VIEWPOINTs VIEWPOINTS GUIDELINES
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria: • Text—maximum of 500 words (not including references) • References—maximum of five • Authors—no more than five • Figures/Tables—no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/ prs/. We strongly encourage authors to submit figures in color. We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
Viewpoints Viewpoints
AQ: 1
Explantation following Nipple-Sparing A Modified Template for Microtia Reconstruction Mastectomy: The Goldilocks Approach to Tested by Surgical Simulation on Ipomoea batatas Traditional Breast Reconstruction
Sir: Sir: reconstruction a challenge for plastic he icrotia Goldilocks approachis to breast reconstrucbecause of its variable clinical tionsurgeons following skin-sparing mastectomy is apresennovel 1 Although tation and reconstruction. method thatdifficult uses thesurgical mastectomy flaps to create a new severalThe reconstructive methods haveasbeen proposed, breast. operation was developed an alternative for patients that desired a breast mound afteras masreconstruction with autologous costal cartilage, elabtectomy but modified did not want to undergo orated and by Tanzer, Brent,conventional and Nagata, breast prosthetic devices or remainsreconstruction the best option using with which to obtain favorable 1 autologous Ideal candidates for a Goldilocks results with tissue. fewer complications than other reconstrucmastectomy tive options.2include women with macromastia or significant breast ptosis. These patients have The three-dimensional topography of usually the external redundant skinreflects and fat the internal mastectomy ear accurately thefollowing shape of the carti3 that may skeleton. be sufficient to recreate a breastand mound. Reproducing anatomical struclaginous The of of the is to an inverted-T turalbasis details theprocedure external ear is ause challenge for any plastic surgeon and requires a high level of surgical skill and training to fulfill the patient’s expectation. Surgical Copyright © 2015 by the American Society of Plastic Surgeons Copyright ©2012 by the American Society of Plastic Surgeons
approach the mastectomy, the vassimulationtoallows developmentdeepithelialize of these skills, reducing cularized mastectomy skin flaps, position the deepimistakes, shortening surgical time, and improving rethelialized skin flap on the chest wall, and close 4 exsults in vivo. We performed a surgical simulation the skin incisions. Although there have been few case perimental study, evaluating traditional and modified reports describing this technique following skinauricular templates as guides for carving ear framesparing mastectomy,1,2 there are no reports following works on Ipomoea batatas, comparing and analyzing the nipple-sparing mastectomy. This innovation repreobtained results. sents the first case of a Goldilocks reconstruction in a The traditional templates were based on sheets of woman with previous nipple-sparing mastectomy and paper and sketched lines representing the main strucprosthetic reconstruction who desired explantation turesnipple-areola of the external ear (i.e., helix, antihelix, tragus, with preservation. antitragus, triangular fossa,(bra scaphoid fossa,presented and conA 35-year-old woman size, 36D) cha) an (Fig. 1). The proposedcore modified templates stage were with ultrasound-guided biopsy–proven based on paper sheets, with lines representing the main IIA (T2N0M0) invasive ductal carcinoma of the left structures and markings detailing theconsisting depths of of each of breast. Neoadjuvant chemotherapy four these structures as follows: whole painted, striped, and cycles of Adriamycin (Bedford Laboratories, Bedford, unpainted deep, not deep, andCorp., elevated, reOhio) and (meaning Cytoxan (Baxter Healthcare Deerspectively). The lines, at (Bristol-Myers the same time,Squibb, reprefield, Ill.) and 12 striped weeks of Taxol sented more depth drawn(Genentech, closer together (Fig. 1). New York, N.Y.) andwhen Herceptin Inc., South San Francisco, Calif.) also was known completed, with potato, a reduction Ipomoea batatas, as sweet was in tumor size. Aofleft mastectomy with sentinel used because itspartial similarity in consistency and 5Pathologic evalulymph node biopsy was performed. flexibility to human rib cartilage. Each sweet poation revealedwas negative margins negative lymph tato model referred to as and an individual case. nodes. Radiation therapy was recommended; however, Five common carving tools with different curves the patient decided against radiation therapy, electing and angles were used sculpt nipple-sparing the models. Eight instead to proceed with atobilateral masnovel surgeons were tested; half of them used the tectomy with immediate reconstruction with tissue traditionalThis template and thethrough other half usedareothe expanders. was performed a lateral lar incision using a 300-cc tissue expander andrepeated acellular modified template. The exercise was dermal matrix. On completion the expansion, the twice. The resulting auricular of sculptures were evalpatient decided that she no longer desired prosthetic uated based on aesthetic results, ranked according reconstruction andtorequested preserto resemblance the real explantation ear model, with being clasvation of the nipple-areola complex. To create a breast sified as poor, fair, or good results. with a natural appearance, Goldilocks principles were Aesthetically different auricular frameworks applied to preserve the nipple-areola complex and crewere ofobtained using the different of ation a breast mound. The two approach was totypes use the templates. Better three-dimensional lateral incision anddefinition perform aoflateral circumareolar
structures (i.e., helix, antihelix, tragus, antitragus, scaphoid fossa, triangular fossa, and concha) and better aesthetic results were obtained using the modified template (n 16).
TM
Fig. 1. Preoperative photograph of the patient before undergoing Goldilocks reconstruction using a lateral circumareolar mastopexy type approach. The patient has had bilateral nipplesparing mastectomy with immediate tissue expander reconstruction. Expanders are filled to 300 cc bilaterally. Fig. 1. Traditional and modified auricular templates.
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795e 1
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Plastic and Reconstructive Surgery • April 2015 disclosure Dr. Nahabedian is a consultant for LifeCell Corp. The other authors have no financial interests or commercial associations to disclose. No funding was received for this study. references
Fig. 2. Six-week postoperative photograph of the patient following explantation and Goldilocks reconstruction. The photographs demonstrate healthy mastectomy flaps and the creation of breast mounds with viable nipple-areola complexes.
mastopexy (Fig. 1). The deepithelialized skin was imbricated such that the subcutaneous tissues were folded onto themselves to create a breast mound. The subdermal plexus and capsular vascularity were preserved to avoid devascularization of the nipple-areola complex. Six-week follow-up shows the healthy and aesthetically appealing appearance of the new breast mounds with preservation of the nipple-areola complex (Fig. 2). The original description of the Goldilocks mastectomy did not address the possibility of saving the nipple-areolar complex because the location and symmetry of the nipple-areola complex were relatively unpredictable. However, in this setting of explantation, positioning of the nipple-areola complex could be better controlled given that a moderate amount of tissue expansion had been achieved. This case has demonstrated the feasibility of this procedure, and this concept can be applied to other situations such as explantation and mastopexy following breast augmentation.3–5 DOI: 10.1097/PRS.0000000000001130
Naveen M. Krishnan, M.D., M.Phil. Department of Plastic Surgery
Ravinder Bamba, M.D. Shawna C. Willey, M.D. Department of Surgery
Maurice Y. Nahabedian, M.D. Department of Plastic Surgery Georgetown University Hospital Washington, D.C. Correspondence to Dr. Nahabedian Department of Plastic Surgery Georgetown University Hospital 3800 Reservoir Road Washington, D.C. 20007 [email protected]
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1. Richardson H, Ma G. The Goldilocks mastectomy. Int J Surg. 2012;10:522–526. 2. Ogawa T. Goldilocks mastectomy for obese Japanese females with breast ptosis. Asian J Surg. August 22, 2013;doi: 10.1016/j.asjsur.2013.07.003. [Epub ahead of print]. 3. Alperovitch M, Choi M, Frey JD, Karp NS. Reconstructive approach for patients with augmentation mammoplasty undergoing nipple-sparing mastectomy. Aesthet Surg J. 2014;34:1059–1065. 4. Gurunluoglu R, Sacak B, Arton J. Outcomes analysis of patients undergoing autoaugmentation after breast implant removal. Plast Reconstr Surg. 2013;132:304–315. 5. Rohrich RJ, Parker TH III. Aesthetic management of the breast after explantation: Evaluation and mastopexy options. Plast Reconstr Surg. 1998;101:312–315.
From Multidisciplinary to Interdisciplinary to Transdisciplinary Care: An Evolution in Craniofacial Surgery Sir: he Institute of Reconstructive Plastic Surgery at New York University was established in 1955 to address an unmet need for a common space—physical and intellectual—where specialists from different disciplines could better interact to optimize the care of patients with facial deformity. The concept of a multidisciplinary team, based on the model developed by the U.S. Army during World War II, established a lasting infrastructure that still defines the craniofacial team: geneticist, neurosurgeon, nurse, ophthalmologist, oral surgeon, orthodontist, otolaryngologist, pediatric dentist, plastic surgeon, prosthodontist, psychologist, social worker, and speech pathologist. Bringing together multiple disciplines under one “home” streamlined comprehensive care, as specialists efficiently and collegially coordinated complex treatment plans at each patient visit. Moreover, it provided each specialist the valuable experience needed to gain expertise, advance patient care and, ultimately, spawn novel craniofacial subdisciplines (e.g., craniofacial orthodontics, craniofacial microsurgery). Predictably, this multidisciplinary team of craniofacial specialists began asking more nuanced questions, seeking answers to previously avoided or underappreciated challenges. Interdisciplinary cooperation, reliant on the transfer of knowledge and methodologies between two or more such disciplines, became instrumental to forging novel technical solutions, and establishing the means to evaluate, refine, and disseminate such advances. Interdisciplinary collaboration has led to several significant clinical advances: craniofacial distraction osteogenesis, presurgical nasoalveolar molding, virtual surgical three-dimensional computer planning, and more. Just as multidisciplinary
T
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria: • Text—maximum of 500 words (not including references) • References—maximum of five • Authors—no more than five • Figures/Tables—no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/ prs/. We strongly encourage authors to submit figures in color. We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
Viewpoints Viewpoints
AQ: 1
Explantation following Nipple-Sparing A Modified Template for Microtia Reconstruction Mastectomy: The Goldilocks Approach to Tested by Surgical Simulation on Ipomoea batatas Traditional Breast Reconstruction
Sir: Sir: reconstruction a challenge for plastic he icrotia Goldilocks approachis to breast reconstrucbecause of its variable clinical tionsurgeons following skin-sparing mastectomy is apresennovel 1 Although tation and reconstruction. method thatdifficult uses thesurgical mastectomy flaps to create a new severalThe reconstructive methods haveasbeen proposed, breast. operation was developed an alternative for patients that desired a breast mound afteras masreconstruction with autologous costal cartilage, elabtectomy but modified did not want to undergo orated and by Tanzer, Brent,conventional and Nagata, breast prosthetic devices or remainsreconstruction the best option using with which to obtain favorable 1 autologous Ideal candidates for a Goldilocks results with tissue. fewer complications than other reconstrucmastectomy tive options.2include women with macromastia or significant breast ptosis. These patients have The three-dimensional topography of usually the external redundant skinreflects and fat the internal mastectomy ear accurately thefollowing shape of the carti3 that may skeleton. be sufficient to recreate a breastand mound. Reproducing anatomical struclaginous The of of the is to an inverted-T turalbasis details theprocedure external ear is ause challenge for any plastic surgeon and requires a high level of surgical skill and training to fulfill the patient’s expectation. Surgical Copyright © 2015 by the American Society of Plastic Surgeons Copyright ©2012 by the American Society of Plastic Surgeons
approach the mastectomy, the vassimulationtoallows developmentdeepithelialize of these skills, reducing cularized mastectomy skin flaps, position the deepimistakes, shortening surgical time, and improving rethelialized skin flap on the chest wall, and close 4 exsults in vivo. We performed a surgical simulation the skin incisions. Although there have been few case perimental study, evaluating traditional and modified reports describing this technique following skinauricular templates as guides for carving ear framesparing mastectomy,1,2 there are no reports following works on Ipomoea batatas, comparing and analyzing the nipple-sparing mastectomy. This innovation repreobtained results. sents the first case of a Goldilocks reconstruction in a The traditional templates were based on sheets of woman with previous nipple-sparing mastectomy and paper and sketched lines representing the main strucprosthetic reconstruction who desired explantation turesnipple-areola of the external ear (i.e., helix, antihelix, tragus, with preservation. antitragus, triangular fossa,(bra scaphoid fossa,presented and conA 35-year-old woman size, 36D) cha) an (Fig. 1). The proposedcore modified templates stage were with ultrasound-guided biopsy–proven based on paper sheets, with lines representing the main IIA (T2N0M0) invasive ductal carcinoma of the left structures and markings detailing theconsisting depths of of each of breast. Neoadjuvant chemotherapy four these structures as follows: whole painted, striped, and cycles of Adriamycin (Bedford Laboratories, Bedford, unpainted deep, not deep, andCorp., elevated, reOhio) and (meaning Cytoxan (Baxter Healthcare Deerspectively). The lines, at (Bristol-Myers the same time,Squibb, reprefield, Ill.) and 12 striped weeks of Taxol sented more depth drawn(Genentech, closer together (Fig. 1). New York, N.Y.) andwhen Herceptin Inc., South San Francisco, Calif.) also was known completed, with potato, a reduction Ipomoea batatas, as sweet was in tumor size. Aofleft mastectomy with sentinel used because itspartial similarity in consistency and 5Pathologic evalulymph node biopsy was performed. flexibility to human rib cartilage. Each sweet poation revealedwas negative margins negative lymph tato model referred to as and an individual case. nodes. Radiation therapy was recommended; however, Five common carving tools with different curves the patient decided against radiation therapy, electing and angles were used sculpt nipple-sparing the models. Eight instead to proceed with atobilateral masnovel surgeons were tested; half of them used the tectomy with immediate reconstruction with tissue traditionalThis template and thethrough other half usedareothe expanders. was performed a lateral lar incision using a 300-cc tissue expander andrepeated acellular modified template. The exercise was dermal matrix. On completion the expansion, the twice. The resulting auricular of sculptures were evalpatient decided that she no longer desired prosthetic uated based on aesthetic results, ranked according reconstruction andtorequested preserto resemblance the real explantation ear model, with being clasvation of the nipple-areola complex. To create a breast sified as poor, fair, or good results. with a natural appearance, Goldilocks principles were Aesthetically different auricular frameworks applied to preserve the nipple-areola complex and crewere ofobtained using the different of ation a breast mound. The two approach was totypes use the templates. Better three-dimensional lateral incision anddefinition perform aoflateral circumareolar
structures (i.e., helix, antihelix, tragus, antitragus, scaphoid fossa, triangular fossa, and concha) and better aesthetic results were obtained using the modified template (n 16).
TM
Fig. 1. Preoperative photograph of the patient before undergoing Goldilocks reconstruction using a lateral circumareolar mastopexy type approach. The patient has had bilateral nipplesparing mastectomy with immediate tissue expander reconstruction. Expanders are filled to 300 cc bilaterally. Fig. 1. Traditional and modified auricular templates.
www.PRSJournal.com www.PRSJournal.com
795e 1
F1
Plastic and Reconstructive Surgery • April 2015 disclosure Dr. Nahabedian is a consultant for LifeCell Corp. The other authors have no financial interests or commercial associations to disclose. No funding was received for this study. references
Fig. 2. Six-week postoperative photograph of the patient following explantation and Goldilocks reconstruction. The photographs demonstrate healthy mastectomy flaps and the creation of breast mounds with viable nipple-areola complexes.
mastopexy (Fig. 1). The deepithelialized skin was imbricated such that the subcutaneous tissues were folded onto themselves to create a breast mound. The subdermal plexus and capsular vascularity were preserved to avoid devascularization of the nipple-areola complex. Six-week follow-up shows the healthy and aesthetically appealing appearance of the new breast mounds with preservation of the nipple-areola complex (Fig. 2). The original description of the Goldilocks mastectomy did not address the possibility of saving the nipple-areolar complex because the location and symmetry of the nipple-areola complex were relatively unpredictable. However, in this setting of explantation, positioning of the nipple-areola complex could be better controlled given that a moderate amount of tissue expansion had been achieved. This case has demonstrated the feasibility of this procedure, and this concept can be applied to other situations such as explantation and mastopexy following breast augmentation.3–5 DOI: 10.1097/PRS.0000000000001130
Naveen M. Krishnan, M.D., M.Phil. Department of Plastic Surgery
Ravinder Bamba, M.D. Shawna C. Willey, M.D. Department of Surgery
Maurice Y. Nahabedian, M.D. Department of Plastic Surgery Georgetown University Hospital Washington, D.C. Correspondence to Dr. Nahabedian Department of Plastic Surgery Georgetown University Hospital 3800 Reservoir Road Washington, D.C. 20007 [email protected]
796e
1. Richardson H, Ma G. The Goldilocks mastectomy. Int J Surg. 2012;10:522–526. 2. Ogawa T. Goldilocks mastectomy for obese Japanese females with breast ptosis. Asian J Surg. August 22, 2013;doi: 10.1016/j.asjsur.2013.07.003. [Epub ahead of print]. 3. Alperovitch M, Choi M, Frey JD, Karp NS. Reconstructive approach for patients with augmentation mammoplasty undergoing nipple-sparing mastectomy. Aesthet Surg J. 2014;34:1059–1065. 4. Gurunluoglu R, Sacak B, Arton J. Outcomes analysis of patients undergoing autoaugmentation after breast implant removal. Plast Reconstr Surg. 2013;132:304–315. 5. Rohrich RJ, Parker TH III. Aesthetic management of the breast after explantation: Evaluation and mastopexy options. Plast Reconstr Surg. 1998;101:312–315.
From Multidisciplinary to Interdisciplinary to Transdisciplinary Care: An Evolution in Craniofacial Surgery Sir: he Institute of Reconstructive Plastic Surgery at New York University was established in 1955 to address an unmet need for a common space—physical and intellectual—where specialists from different disciplines could better interact to optimize the care of patients with facial deformity. The concept of a multidisciplinary team, based on the model developed by the U.S. Army during World War II, established a lasting infrastructure that still defines the craniofacial team: geneticist, neurosurgeon, nurse, ophthalmologist, oral surgeon, orthodontist, otolaryngologist, pediatric dentist, plastic surgeon, prosthodontist, psychologist, social worker, and speech pathologist. Bringing together multiple disciplines under one “home” streamlined comprehensive care, as specialists efficiently and collegially coordinated complex treatment plans at each patient visit. Moreover, it provided each specialist the valuable experience needed to gain expertise, advance patient care and, ultimately, spawn novel craniofacial subdisciplines (e.g., craniofacial orthodontics, craniofacial microsurgery). Predictably, this multidisciplinary team of craniofacial specialists began asking more nuanced questions, seeking answers to previously avoided or underappreciated challenges. Interdisciplinary cooperation, reliant on the transfer of knowledge and methodologies between two or more such disciplines, became instrumental to forging novel technical solutions, and establishing the means to evaluate, refine, and disseminate such advances. Interdisciplinary collaboration has led to several significant clinical advances: craniofacial distraction osteogenesis, presurgical nasoalveolar molding, virtual surgical three-dimensional computer planning, and more. Just as multidisciplinary
T
