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.
AQ: 1
Viewpoints Viewpoints A Modified Template for Microtia Reconstruction
Tested by Surgical Simulation on Ipomoea batatas Prophylactic Mastectomy after Planned Sir: Submuscular Breast Augmentation icrotia reconstruction is a challenge for plastic
M
Sir: surgeons because of its variable clinical presenwith the BRCA1 and BRCA2 1 genes are Although tationomen and difficult surgical reconstruction. increasingly opting for prophylactic mastectoseveral reconstructive methods have been proposed, 1 mies with immediate reconstruction. expansion reconstruction with autologous costal Tissue cartilage, as elabis often and needed after mastectomy, especially there is orated modified by Tanzer, Brent, andif Nagata, insufficient coverage an implant. Removal of remains thetissue best option withfor which to obtain favorable the pectoralis major fascia during mastectomy makes results with fewer complications than other reconstructhe This tends to make coverage of the 2 tive muscle options.fragile. implant with muscle technically moreofdifficult. The The three-dimensional topography the external 2 incidence of complications is higher. ear accurately reflects the shape of the internal cartiWe present an 3 alternative approach. Pocket creReproducing anatomical and struclaginous skeleton. ation before prophylactic createsfor stable tural details of the externalmastectomy ear is a challenge any tissue coverage for the definitive implant. Chasan plastic surgeon and requires a high level of surgical skill has previously reported performing a prophylactic and training to fulfill the patient’s expectation. Surgical
W
Copyright ©2012 © 2014by bythe the American American Society Society of Plastic Surgeons
230e
mastectomyallows on adevelopment patient who, 5 years earlier, had simulation of these skills, reducing 3 undergone a breast augmentation. mistakes, shortening surgical time, and improving recarry4 We outperformed a bilaterala breast surgicalaugmentation simulation ex-3 sultsWe in vivo. months before prophylactic mastectomy as part of the perimental study, evaluating traditional and modified planned management of women requiring prophylacauricular templates as guides for carving ear frametic mastectomy. Using this method, a stable submuscuworks on Ipomoea batatas, comparing and analyzing the lar pocket is available, after mastectomy, for complete obtained results. coverage of the implant. The traditional templates were based on sheets of Six female patients were recruited for this novel paper and sketched linesage representing strucprocedure with a mean of 42 years.the All main the women tures of the external ear (i.e., helix, antihelix, tragus, carried the BRCA1 or BRCA2 gene mutation. The antitragus, triangular fossa, scaphoid fossa, and conpatients included in the study have had a minimum cha) (Fig. 1). The proposed modified templates were follow-up of 1 year. based on paper with lines representing main During thesheets, first stage, the silicone breastthe implant structures detailing the depths eachsubof (Allergan, and Inc.,markings Irvine, Calif.) is placed in a trueoftotal 4 and these structures as follows: whole painted, striped, muscular plane, as described by Little et al. in 1980 and 5 unpainted deep, not deep, elevated, reby Dempsey(meaning and Latham in 1968. The and muscles involved spectively). The striped lines, at theanterior, same time, were the pectoralis major, serratus andrepreoccasented depth when together (Fig.and 1). sionallymore the superior poledrawn of thecloser rectus abdominis Ipomoea batatas, known as sweet potato, was external oblique. A 4-also to 5-cm inframammary approach was used for implant left and center). used because of itsplacement similarity(Fig. 1, in consistency and Stage 2toishuman carried rib out cartilage. 3 months 5after submusflexibility Eachthe sweet pocularmodel augmentation. The toprophylactic mastectomy tato was referred as an individual case. precedes placement of the definitive implant. In our Five common carving tools with different curves clinic, the nipple-areola complex and pectoralis major and angles were used to sculpt the models. Eight fascia are removed during the bilateral prophylactic novel surgeons were tested; half of them used the mastectomy. The implants may be removed temporartraditional template andThe theoperation other half used the ily to facilitate mastectomy. is completed with placement of the The definitive silicone implants modified template. exercise wasgelrepeated in the preexisting submuscular twice. The resulting auricularpocket. sculptures were evalAllbased of theon patients had results, their nipples reconstructed uated aesthetic ranked according 6 months after stage 2. This was followed 3 later to resemblance to the real ear model, months being clasby nipple and areola tattooing. None of the women sified as poor, fair, or good results. developed local wound complications. One patient Aesthetically differentcorrected auricular frameworks had a high-riding implant during the maswere obtained using the two different types of tectomy stage (Fig. 1, right). templates. Better definition of three-dimensional Breast surgeons tend to remove the pectoralis major fascia during prophylactic mastectomy, making the musstructures (i.e., helix, antihelix, tragus, antitragus, cle fragile and increasing the possibility of implant loss scaphoid fossa, triangular fossa, and concha) and following complications. The technique used by the better aesthetic results were obtained using the senior author (T.B.W.) is an attempt to redress this issue. modified template (n 16). We propose that this method of reconstruction is acceptable in selected patients and creates a stable submuscular pocket for the silicone breast implants. The preaugmentation followed by prophylactic mastectomy eliminates the long and sometimes uncomfortable process of tissue expansion. This also reduces the total number of outpatient visits for the patients. The patients also tend to have more ptotic breasts immediately after their prophylactic mastectomy. DOI: 10.1097/01.prs.0000437241.38424.bb
Vicknesh Sreetharan, B.(Med.)Sci.(Hons.), M.R.C.S.(Eng.) Berend van der Lei, M.D., Ph.D. Department of Plastic Surgery
Jakob de Vries, M.D., Ph.D.
Department of Surgery University Medical Centre Groningen Groningen, The Netherlands Fig. 1. Traditional and modified auricular templates.
www.PRSJournal.com www.PRSJournal.com
1
rich3/zpr-prs/zpr-prs/zpr01012/zpr6009-12a angnes S 8 8/13/12 18:01 4/Color Figure(s): F1-21 Art: PRS204746 Input-nlm
F1
Volume 133, Number 2 • Viewpoints
Fig. 1. (Left) Preoperative photograph. (Center) View after augmentation and before prophylactic mastectomy. (Right) Final result after nipple reconstruction and areola tattooing.
Thomas B. Wermter, M.D. HPC Oldenberg Institute of Hand and Plastic Surgery Oldenburg, Germany Correspondence to Dr. Sreetharan Department of Plastic Surgery University Medical Centre Groningen Postbus 30.001 9700 RB Groningen, The Netherlands [email protected]
ACKNOWLEDGMENT The authors would like to thank the Breast Cancer Workgroup, University Medical Center Groningen, for logistical help in making this treatment option a reality.
ing mastectomy for malignant and nonmalignant disease. Plast Reconstr Surg. 1981;68:392–403. 5. Dempsey WC, Latham WD. Subpectoral implants in augmentation mammaplasty: Preliminary report. Plast Reconstr Surg. 1968;42:515–521.
13
Lambda Laser Nymphoplasty: Retrospective Study of 231 Cases Sir:
A
retrospective study was conducted of 231 patients who underwent resection of enlarged labia minora with a lambda drawing, associated with superior flap, with the incision and cutting being performed by carbon dioxide laser. Preoperative drawing was performed in the form of the Greek letter lambda, rounding a
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Metcalfe KA, Goel V, Lickley L, Semple J, Narod SA. Prophylactic bilateral mastectomy: Patterns of practice. Cancer 2002;95:236–242. 2. Heemskerk-Gerritsen BA, Brekelmans CT, Menke-Pluymers MB, et al. Prophylactic mastectomy in BRCA1/2 mutation carriers and women at risk of hereditary breast cancer: Long-term experiences at the Rotterdam Family Cancer Clinic. Ann Surg Oncol. 2007;14:3335–3344. 3. Chasan PE. The case for performing initial breast augmentation prior to bilateral prophylactic mastectomy in BRCA-1-positive patients. Plast Reconstr Surg. 2004;114:817–818. 4. Little JW III, Golembe EV, Fisher JB. The “living bra” in immediate and delayed reconstruction of the breast follow-
Fig. 1. Preoperative design.
231e
2
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.
AQ: 1
Viewpoints Viewpoints A Modified Template for Microtia Reconstruction
Tested by Surgical Simulation on Ipomoea batatas Prophylactic Mastectomy after Planned Sir: Submuscular Breast Augmentation icrotia reconstruction is a challenge for plastic
M
Sir: surgeons because of its variable clinical presenwith the BRCA1 and BRCA2 1 genes are Although tationomen and difficult surgical reconstruction. increasingly opting for prophylactic mastectoseveral reconstructive methods have been proposed, 1 mies with immediate reconstruction. expansion reconstruction with autologous costal Tissue cartilage, as elabis often and needed after mastectomy, especially there is orated modified by Tanzer, Brent, andif Nagata, insufficient coverage an implant. Removal of remains thetissue best option withfor which to obtain favorable the pectoralis major fascia during mastectomy makes results with fewer complications than other reconstructhe This tends to make coverage of the 2 tive muscle options.fragile. implant with muscle technically moreofdifficult. The The three-dimensional topography the external 2 incidence of complications is higher. ear accurately reflects the shape of the internal cartiWe present an 3 alternative approach. Pocket creReproducing anatomical and struclaginous skeleton. ation before prophylactic createsfor stable tural details of the externalmastectomy ear is a challenge any tissue coverage for the definitive implant. Chasan plastic surgeon and requires a high level of surgical skill has previously reported performing a prophylactic and training to fulfill the patient’s expectation. Surgical
W
Copyright ©2012 © 2014by bythe the American American Society Society of Plastic Surgeons
230e
mastectomyallows on adevelopment patient who, 5 years earlier, had simulation of these skills, reducing 3 undergone a breast augmentation. mistakes, shortening surgical time, and improving recarry4 We outperformed a bilaterala breast surgicalaugmentation simulation ex-3 sultsWe in vivo. months before prophylactic mastectomy as part of the perimental study, evaluating traditional and modified planned management of women requiring prophylacauricular templates as guides for carving ear frametic mastectomy. Using this method, a stable submuscuworks on Ipomoea batatas, comparing and analyzing the lar pocket is available, after mastectomy, for complete obtained results. coverage of the implant. The traditional templates were based on sheets of Six female patients were recruited for this novel paper and sketched linesage representing strucprocedure with a mean of 42 years.the All main the women tures of the external ear (i.e., helix, antihelix, tragus, carried the BRCA1 or BRCA2 gene mutation. The antitragus, triangular fossa, scaphoid fossa, and conpatients included in the study have had a minimum cha) (Fig. 1). The proposed modified templates were follow-up of 1 year. based on paper with lines representing main During thesheets, first stage, the silicone breastthe implant structures detailing the depths eachsubof (Allergan, and Inc.,markings Irvine, Calif.) is placed in a trueoftotal 4 and these structures as follows: whole painted, striped, muscular plane, as described by Little et al. in 1980 and 5 unpainted deep, not deep, elevated, reby Dempsey(meaning and Latham in 1968. The and muscles involved spectively). The striped lines, at theanterior, same time, were the pectoralis major, serratus andrepreoccasented depth when together (Fig.and 1). sionallymore the superior poledrawn of thecloser rectus abdominis Ipomoea batatas, known as sweet potato, was external oblique. A 4-also to 5-cm inframammary approach was used for implant left and center). used because of itsplacement similarity(Fig. 1, in consistency and Stage 2toishuman carried rib out cartilage. 3 months 5after submusflexibility Eachthe sweet pocularmodel augmentation. The toprophylactic mastectomy tato was referred as an individual case. precedes placement of the definitive implant. In our Five common carving tools with different curves clinic, the nipple-areola complex and pectoralis major and angles were used to sculpt the models. Eight fascia are removed during the bilateral prophylactic novel surgeons were tested; half of them used the mastectomy. The implants may be removed temporartraditional template andThe theoperation other half used the ily to facilitate mastectomy. is completed with placement of the The definitive silicone implants modified template. exercise wasgelrepeated in the preexisting submuscular twice. The resulting auricularpocket. sculptures were evalAllbased of theon patients had results, their nipples reconstructed uated aesthetic ranked according 6 months after stage 2. This was followed 3 later to resemblance to the real ear model, months being clasby nipple and areola tattooing. None of the women sified as poor, fair, or good results. developed local wound complications. One patient Aesthetically differentcorrected auricular frameworks had a high-riding implant during the maswere obtained using the two different types of tectomy stage (Fig. 1, right). templates. Better definition of three-dimensional Breast surgeons tend to remove the pectoralis major fascia during prophylactic mastectomy, making the musstructures (i.e., helix, antihelix, tragus, antitragus, cle fragile and increasing the possibility of implant loss scaphoid fossa, triangular fossa, and concha) and following complications. The technique used by the better aesthetic results were obtained using the senior author (T.B.W.) is an attempt to redress this issue. modified template (n 16). We propose that this method of reconstruction is acceptable in selected patients and creates a stable submuscular pocket for the silicone breast implants. The preaugmentation followed by prophylactic mastectomy eliminates the long and sometimes uncomfortable process of tissue expansion. This also reduces the total number of outpatient visits for the patients. The patients also tend to have more ptotic breasts immediately after their prophylactic mastectomy. DOI: 10.1097/01.prs.0000437241.38424.bb
Vicknesh Sreetharan, B.(Med.)Sci.(Hons.), M.R.C.S.(Eng.) Berend van der Lei, M.D., Ph.D. Department of Plastic Surgery
Jakob de Vries, M.D., Ph.D.
Department of Surgery University Medical Centre Groningen Groningen, The Netherlands Fig. 1. Traditional and modified auricular templates.
www.PRSJournal.com www.PRSJournal.com
1
rich3/zpr-prs/zpr-prs/zpr01012/zpr6009-12a angnes S 8 8/13/12 18:01 4/Color Figure(s): F1-21 Art: PRS204746 Input-nlm
F1
Volume 133, Number 2 • Viewpoints
Fig. 1. (Left) Preoperative photograph. (Center) View after augmentation and before prophylactic mastectomy. (Right) Final result after nipple reconstruction and areola tattooing.
Thomas B. Wermter, M.D. HPC Oldenberg Institute of Hand and Plastic Surgery Oldenburg, Germany Correspondence to Dr. Sreetharan Department of Plastic Surgery University Medical Centre Groningen Postbus 30.001 9700 RB Groningen, The Netherlands [email protected]
ACKNOWLEDGMENT The authors would like to thank the Breast Cancer Workgroup, University Medical Center Groningen, for logistical help in making this treatment option a reality.
ing mastectomy for malignant and nonmalignant disease. Plast Reconstr Surg. 1981;68:392–403. 5. Dempsey WC, Latham WD. Subpectoral implants in augmentation mammaplasty: Preliminary report. Plast Reconstr Surg. 1968;42:515–521.
13
Lambda Laser Nymphoplasty: Retrospective Study of 231 Cases Sir:
A
retrospective study was conducted of 231 patients who underwent resection of enlarged labia minora with a lambda drawing, associated with superior flap, with the incision and cutting being performed by carbon dioxide laser. Preoperative drawing was performed in the form of the Greek letter lambda, rounding a
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Metcalfe KA, Goel V, Lickley L, Semple J, Narod SA. Prophylactic bilateral mastectomy: Patterns of practice. Cancer 2002;95:236–242. 2. Heemskerk-Gerritsen BA, Brekelmans CT, Menke-Pluymers MB, et al. Prophylactic mastectomy in BRCA1/2 mutation carriers and women at risk of hereditary breast cancer: Long-term experiences at the Rotterdam Family Cancer Clinic. Ann Surg Oncol. 2007;14:3335–3344. 3. Chasan PE. The case for performing initial breast augmentation prior to bilateral prophylactic mastectomy in BRCA-1-positive patients. Plast Reconstr Surg. 2004;114:817–818. 4. Little JW III, Golembe EV, Fisher JB. The “living bra” in immediate and delayed reconstruction of the breast follow-
Fig. 1. Preoperative design.
231e
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