- Email: [email protected]
Pedicle particulars
1154
Correspondence and communications
Dear Sir,
scar and the inverted T scar reduction mammaplasties. We commend the authors on the long term follow up of their patient cohort and on the findings of their study which show that at 10 years bottoming out was 50% in the inverted T scar group and 20% in the vertical scar group. This study is a useful adjunct to encourage the use of the vertical scar technique in the long term prevention of bottoming out of mammaplasty techniques as it somewhat contradicts what previous results have shown - higher complications with vertical scar reductions particularly when the patients BMI is greater than 30. What this study does not mention however, is what pedicle was used in this series. Breast reduction surgery is well documented as holding a very high satisfaction rate among its patients, with frequent reports of over 95% satisfaction rates and improvement in quality of life. Vertical scar techniques have rapidly increased in popularity over the last decade, and are usually based on either the superior or superomedial nipple areolar complex pedicles. Use of the superomedial pedicle has been shown to be a safe and reliable technique and is gaining popularity.1 It can be used with a variety of skin excision patterns, saves operating time, gives lasting superomedial fullness compared with inferior pedicle techniques.2,3 James et al. and Spear et al. showed superior results with the utilization of this pedicle, with less complications including skin necrosis and hypertrophic scarring as well as a better aesthetic shape.2,4 By design, the majority of the tissue resection in superomedial/superior pedicle techniques is in the lower pole, leaving no residual tissue across the inferomammary fold, and therefore no opposing vectors of tension at the most critical area. With pillar plication and breast coning, these techniques do not rely on the transverse inframammary skin closure for tension relief and breast shaping, which contributes to the reduction in bottoming out. By contrast, inverted T techniques, traditionally and still predominantly, utilise an inferior pedicle, which by design preserves the lower pole breast tissue as the vascular pedicle. The remnant weight of the lower pole pedicle on the inferior skin stretched the lower pole skin with time, occasionally resulting in bottoming out. Inverted T skin pattern can of course be combined with any pedicle, and certainly with superior or superomedial pedicles to allow maximum skin excision, particularly with large reductions or poor quality skin. We believe it is the internal vascular pedicle design that determines long term tissue distribution, and, therefore, the likelihood of later “bottoming out”. Tissue excess in this lower pole will inevitably lead to tissue strain and bottoming out, regardless of the skin pattern utilized. It would be most useful to know whether different pedicles were used in this series, or which single pedicle technique was combined with the different skin excision patterns. This would not only alter the results, but would contribute significantly to the understanding of the difficult problem and process of bottoming out. Yours etc
We read with interest the above retrospective study on the initial and long term compared outcomes of the vertical
Conflict of interest/funding
Figure 3 Appearance of the reconstructed ear at 6 months after surgery.
Conflict of interest We have not any interest to disclose.
References 1. Nagata S. Modification of the stages in total reconstruction of the auricle: part I. Grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg 1994;93(2):221e30 [discussion 267e8]. 2. Nagata S. Modification of the stages in total reconstruction of the auricle: part IV. Ear elevation for the constructed auricle. Plast Reconstr Surg 1994;93(2):254e66 [discussion 267e8]. 3. Firmin F. Auricular reconstruction in cases of microtia. Principles, methods and classification. Ann Chir Plast Esthet 2001 Oct; 46(5):447e66. 4. Sabbagh W. Early experience in microtia reconstruction: the first 100 cases. J Plast Reconstr Aesthet Surg 2011 Apr;64(4):452e8.
Patricia Cecchi Maria Francesca Bianciardi Valassina Federica Maggiulli Mario Zama Plastic and Maxillofacial Surgery Unit, Children’s Hospital Bambino Gesu`, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy 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.2013.03.015
Pedicle particulars
DOI of original article: 10.1016/j.bjps.2012.04.033.
None.
Correspondence and communications
References 1. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004; 114(7):1724e33 [discussion 1734e6]. 2. Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg 2007;120(6): 1466e76. 3. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999;104(3): 748e59 [discussion 760e3]. 4. James A, Verheyden C. A retrospective study comparing patient outcomes of wise pattern-inferior pedicle and vertical patternmedial pedicle reduction mammoplasty. Ann Plast Surg 2011; 67(5):481e3.
Siun M. Murphy Steve Merten Macquarie Cosmetic and Plastic Surgery, Macquarie University Hospital, Suite 301, 2 Technology Place, Sydney 2109, NSW, Australia 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.2013.03.046
Mid-palm hand amputation: Reconstruction of the superficial palmar arch Dear Sir, Hand revascularization still remains a major surgical challenge where successful outcome depends on multiple factors. The anatomical level at which the amputation occurs has significant implications for surgical repair with amputations through the mid-palm presenting a particularly challenge for vascular reconstruction. These injuries can be classified according to the level and angle of injury with oblique lacerations from the ulnar carpometacarpal border to the mid-metacarpal radial border representing the most devastating vascular injury as both deep and superficial palmar arches are likely to be disrupted.1 We describe the case of a 33-year-old gentleman, selfemployed builder, who presented with a circular saw injury to his left non-dominant hand. The soft tissue injury comprised a deep dorsal laceration, leaving only a palmar skin bridge intact (Figure 1), a thumb relatively preserved except for the thenar eminence muscles which were fully divided. Pale and cold fingers demonstrated absence of blood supply. The intra-operative findings were as follows: four displaced transverse metacarpal fractures in their proximal third, division of palmar and dorsal interossei and
1155 lumbricals, division of the ulnar nerve in the distal half of Guyon’s canal, division of the median nerve at the bifurcation of the second and third common digital nerves, four flexor digitorum profundus and four flexor digitorum superficialis tendons divided in zone III and four extensor tendons divided in zone VI. Disruption of the superficial and deep palmar arches at the level of the bifurcation of the three common digital arteries in the palm was confirmed. Reduction and K-wire fixation of the fractures and primary suture repair of the tendons and digital nerves were carried out. The left greater saphenous vein graft including part of the dorsal venous arch of the foot was simultaneously harvested, preserving the side branches with the purpose to facilitate end-to-end anastomoses to the common digital arteries (CDA). This was used to reconstruct the superficial palmar arch anastomosing the proximal end of the vein graft onto the ulnar artery proximally at the wrist level. The three common digital arteries were anastomosed to the saphenous vein graft as follows: 3rd CDA end-to-end to a vein graft side branch, 2nd CDA end-to-side, and 1st CDA end-to-end to the reversed distal end of the graft. Blood supply to all four digits was restored within five hours from the start of the surgical procedure. Total warm ischemia time was approximately 9.5 h. A large vein in the dorsum of the hand was anastomosed at the wrist level using a 3.5 mm venous coupler device. Mobilization of the hand and fingers was commenced one week post-operatively and the patient resumed activities at work at four months. At seven months, a CT angiogram demonstrated a patent graft with arterial flow through the common digital arteries (Figure 2). The QuickDash score was 2.3 at 12 months post-injury, indicating a very good level of function achieved in relation to the severity of the injury. All digits demonstrated return of protective sensation. The patient resumed full activities at his previous job and was very satisfied with the functional outcome. Extensor tendons tenolysis has been offered but the patient declined further surgery. Revascularization of the hand may be achieved through a variety of techniques depending on the degree and level of injury. Within the palm, vein grafts have been used to replace thrombosed sections of the superficial palmar arch in patients with chronic digital ischemia leading to restored perfusion and rapid healing of distal finger tips.2 Elective reconstruction with a vein graft anastomosed end-to-end to the ulnar artery proximally and anastomoses of the common digital arteries end-toside to the graft has been previously described.3 This has been replicated in the trauma setting,4 with anastomosis of a single common digital artery to the ulnar or radial artery via a vein graft for the revascularization of multiple digits, due to communicating branches between the ulnar and radial digital vessels allowing retrograde flow into the adjacent common digital arteries.5 The present case describes the successful revascularization of a mid-palm hand amputation, representing one of the most complex levels of hand amputation for reconstruction, by recreating the superficial palmar arch. At the level of the midpalm this injury, complicated by the mechanism of injury, presented different challenges that were methodically addressed step by step by the surgical team, in particular the revascularization of multiple digits.
Correspondence and communications
Dear Sir,
scar and the inverted T scar reduction mammaplasties. We commend the authors on the long term follow up of their patient cohort and on the findings of their study which show that at 10 years bottoming out was 50% in the inverted T scar group and 20% in the vertical scar group. This study is a useful adjunct to encourage the use of the vertical scar technique in the long term prevention of bottoming out of mammaplasty techniques as it somewhat contradicts what previous results have shown - higher complications with vertical scar reductions particularly when the patients BMI is greater than 30. What this study does not mention however, is what pedicle was used in this series. Breast reduction surgery is well documented as holding a very high satisfaction rate among its patients, with frequent reports of over 95% satisfaction rates and improvement in quality of life. Vertical scar techniques have rapidly increased in popularity over the last decade, and are usually based on either the superior or superomedial nipple areolar complex pedicles. Use of the superomedial pedicle has been shown to be a safe and reliable technique and is gaining popularity.1 It can be used with a variety of skin excision patterns, saves operating time, gives lasting superomedial fullness compared with inferior pedicle techniques.2,3 James et al. and Spear et al. showed superior results with the utilization of this pedicle, with less complications including skin necrosis and hypertrophic scarring as well as a better aesthetic shape.2,4 By design, the majority of the tissue resection in superomedial/superior pedicle techniques is in the lower pole, leaving no residual tissue across the inferomammary fold, and therefore no opposing vectors of tension at the most critical area. With pillar plication and breast coning, these techniques do not rely on the transverse inframammary skin closure for tension relief and breast shaping, which contributes to the reduction in bottoming out. By contrast, inverted T techniques, traditionally and still predominantly, utilise an inferior pedicle, which by design preserves the lower pole breast tissue as the vascular pedicle. The remnant weight of the lower pole pedicle on the inferior skin stretched the lower pole skin with time, occasionally resulting in bottoming out. Inverted T skin pattern can of course be combined with any pedicle, and certainly with superior or superomedial pedicles to allow maximum skin excision, particularly with large reductions or poor quality skin. We believe it is the internal vascular pedicle design that determines long term tissue distribution, and, therefore, the likelihood of later “bottoming out”. Tissue excess in this lower pole will inevitably lead to tissue strain and bottoming out, regardless of the skin pattern utilized. It would be most useful to know whether different pedicles were used in this series, or which single pedicle technique was combined with the different skin excision patterns. This would not only alter the results, but would contribute significantly to the understanding of the difficult problem and process of bottoming out. Yours etc
We read with interest the above retrospective study on the initial and long term compared outcomes of the vertical
Conflict of interest/funding
Figure 3 Appearance of the reconstructed ear at 6 months after surgery.
Conflict of interest We have not any interest to disclose.
References 1. Nagata S. Modification of the stages in total reconstruction of the auricle: part I. Grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg 1994;93(2):221e30 [discussion 267e8]. 2. Nagata S. Modification of the stages in total reconstruction of the auricle: part IV. Ear elevation for the constructed auricle. Plast Reconstr Surg 1994;93(2):254e66 [discussion 267e8]. 3. Firmin F. Auricular reconstruction in cases of microtia. Principles, methods and classification. Ann Chir Plast Esthet 2001 Oct; 46(5):447e66. 4. Sabbagh W. Early experience in microtia reconstruction: the first 100 cases. J Plast Reconstr Aesthet Surg 2011 Apr;64(4):452e8.
Patricia Cecchi Maria Francesca Bianciardi Valassina Federica Maggiulli Mario Zama Plastic and Maxillofacial Surgery Unit, Children’s Hospital Bambino Gesu`, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy 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.2013.03.015
Pedicle particulars
DOI of original article: 10.1016/j.bjps.2012.04.033.
None.
Correspondence and communications
References 1. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004; 114(7):1724e33 [discussion 1734e6]. 2. Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg 2007;120(6): 1466e76. 3. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999;104(3): 748e59 [discussion 760e3]. 4. James A, Verheyden C. A retrospective study comparing patient outcomes of wise pattern-inferior pedicle and vertical patternmedial pedicle reduction mammoplasty. Ann Plast Surg 2011; 67(5):481e3.
Siun M. Murphy Steve Merten Macquarie Cosmetic and Plastic Surgery, Macquarie University Hospital, Suite 301, 2 Technology Place, Sydney 2109, NSW, Australia 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.2013.03.046
Mid-palm hand amputation: Reconstruction of the superficial palmar arch Dear Sir, Hand revascularization still remains a major surgical challenge where successful outcome depends on multiple factors. The anatomical level at which the amputation occurs has significant implications for surgical repair with amputations through the mid-palm presenting a particularly challenge for vascular reconstruction. These injuries can be classified according to the level and angle of injury with oblique lacerations from the ulnar carpometacarpal border to the mid-metacarpal radial border representing the most devastating vascular injury as both deep and superficial palmar arches are likely to be disrupted.1 We describe the case of a 33-year-old gentleman, selfemployed builder, who presented with a circular saw injury to his left non-dominant hand. The soft tissue injury comprised a deep dorsal laceration, leaving only a palmar skin bridge intact (Figure 1), a thumb relatively preserved except for the thenar eminence muscles which were fully divided. Pale and cold fingers demonstrated absence of blood supply. The intra-operative findings were as follows: four displaced transverse metacarpal fractures in their proximal third, division of palmar and dorsal interossei and
1155 lumbricals, division of the ulnar nerve in the distal half of Guyon’s canal, division of the median nerve at the bifurcation of the second and third common digital nerves, four flexor digitorum profundus and four flexor digitorum superficialis tendons divided in zone III and four extensor tendons divided in zone VI. Disruption of the superficial and deep palmar arches at the level of the bifurcation of the three common digital arteries in the palm was confirmed. Reduction and K-wire fixation of the fractures and primary suture repair of the tendons and digital nerves were carried out. The left greater saphenous vein graft including part of the dorsal venous arch of the foot was simultaneously harvested, preserving the side branches with the purpose to facilitate end-to-end anastomoses to the common digital arteries (CDA). This was used to reconstruct the superficial palmar arch anastomosing the proximal end of the vein graft onto the ulnar artery proximally at the wrist level. The three common digital arteries were anastomosed to the saphenous vein graft as follows: 3rd CDA end-to-end to a vein graft side branch, 2nd CDA end-to-side, and 1st CDA end-to-end to the reversed distal end of the graft. Blood supply to all four digits was restored within five hours from the start of the surgical procedure. Total warm ischemia time was approximately 9.5 h. A large vein in the dorsum of the hand was anastomosed at the wrist level using a 3.5 mm venous coupler device. Mobilization of the hand and fingers was commenced one week post-operatively and the patient resumed activities at work at four months. At seven months, a CT angiogram demonstrated a patent graft with arterial flow through the common digital arteries (Figure 2). The QuickDash score was 2.3 at 12 months post-injury, indicating a very good level of function achieved in relation to the severity of the injury. All digits demonstrated return of protective sensation. The patient resumed full activities at his previous job and was very satisfied with the functional outcome. Extensor tendons tenolysis has been offered but the patient declined further surgery. Revascularization of the hand may be achieved through a variety of techniques depending on the degree and level of injury. Within the palm, vein grafts have been used to replace thrombosed sections of the superficial palmar arch in patients with chronic digital ischemia leading to restored perfusion and rapid healing of distal finger tips.2 Elective reconstruction with a vein graft anastomosed end-to-end to the ulnar artery proximally and anastomoses of the common digital arteries end-toside to the graft has been previously described.3 This has been replicated in the trauma setting,4 with anastomosis of a single common digital artery to the ulnar or radial artery via a vein graft for the revascularization of multiple digits, due to communicating branches between the ulnar and radial digital vessels allowing retrograde flow into the adjacent common digital arteries.5 The present case describes the successful revascularization of a mid-palm hand amputation, representing one of the most complex levels of hand amputation for reconstruction, by recreating the superficial palmar arch. At the level of the midpalm this injury, complicated by the mechanism of injury, presented different challenges that were methodically addressed step by step by the surgical team, in particular the revascularization of multiple digits.