Volume 133, Number 5 • Letters component of the repair must be lengthened, and this is accomplished by means of a back-cut that incorporates both the skin and the underlying orbicularis oris muscle to achieve lengthening of the lip. Classic descriptions of the rotation-advancement repair describe methods to transpose skin into this back-cut. In the classic Millard repair, this skin is brought in with the advancement segment, and in the Mohler repair, the caudal end of the C flap brings in this skin. However, if one were to rely on skin alone to fill the defect, the muscle release would remain an area of dead space. This will contribute to subsequent contracture, with resultant shortening of the lip and recurrence of columellar deviation. The solution to this problem is to fill the dead space beneath the skin with muscle imported from the advancement segment. With judicious inset of this muscle, tension can be placed on the displaced columella and/or the adjacent tissues that will serve to centralize the columella. Therefore, this maneuver serves two purposes: (1) to fill the dead space in the muscular component of the backcut to prevent subsequent contracture and (2) to reset the columella to the midline. The authors did not mention an additional component contributing to the columellar deviation. The caudal septum is also deviated toward the noncleft side, and I believe this should also be corrected at the time of primary repair. My technique is to elevate the mucoperichondrium from the septum through an incision at the posterior caudal aspect of the septum from the incisive foramen forward. The caudal extent of this dissection provides complete exposure to the caudal septum, which can be detached from the deviated anterior nasal spine, scored on the concave (noncleft) side to use the Stenstrom principle to straighten the cartilage, and repositioned in the midline. I find that suture fixation of the caudal septum is not necessary because the soft-tissue anchors described by the authors will reposition both the columella and the caudal septum. In addition, there is no skeletal structure on which to secure the caudal septum because the anterior nasal spine is not in the midline. Therefore, by combining the technique that the authors have described with a caudal septoplasty, one can achieve midline repositioning of both the caudal septum and the columella. Once again, the authors are to be congratulated on their astute observations, and they have provided a forum for discussion by which each of us can strive to improve the long-term outcomes of primary cleft lip repair.

Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches Sir:

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e read with great interest the remarks by Hwang1 relating to the article “Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches” by Janis et  al.2 With regard to the presence of a supratrochlear foramen, Janis et al. state that in nine facial halves (18.0 percent) there was a true bony foramen. In the study published by Miller et al.,3 none of the supratrochlear nerves exited from a foramen in their series of dissections. Andersen et  al.4 did not find a foramen or notch for the supratrochlear nerve at its exit from the orbita either. Hwang requested a photograph of the supratrochlear foramen containing the supratrochlear nerve. In his reply, Janis et al. provided three photographs that support their findings. It might be of interest that in our own dissection series examining the periorbital region (10 hemifaces) for a diploma thesis, we found a true bony foramen containing the supratrochlear nerve in four of 10 hemifaces (40 percent). Therefore, we can confirm the findings of Janis et al. (Figs. 1 and 2) and congratulate the authors for their study on the surgical treatment of migraine headaches. DOI: 10.1097/PRS.0000000000000137

Reinhard Pauzenberger, M.D. Rajmond Pikula, M.D. Department of Plastic, Reconstructive and Aesthetic Surgery Medical University Innsbruck

DOI: 10.1097/PRS.0000000000000122

Arun K. Gosain, M.D. Division of Plastic Surgery Lurie Children’s Hospital 225 East Chicago Avenue, Box 93 Chicago, Ill. 60611 [email protected]

DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.

Fig. 1. The supratrochlear nerve is shown exiting through a true foramen.

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Plastic and Reconstructive Surgery • May 2014 Analysis of Surgical Treatments for Earlobe Keloids: Analysis of 174 Lesions in 145 Patients Sir:

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Fig. 2. The supratrochlear nerve is shown exiting through a true foramen bilaterally in another specimen.

Valeria Berchtold Medical University Innsbruck Innsbruck

Jakob Mühlbacher, M.D. Department of Surgery Medical University Vienna Vienna, Austria

Ulrich M. Rieger, M.D. Department of Plastic and Aesthetic, Reconstructive, and Hand Surgery Agaplesion St. Markus Krankenhaus Teaching Hospital of the Johann Wolfgang von Goethe University Frankfurt am Main, Germany Correspondence to Dr. Rieger Wilhelm-Epstein-Straße 4 D-60431 Frankfurt, Germany [email protected]

e read with great interest the article by Ogawa et  al. entitled “Analysis of Surgical Treatments for Earlobe Keloids: Analysis of 174 Lesions in 145 Patients.”1 The authors introduce their 6-year experience with surgical treatment followed by adjuvant radiation therapy for the treatment of earlobe keloids. According to the analysis of cases in Table  1, their recurrent cases originated totally from primary keloids. We were surprised by the result, which conflicted with our previous work,2 which is referenced in the article by Ogawa et  al. As shown in our work, the relationship between previous treatment history and the risk of keloid recurrence had been strongly suspected, and we also found a positive correlation between them. However, present work revealed that all recurrences were from secondary keloids. More recently, we analyzed and compared the characteristics of patients with primary keloids and secondary keloids as separate groups.3 As shown in Table  1, primary keloids were significantly associated with a lower degree of recurrence compared with secondary keloids (2.3 percent compared with 14.2 percent; p < 0.001). In addition, we have adopted postoperative silicone gel sheeting therapy since 2012, which is an effective adjuvant modality as suggested by Ogawa et  al. Especially, with the aid of magnets, we have come up with “Magsil,” which has been found to be an effective method based on our clinical practice.4 We totally agree with Dr. Ogawa et al. that stabilizing the local environment reduces mechanical input, which helps to prevent the activation of mechanobiological mechanisms inside the cells, which in turn stops further fibroproliferation. We also believe that our Magsil would exert this fascinating role (Figs. 1 and 2). DOI: 10.1097/PRS.0000000000000136

Tae Hwan Park, M.D. Deokjeok Health Care Center Incheon, Republic of Korea, and Keloid Research Foundation New York, N.Y.

DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Hwang K. Anatomy of the supratrochlear nerve: Implications for the surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;132:866e–867e. 2. Janis JE, Hatef DA, Hagan R, et  al. Anatomy of the supratrochlear nerve: Implications for the surgical treatment of migraine headaches. Plast Reconstr Surg. 2013;131:743–750. 3. Miller TA, Rudkin G, Honig M, Elahi M, Adams J. Lateral subcutaneous brow lift and interbrow muscle resection: Clinical experience and anatomic studies. Plast Reconstr Surg. 2000;105:1120–1127; discussion 1128. 4. Andersen NB, Bovim G, Sjaastad O. The frontotemporal peripheral nerves: Topographic variations of the supraorbital, supratrochlear and auriculotemporal nerves and their possible clinical significance. Surg Radiol Anat. 2001;23:97–104.

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Ji Hae Park, M.D. Choong Hyun Chang, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul, Republic of Korea

Table 1.  Primary versus Secondary Keloid Groups

No. Recurrence  No  Yes

Primary Keloids (%)

Secondary Keloids (%)

263

605

257 (97.7) 6 (2.3)

519 (85.8) 86 (14.2)

p*