Figure 1 with *). The trefoil flap is carefully dissected with a small cuff of subcutaneous fat and the donorsites closed directly with continuous Vicryl rapide 5/0 sutures.
1010
Correspondence and communications
Statements for conflict of interest, funding and ethical approval Funding: None. Conflicts of interest: None declared. Ethical approval: Not required.
References
Figure 1 Design of the VV flap e the de-epithelialised tip of the vertical V flap is marked with *.
The lateral V flaps are wrapped around each other to create the circumference of the nipple corpus and held in place by interrupted Vicryl rapide 5/0 sutures. The de-epithelialised tip of the vertical V flap is introduced into the core (Figure 2), so that the core now not only contains the subcutaneous fat of the flaps but also the de-epithelialised tip of the vertical V flap. The epithelialised borders of the vertical V flap come to meet the horizontal V flap borders and again interrupted skin sutures Vicryl rapide 5/0 are used to fix the flap in its position. The final result is shown as inset in Figure 2. Postoperatively we use the nipple projector as described by Valdatta et al. 20082 and arrange for tattooing of the nipple areola 6 weeks post surgery. In the 84 cases of modified V-V flaps for nipple reconstruction that we traced over the last 4 years (since introduction of a computerized theatre logbook), no flap necrosis occurred and to our knowledge, no further surgery to improve postoperative outcome was required.
1. Jones G, Bostwick III J. Nipple-areolar reconstruction. Oper Tech Plast Reconstr Surg 1994;1:35. 2. Valdatta L, Montemurro P, Tamborini F, Fidanza C, Gottardi A, Scamoni S. Our experience of nipple reconstruction using the C-V flap technique: 1 year evaluation. J Plast Reconstr Aesthet Surg 2009;62(10):1293e8. 3. Brackley PT, Iqbal A. Enhancing your C-V flap nipple reconstruction. J Plast Reconstr Aesthet Surg 2009;62(1):128e30. 4. Mori H, Hata Y. Modified C-V flap in nipple reconstruction. J Plast Reconstr Aesthet Surg 2009;62(1):115e6. 5. O’Neil J, Goodwin-Walters A. Modification of the C-V flap for nipple reconstruction. J Plast Reconstr Aesthet Surg 2010;63(4):e418e9.
P. Witt D.G. Dujon Department of Plastic Surgery, Royal Hallamshire Hospital, Sheffield S10 2JF, United Kingdom E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.001
Salvage of free flaps by supermicrosurgical techniques following accidental rupture of the perforator pedicle Dear Sir,
Figure 2 Inset of the vertical V flap e the de-epithelialised tip of the vertical V flap (elevated with a skin hook) is introduced into the core, after the horizontal V flaps have been positioned and the donorsite has been closed. The final result is shown as inset in the picture.
Perforator flaps have gained immense popularity recently, because they reduce donor site morbidity and increase cosmesis.1 Despite meticulous dissection when elevating a perforator flap, injury to the perforator may occur. We have experience of five cases of accidental rupture of the perforator pedicle during pedicle dissection, and in all cases the pedicle was repaired using supermicrosurgical techniques. This study includes all cases of perforator rupture during flap dissection in the experience of the senior surgeon (J.T.K.). Electronic charts were reviewed where available. Patient demographics, type of flap, cause of perforator rupture, solution used to mend the rupture, and postoperative
Results Of the 135 volume discrepancy questions, participants were correct 95 times, and incorrect 40 times. Consultants were correct 37 times, and incorrect 17 times whereas the registrars were correct 58 times and incorrect 23 times. No correlation was found between correct estimation of volume discrepancy and the training grade of the participant (c2 Z 0.148, p Z 0.700). Table 1 shows the results of the binomial analysis.
Discussion The volumes used were decided upon as they have been found to roughly reflect average breast volumes on MRI scan.3 When surgeons are visually assessing the patient at the end of the procedure, looking from the end of the table with the patient sat slightly head up is the normal method of assessment. However, during resection of tissue, assessing volume by feel is easier than visual estimation as the tissue may not all be in a skin envelope and thus difficult to compare. Stark defined breast asymmetry by differences in volume and form. He stated that the differences in volume should be at least 30% to diagnose asymmetry.4 Even with a small volume of breast tissue (here, equivalent to 20 ml), these results suggest that the surgeon estimating by feel would be able to easily distinguish this volume discrepancy between sides (p Z 0.017).
Conclusion Although this is a non-living model, these results show that surgeons of varying surgical experience are capable of reliably detecting even relatively small differences in volume. This suggests that tactile volume estimation of the breasts during breast reduction can be a surprisingly accurate aid for achieving better breast symmetry.
Conflict of interest statement None.
Funding None.
References 1. Giacalone PL, Bricout N, Dantas M, Daure ´s J, Laffargue F. Achieving symmetry in unilateral breast reconstruction: 17 years experience with 683 patients. Aesthetic Plast Surg 2002; 26(4):299e302. 2. Hudson DA. Factors determining shape and symmetry in immediate breast reconstruction. Ann Plast Surg 2004;52(1):15e21. 3. Hussain Z, Roberts N, Whitehouse GH, Garcia-Finana M, Percy D. Estimation of breast volume and its variation during the menstrual cycle using MRI and stereology. Br J Radiol 1999;72: 236e45. 4. Stark B. Author’s reply. Eur J Plast Surg 1992;15:205.
1009 Thomas A. Reekie Plastic Surgery CT2, University Hospital North Durham, Durham, England, UK E-mail address: [email protected] Elizabeth Wharton Paul Sugden Plastic Surgery Department, University Hospital North Durham, Durham, England, UK ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.005
The V-V flap e A simple modification of the C-V flap for nipple reconstruction Dear Sir, We have been following the discussion of various modifications of the C-V flap for nipple reconstruction in your journal over the last years with great interest. The C-V flap as described by Bostwick in 19941 is a standard flap in nipple reconstruction, but as every local flap creating a three dimensional structure out of two dimensional design, prone to loss of projection due to scarring and tissue shrinkage. According to the literature published to date the loss of intra-operative achieved volume averages 30e40%2 and therefore several modifications have been developed to limit the loss of volume and to improve the postoperative outcome. The original flap design is a trefoil, two V flaps in the horizontal axis with a central C flap in the vertical axis. The previously described modifications include deepithelisation and integration of the tips of the V flaps into the nipple core to achieve more volume3,4 or raising the C flap in a deep dermal layer to create a supporting base under the nipple itself.5 We would like to use the opportunity to introduce our simple modification, best described as a VV-flap. This flap design provides more substantial volume to the neo-nipple by introducing dermis rather than fat into its core and allowed the senior author to achieve very satisfying results since its introduction 14 years ago. In our modification, the C flap is designed as a further V and the tip de-epithelialised to provide more substance in the core of the nipple corpus, when enveloped by the V flaps. The design of our V-V flap is shown in Figure 1, slightly larger than the contralateral nipple to anticipate the postoperative shrinkage. The tip of the vertical V flap is deepithelialised (marked in Figure 1 with *). The trefoil flap is carefully dissected with a small cuff of subcutaneous fat and the donorsites closed directly with continuous Vicryl rapide 5/0 sutures.
1010
Correspondence and communications
Statements for conflict of interest, funding and ethical approval Funding: None. Conflicts of interest: None declared. Ethical approval: Not required.
References
Figure 1 Design of the VV flap e the de-epithelialised tip of the vertical V flap is marked with *.
The lateral V flaps are wrapped around each other to create the circumference of the nipple corpus and held in place by interrupted Vicryl rapide 5/0 sutures. The de-epithelialised tip of the vertical V flap is introduced into the core (Figure 2), so that the core now not only contains the subcutaneous fat of the flaps but also the de-epithelialised tip of the vertical V flap. The epithelialised borders of the vertical V flap come to meet the horizontal V flap borders and again interrupted skin sutures Vicryl rapide 5/0 are used to fix the flap in its position. The final result is shown as inset in Figure 2. Postoperatively we use the nipple projector as described by Valdatta et al. 20082 and arrange for tattooing of the nipple areola 6 weeks post surgery. In the 84 cases of modified V-V flaps for nipple reconstruction that we traced over the last 4 years (since introduction of a computerized theatre logbook), no flap necrosis occurred and to our knowledge, no further surgery to improve postoperative outcome was required.
1. Jones G, Bostwick III J. Nipple-areolar reconstruction. Oper Tech Plast Reconstr Surg 1994;1:35. 2. Valdatta L, Montemurro P, Tamborini F, Fidanza C, Gottardi A, Scamoni S. Our experience of nipple reconstruction using the C-V flap technique: 1 year evaluation. J Plast Reconstr Aesthet Surg 2009;62(10):1293e8. 3. Brackley PT, Iqbal A. Enhancing your C-V flap nipple reconstruction. J Plast Reconstr Aesthet Surg 2009;62(1):128e30. 4. Mori H, Hata Y. Modified C-V flap in nipple reconstruction. J Plast Reconstr Aesthet Surg 2009;62(1):115e6. 5. O’Neil J, Goodwin-Walters A. Modification of the C-V flap for nipple reconstruction. J Plast Reconstr Aesthet Surg 2010;63(4):e418e9.
P. Witt D.G. Dujon Department of Plastic Surgery, Royal Hallamshire Hospital, Sheffield S10 2JF, United Kingdom E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.001
Salvage of free flaps by supermicrosurgical techniques following accidental rupture of the perforator pedicle Dear Sir,
Figure 2 Inset of the vertical V flap e the de-epithelialised tip of the vertical V flap (elevated with a skin hook) is introduced into the core, after the horizontal V flaps have been positioned and the donorsite has been closed. The final result is shown as inset in the picture.
Perforator flaps have gained immense popularity recently, because they reduce donor site morbidity and increase cosmesis.1 Despite meticulous dissection when elevating a perforator flap, injury to the perforator may occur. We have experience of five cases of accidental rupture of the perforator pedicle during pedicle dissection, and in all cases the pedicle was repaired using supermicrosurgical techniques. This study includes all cases of perforator rupture during flap dissection in the experience of the senior surgeon (J.T.K.). Electronic charts were reviewed where available. Patient demographics, type of flap, cause of perforator rupture, solution used to mend the rupture, and postoperative