Plastic and Reconstructive Surgery • July 2015 REFERENCES 1. Song J, Lee GK, Kwon ST, Kim SW, Jeong EC. Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: The lateral paracanthal incision revisited. Plast Reconstr Surg. 2014;134:1023–1030. 2. Kim DW, Choi SR, Park SH, Koo SH. Versatile use of extended transconjunctival approach for orbital reconstruction. Ann Plast Surg. 2009;62:374–380. 3. Suga H, Sugawara Y, Uda H, et al. The transconjunctival approach for orbital bony surgery: In which cases should it be used? J Craniofac Surg. 2004;15:454–457 4. Yoon ES, Koo SH, Park SH, et al. Lateral paracanthal transconjunctival incision for orbital fractures. J Korean Soc Plast Reconstr Surg. 1998;25:411–418.
Reply: Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited Sir:
We appreciate Dr. Kim’s great interest and thoughtful comments on our article. Regarding his use of a paracanthal incision in orbital surgery, we generally agree with his concept of modified lateral canthal incision, published in 2009.1 Our techniques are further refinements and modifications of transconjuctival approaches, and we believe that they are also sufficient to trigger interest in readers who are searching for information regarding lateral cantholysis, a common procedure used in orbital surgery, including repair of orbital trauma. Sharing the knowledge is fundamental for the improvement of the previous idea. Our modifications were developed from comprehensive knowledge gathered from other articles and our own efforts to minimize adverse effects.2,3 The tarsal plate was a better anatomical landmark for repair rather than the delicate fascial structure of the lateral canthal tendon,4 and the overall results of the transconjuctival paracanthal incision were satisfactory in every case to both patients and surgeons; however, there are some technical pitfalls for those attempting to use this approach for the first time. First, the location of the paracanthal incision is important. The amount of remaining lateral portion of tarsus should be sufficient to be reapproximated later. Observing the tarsus from the conjuctival side with eversion of the lower eyelid is helpful in marking the point of transection of the tarsus.4 Second, the paracanthal incision line should be closed layer by layer and the repaired wound unexposed during wound healing. Postoperatively, ophthalmic solutions are commonly used for approximately 1 week. When applying eyedrops, the patients touch the eyelids to drop the solution into the eye, a maneuver that can expose the repaired paracanthal area. I recently added temporary tarsorrhapy between the lateral limbus of the pupil and lateral canthus for 1 week to keep the repaired wounds safe and at the same time allow space for vision.5 The scar is quite unnoticeable and lid deformity is rare, even on close examination after several months.
Consequently, I believe that the paracanthal incision is very useful, especially in patients who abhor external scars. DOI: 10.1097/PRS.0000000000001340
Euicheol C. Jeong, M.D., Ph.D. Jihyeon Han, M.D. Department of Plastic Surgery SMG-SNU Boramae Medical Center affiliated to Department of Plastic and Reconstructive Surgery Seoul National University College of Medicine Seoul, Republic of Korea Correspondence to Dr. Jeong Department of Plastic Surgery SMG-SNU Boramae Medical Center 20 Boramae-ro 5-gil, Dongjak-gu Seoul 156-707, Republic of Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kim DW, Choi SR, Park SH, Koo SH. Versatile use of extended transconjunctival approach for orbital reconstruction. Ann Plast Surg. 2009;62:374–380. 2. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The incidence of lower eyelid malposition after facial fracture repair: A retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg. 2009;124:1578–1586. 3. de Chalain TM, Cohen SR, Burstein FD. Modification of the transconjunctival lower lid approach to the orbital floor: Lateral paracanthal incision. Plast Reconstr Surg. 1994;94:877–880. 4. Song J, Lee GK, Kwon ST, Kim SW, Jeong EC. Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: The lateral paracanthal incision revisited. Plast Reconstr Surg. 2014;134:1023–1030. 5. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011;127:386–395.
Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair Sir:
W
e read with great interest the article by Dr. Greives et al.1 entitled “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” We would like to acknowledge the authors for sharing with us this very comprehensive analysis, performed to provide us with a practice-based assessment of preoperative evaluation, anesthesia, surgical treatment plan, perioperative management, and outcomes. Moreover, the different techniques used for cheiloplasty and nasal repair are critically discussed, giving us a complete overview and providing us with exceptional consultation material for decision-making.
118e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 1 • Letters However, Dr. Greives et al. did not mention in their review the use of autologous fat grafting in primary cleft lip repair, which has been recently described as a further, new and emerging technique.2 We believe that this technique needs to be considered as an option for this operation. Indeed, fat tissue transfer can be considered as an excellent tool with which to solve the lack of tissue in the nasolabial complex, which is typical for this deformity. So doing can avoid one of the detailed stigmatizing signs, which is that resulting from the low projection of the upper lip, usually found together with a similarly affected nasal columella. These two deformities are, together, responsible for an unsuitable nasolabial angle.3 Fat transfer techniques have gained worldwide acceptance for the correction of a host of deformities through soft-tissue augmentation.4 Their efficacy in providing wound healing and regeneration has been related to the evidence that fat grafts harbor stem cells, termed adipose-derived stem cells, pluripotent cells producing beneficial factors. This autologous tissue may also improve scar caliber and minimize scar burden. Most importantly, for primary treatment of cleft lip and nose, research from Wu et al.5 has revealed that infant-derived adipose-derived stem cells are more biologically robust than those obtained from adult tissue. Therefore, in our opinion, the section of the article by Dr. Greives et al. regarding the surgical techniques can be enriched by considering the recent article of Dr. Balkin et al.,2 that described their experience with autologous fat tissue transplantation for primary cleft lip and nose repair. In their retrospective analysis, Dr. Balkin et al.2 performed fat grafting to various elements of the lip and nose in a series of consecutive infants who underwent primary cleft lip and nose repair with immediate fat grafting. The results, judged with clinical examination, were reported as excellent, without complications or delays in recovery. According to these results and to the well-accepted background regarding the biophysical and biochemical properties of adipose tissue, we strongly believe that adipose tissue fat grafting for the correction of primary cleft lip and nose should be taken into consideration. Thus, prospective investigations, with long follow-up, are needed to corroborate these findings. DOI: 10.1097/PRS.0000000000001345
Andrea Sisti, M.D. General and Specialist Surgery Department Plastic Surgery Division University of Siena Siena, Italy
Carlo M. Oranges, M.D. Plastic, Reconstructive, and Aesthetic Surgery School Marche Polytechnic University Ancona, Italy Correspondence to Dr. Oranges Plastic, Reconstructive, and Aesthetic Surgery School Marche Polytechnic University
Ancona, Italy [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No external funding was received. REFERENCES 1. Greives MR, Camison L, Losee JE. Evidence-based medicine: Unilateral cleft lip and nose repair. Plast Reconstr Surg. 2014;134:1372–1380. 2. Balkin DM, Samra S, Steinbacher DM. Immediate fat grafting in primary cleft lip repair. J Plast Reconstr Aesthet Surg. 2014;67:1644–1650. 3. Duskova M, Kristen M. Augmentation by autologous adipose tissue in cleft lip and nose: Final esthetic touches in clefts: Part I. J Craniofac Surg. 2004;15:478–481; discussion 482. 4. Cao Y, Ma T, Wu D, Yin N, Zhao Z. Autologous fat injection combined with palatoplasty and pharyngoplasty for velopharyngeal insufficiency and cleft palate: Preliminary experience. Otolaryngol Head Neck Surg. 2013;149:284–291. 5. Wu W, Niklason L, Steinbacher DM. The effect of age on human adipose-derived stem cells. Plast Reconstr Surg. 2013;131:27–37.
Reply: Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair Sir:
We thank the authors for their comments regarding our recent publication, “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” Through our analysis of the literature, we sought to find publications with the highest level of evidence to help guide clinical practice. Our goals were not only to describe what has been accomplished, but to critically examine the evidence behind the literature that exists in the published realm. The use of autologous fat in the form of dermal fat grafts1,2 or structural fat grafts3 for the treatment of secondary cleft lip and nasal deformities has been reported in the literature and has been used in the authors’ own practice. As mentioned, the use of autologous fat grafting in the primary lip and nasal repair has entered the literature recently as a technique for augmenting the paucity of tissue that exists in the cleft lip deformity. As in all arenas in plastic surgery, autologous fat grafting has been demonstrated to be a safe and effective technique to improve asymmetries and areas of hypoplasia. In the cleft lip patient, autologous fat grafting can provide extra volume for lip and alar base support, as well described by Balkin et al.4 However, the fate and outcomes of autologous fat placed in the infant’s lip have yet to be proven in the long term. The impact of growth, development, future operations such as alveolar bone grafting, and other unknown variables on the long-term outcomes have yet to be proven. The purpose of our CME article was to provide the highest levels of evidence supporting the techniques
119e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Reply: Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited Sir:
We appreciate Dr. Kim’s great interest and thoughtful comments on our article. Regarding his use of a paracanthal incision in orbital surgery, we generally agree with his concept of modified lateral canthal incision, published in 2009.1 Our techniques are further refinements and modifications of transconjuctival approaches, and we believe that they are also sufficient to trigger interest in readers who are searching for information regarding lateral cantholysis, a common procedure used in orbital surgery, including repair of orbital trauma. Sharing the knowledge is fundamental for the improvement of the previous idea. Our modifications were developed from comprehensive knowledge gathered from other articles and our own efforts to minimize adverse effects.2,3 The tarsal plate was a better anatomical landmark for repair rather than the delicate fascial structure of the lateral canthal tendon,4 and the overall results of the transconjuctival paracanthal incision were satisfactory in every case to both patients and surgeons; however, there are some technical pitfalls for those attempting to use this approach for the first time. First, the location of the paracanthal incision is important. The amount of remaining lateral portion of tarsus should be sufficient to be reapproximated later. Observing the tarsus from the conjuctival side with eversion of the lower eyelid is helpful in marking the point of transection of the tarsus.4 Second, the paracanthal incision line should be closed layer by layer and the repaired wound unexposed during wound healing. Postoperatively, ophthalmic solutions are commonly used for approximately 1 week. When applying eyedrops, the patients touch the eyelids to drop the solution into the eye, a maneuver that can expose the repaired paracanthal area. I recently added temporary tarsorrhapy between the lateral limbus of the pupil and lateral canthus for 1 week to keep the repaired wounds safe and at the same time allow space for vision.5 The scar is quite unnoticeable and lid deformity is rare, even on close examination after several months.
Consequently, I believe that the paracanthal incision is very useful, especially in patients who abhor external scars. DOI: 10.1097/PRS.0000000000001340
Euicheol C. Jeong, M.D., Ph.D. Jihyeon Han, M.D. Department of Plastic Surgery SMG-SNU Boramae Medical Center affiliated to Department of Plastic and Reconstructive Surgery Seoul National University College of Medicine Seoul, Republic of Korea Correspondence to Dr. Jeong Department of Plastic Surgery SMG-SNU Boramae Medical Center 20 Boramae-ro 5-gil, Dongjak-gu Seoul 156-707, Republic of Korea [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Kim DW, Choi SR, Park SH, Koo SH. Versatile use of extended transconjunctival approach for orbital reconstruction. Ann Plast Surg. 2009;62:374–380. 2. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The incidence of lower eyelid malposition after facial fracture repair: A retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg. 2009;124:1578–1586. 3. de Chalain TM, Cohen SR, Burstein FD. Modification of the transconjunctival lower lid approach to the orbital floor: Lateral paracanthal incision. Plast Reconstr Surg. 1994;94:877–880. 4. Song J, Lee GK, Kwon ST, Kim SW, Jeong EC. Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: The lateral paracanthal incision revisited. Plast Reconstr Surg. 2014;134:1023–1030. 5. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011;127:386–395.
Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair Sir:
W
e read with great interest the article by Dr. Greives et al.1 entitled “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” We would like to acknowledge the authors for sharing with us this very comprehensive analysis, performed to provide us with a practice-based assessment of preoperative evaluation, anesthesia, surgical treatment plan, perioperative management, and outcomes. Moreover, the different techniques used for cheiloplasty and nasal repair are critically discussed, giving us a complete overview and providing us with exceptional consultation material for decision-making.
118e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 1 • Letters However, Dr. Greives et al. did not mention in their review the use of autologous fat grafting in primary cleft lip repair, which has been recently described as a further, new and emerging technique.2 We believe that this technique needs to be considered as an option for this operation. Indeed, fat tissue transfer can be considered as an excellent tool with which to solve the lack of tissue in the nasolabial complex, which is typical for this deformity. So doing can avoid one of the detailed stigmatizing signs, which is that resulting from the low projection of the upper lip, usually found together with a similarly affected nasal columella. These two deformities are, together, responsible for an unsuitable nasolabial angle.3 Fat transfer techniques have gained worldwide acceptance for the correction of a host of deformities through soft-tissue augmentation.4 Their efficacy in providing wound healing and regeneration has been related to the evidence that fat grafts harbor stem cells, termed adipose-derived stem cells, pluripotent cells producing beneficial factors. This autologous tissue may also improve scar caliber and minimize scar burden. Most importantly, for primary treatment of cleft lip and nose, research from Wu et al.5 has revealed that infant-derived adipose-derived stem cells are more biologically robust than those obtained from adult tissue. Therefore, in our opinion, the section of the article by Dr. Greives et al. regarding the surgical techniques can be enriched by considering the recent article of Dr. Balkin et al.,2 that described their experience with autologous fat tissue transplantation for primary cleft lip and nose repair. In their retrospective analysis, Dr. Balkin et al.2 performed fat grafting to various elements of the lip and nose in a series of consecutive infants who underwent primary cleft lip and nose repair with immediate fat grafting. The results, judged with clinical examination, were reported as excellent, without complications or delays in recovery. According to these results and to the well-accepted background regarding the biophysical and biochemical properties of adipose tissue, we strongly believe that adipose tissue fat grafting for the correction of primary cleft lip and nose should be taken into consideration. Thus, prospective investigations, with long follow-up, are needed to corroborate these findings. DOI: 10.1097/PRS.0000000000001345
Andrea Sisti, M.D. General and Specialist Surgery Department Plastic Surgery Division University of Siena Siena, Italy
Carlo M. Oranges, M.D. Plastic, Reconstructive, and Aesthetic Surgery School Marche Polytechnic University Ancona, Italy Correspondence to Dr. Oranges Plastic, Reconstructive, and Aesthetic Surgery School Marche Polytechnic University
Ancona, Italy [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No external funding was received. REFERENCES 1. Greives MR, Camison L, Losee JE. Evidence-based medicine: Unilateral cleft lip and nose repair. Plast Reconstr Surg. 2014;134:1372–1380. 2. Balkin DM, Samra S, Steinbacher DM. Immediate fat grafting in primary cleft lip repair. J Plast Reconstr Aesthet Surg. 2014;67:1644–1650. 3. Duskova M, Kristen M. Augmentation by autologous adipose tissue in cleft lip and nose: Final esthetic touches in clefts: Part I. J Craniofac Surg. 2004;15:478–481; discussion 482. 4. Cao Y, Ma T, Wu D, Yin N, Zhao Z. Autologous fat injection combined with palatoplasty and pharyngoplasty for velopharyngeal insufficiency and cleft palate: Preliminary experience. Otolaryngol Head Neck Surg. 2013;149:284–291. 5. Wu W, Niklason L, Steinbacher DM. The effect of age on human adipose-derived stem cells. Plast Reconstr Surg. 2013;131:27–37.
Reply: Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair Sir:
We thank the authors for their comments regarding our recent publication, “Evidence-Based Medicine: Unilateral Cleft Lip and Nose Repair.” Through our analysis of the literature, we sought to find publications with the highest level of evidence to help guide clinical practice. Our goals were not only to describe what has been accomplished, but to critically examine the evidence behind the literature that exists in the published realm. The use of autologous fat in the form of dermal fat grafts1,2 or structural fat grafts3 for the treatment of secondary cleft lip and nasal deformities has been reported in the literature and has been used in the authors’ own practice. As mentioned, the use of autologous fat grafting in the primary lip and nasal repair has entered the literature recently as a technique for augmenting the paucity of tissue that exists in the cleft lip deformity. As in all arenas in plastic surgery, autologous fat grafting has been demonstrated to be a safe and effective technique to improve asymmetries and areas of hypoplasia. In the cleft lip patient, autologous fat grafting can provide extra volume for lip and alar base support, as well described by Balkin et al.4 However, the fate and outcomes of autologous fat placed in the infant’s lip have yet to be proven in the long term. The impact of growth, development, future operations such as alveolar bone grafting, and other unknown variables on the long-term outcomes have yet to be proven. The purpose of our CME article was to provide the highest levels of evidence supporting the techniques
119e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
