letters GUIDELINES
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor 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. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
virtually all other surgical anatomists4–10 consider the origin of the depressor septi nasalis to be the maxilla just above the lateral incisor and its insertion to be the anterior nasal spine, medial crura footplates, and a continuation into the membranous septum. Why the discrepancy and how to resolve it? In a previous article,4 we emphasized that the plane of dissection can influence one’s interpretation of the depressor septi nasalis—a top-down dissection from the skin tends to indicate a more superficial labial course for the muscle, whereas a bottom-up gingival dissection reveals the bony origin. Because the only article that assigns the origin of the depressor septi nasalis to the medial crura footplates and its insertion into the lip is that of Rohrich et al.,3 perhaps they could resolve the conundrum. They could repeat their original study with two modifications. First, the dissections would be performed on fresh cadavers, not fresh frozen cadavers with their storage distortions. Second, a bottom-up gingival approach could be used, which is similar to that of their surgical procedure. Obviously, it makes sense to conduct the anatomical studies through the same incision as the preferred operative incision. Certainly, the time has come for rhinoplasty surgeons to resolve the conundrum of the origin and insertion of the depressor septi nasalis. DOI: 10.1097/PRS.0000000000000418
Rollin K. Daniel, M.D.
1441 Avocado Avenue, Suite 308 Newport Beach, Calif. 92660-7721 [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES
Letters The Conundrum of the Depressor Septi Nasi Muscle Sir: n their discussion of Kalantar-Hormozi and BeiraghiToosi’s article on smile analysis in rhinoplasty, Ahmad and Rohrich have raised the conundrum of the depressor septi nasalis.1,2 The discussants state that the origin of the depressor septi nasalis is the medial crural footplates. They cite the original work of Rohrich et al.,3 which describes three types of depressor septi nasalis whose insertion varies: type I, interdigitating with the orbicularis oris muscle (62 percent); type II, onto the periosteum (22 percent); and type III, rudimentary or not present (16 percent). The conundrum is that
I
Copyright © 2014 by the American Society of Plastic Surgeons
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1. Kalantar-Hormozi A, Beiraghi-Toosi A. Smile analysis in rhinoplasty: A randomized study for comparing resection and transposition of the depressor septi nasi muscle. Plast Reconstr Surg. 2014;133:261–268. 2. Ahmad J, Rohrich RJ. Discussion: Smile analysis in rhinoplasty: A randomized study for comparing resection and transposition of the depressor septi nasi muscle. Plast Reconstr Surg. 2014;133:269–271. 3. Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr, Robinson JB Jr. Importance of the depressor septi nasi muscle in rhinoplasty: Anatomic study and clinical application. Plast Reconstr Surg. 2000;105:376–383; discussion 384. 4. Daniel RK, Glasz T, Molnar G, Palhazi P, Saban Y, Journel B. The lower nasal base: An anatomical study. Aesthet Surg J. 2013;33:222–232. 5. de Souza Pinto EB. Relationship between tip nasal muscles and the short upper lip. Aesthetic Plast Surg. 2003;27: 381–387. 6. DeSouza Pinto EB, Rocah RP, Filho WQ, et al. Anatomy of the median part of the septum depressor muscle in aesthetic surgery. Aesthetic Plast Surg. 1998;22:111–115. 7. Letourneau A, Daniel RK. The superficial musculoaponeurotic system of the nose. Plast Reconstr Surg. 1988;82:48–57.
www.PRSJournal.com
Volume 134, Number 3 • Letters 8. Saban Y, Polselli R. Atlas d’Anatomie Chrirurgicale de la Face et du Cou. Firenze, Italy: SEE Editrice; 2009. 9. Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An anatomical study of the nasal superficial musculoaponeurotic system: Surgical applications in rhinoplasty. Arch Facial Plast Surg. 2008;10:109–115. 10. Kosins AM, Lambros V, Daniel RK. The plunging tip: Illusion and reality. Aesthet Surg J. 2014;34:45–55.
Zhibo Xiao, Ph.D.
Department of Plastic Surgery The Second Hospital of Harbin Medical University 194 Xuefu Road Harbin, People’s Republic of China 150086 [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.
A Novel Murine Model of Hypertrophic Scarring Using Subcutaneous Infusion of Bleomycin Sir: was pleased to read the article entitled “A Novel Murine Model of Hypertrophic Scarring Using Subcutaneous Infusion of Bleomycin” (Plast Reconstr Surg. 2014;133:69–78). This article focused on an animal model of hypertrophic scarring. The authors created the methods about bleomycin infusion for stimulating dermal fibroproliferation and building reproducible murine scars. They also analyzed histologic features and collagen content and organization, transforming growth factor-β, and cellularity for this model tissue. They concluded that the bleomycin model represents a promising technique for studying scar formation and testing new antiscarring therapies. According to the information from this article, I think this model has not solved the root of the problem about the hypertrophic scar model. As you know, apart from the animal model mentioned in this article, some other animal models can also produce the hypertropic scar and meet all of the characteristics of fibroblasts and tissue of scar collagen hypertrophy, for example, the nude mouse model1 and the rabbit ear model.2 This model does not have unique advantages compared with the other models published before. It was not perfect, and although it suggests a new method for a hypertrophic scar model, there exists a serious problem. As we all know, hypertrophic scarring is a genetic disease with different incidence rates and different susceptibilities in different human races, different families, and different individuals. Thus, the ideal model should reflect genetic characteristic of human hypertrophic scars to some extent, which is the key to the perfect animal model. It is very difficult to find a perfect animal model that includes the genetic characteristic. Without genetic characteristic of human hypertrophic scars, no model can provide precise results for a study of hypertrophic scarring. Like the animal models published before, this model does not reflect the genetic characteristics of hypertrophic scars and does not include any information regarding the genetic characteristics of scars. Nevertheless, this model does not give any consideration regarding this important factor. Therefore, I think this model may be no more significant in the area of hypertrophic scar research than other animal models before.
I
DOI: 10.1097/PRS.0000000000000480
REFERENCES 1. Momtazi M, Kwan P, Ding J, et al. A nude mouse model of hypertrophic scar shows morphologic and histologic characteristics of human hypertrophic scar. Wound Repair Regen. 2013;21:77–87. 2. Kloeters O, Tandara A, Mustoe TA. Hypertrophic scar model in the rabbit ear: A reproducible model for studying scar tissue behavior with new observations on silicone gel sheeting for scar reduction. Wound Repair Regen. 2007;15(Suppl 1):S40–S45.
Distal Digital Replantation Sir:
W
e read with great interest the article by Leila Jazayeri et al.1 entitled “Distal Digital Replantation.” However, as microsurgical reconstructive surgeons, we wonder whether there is another approach in addition to leech therapy, heparin injection, or nail-bed scrubbing for the venous drainage problems in zone IA, IB, and IC. Therefore, we also reviewed the following studies. The articles we refer to covered several interesting and important points. They discuss the use of arteriovenous anastomoses,2 venocutaneous fistulas,3 or even delayed venous repairs.4 These methods may increase the replantation success rate. To successfully make a very distal digital replantation, we usually harvest a vein graft and interposition it between injured vessels. Besides pulling a tortuous vessel straight, we also can apply the reverse digital arterial arch, because the digital arteries run on both sides of the digit and form an arch near the fingertip. Therefore, we can ligate the artery on the opposite side of the digit, mobilize the arch, and make a transfer for anastomosis to the distal amputated artery (Fig. 1). As the traumatic amputation level is above the digital arterial arch, with this method we can avoid using a vein graft. Another important issue is the ideal ischemic time. Some case reports5 have shown that successful digital replantation can take place after 42 hours of warm ischemia. Also, three successful digital replantations have been performed in patients after 84, 86, and 94 hours of cold ischemia time. Therefore, patients and surgeons should not give up the
481e
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor 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. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
virtually all other surgical anatomists4–10 consider the origin of the depressor septi nasalis to be the maxilla just above the lateral incisor and its insertion to be the anterior nasal spine, medial crura footplates, and a continuation into the membranous septum. Why the discrepancy and how to resolve it? In a previous article,4 we emphasized that the plane of dissection can influence one’s interpretation of the depressor septi nasalis—a top-down dissection from the skin tends to indicate a more superficial labial course for the muscle, whereas a bottom-up gingival dissection reveals the bony origin. Because the only article that assigns the origin of the depressor septi nasalis to the medial crura footplates and its insertion into the lip is that of Rohrich et al.,3 perhaps they could resolve the conundrum. They could repeat their original study with two modifications. First, the dissections would be performed on fresh cadavers, not fresh frozen cadavers with their storage distortions. Second, a bottom-up gingival approach could be used, which is similar to that of their surgical procedure. Obviously, it makes sense to conduct the anatomical studies through the same incision as the preferred operative incision. Certainly, the time has come for rhinoplasty surgeons to resolve the conundrum of the origin and insertion of the depressor septi nasalis. DOI: 10.1097/PRS.0000000000000418
Rollin K. Daniel, M.D.
1441 Avocado Avenue, Suite 308 Newport Beach, Calif. 92660-7721 [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES
Letters The Conundrum of the Depressor Septi Nasi Muscle Sir: n their discussion of Kalantar-Hormozi and BeiraghiToosi’s article on smile analysis in rhinoplasty, Ahmad and Rohrich have raised the conundrum of the depressor septi nasalis.1,2 The discussants state that the origin of the depressor septi nasalis is the medial crural footplates. They cite the original work of Rohrich et al.,3 which describes three types of depressor septi nasalis whose insertion varies: type I, interdigitating with the orbicularis oris muscle (62 percent); type II, onto the periosteum (22 percent); and type III, rudimentary or not present (16 percent). The conundrum is that
I
Copyright © 2014 by the American Society of Plastic Surgeons
480e
1. Kalantar-Hormozi A, Beiraghi-Toosi A. Smile analysis in rhinoplasty: A randomized study for comparing resection and transposition of the depressor septi nasi muscle. Plast Reconstr Surg. 2014;133:261–268. 2. Ahmad J, Rohrich RJ. Discussion: Smile analysis in rhinoplasty: A randomized study for comparing resection and transposition of the depressor septi nasi muscle. Plast Reconstr Surg. 2014;133:269–271. 3. Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr, Robinson JB Jr. Importance of the depressor septi nasi muscle in rhinoplasty: Anatomic study and clinical application. Plast Reconstr Surg. 2000;105:376–383; discussion 384. 4. Daniel RK, Glasz T, Molnar G, Palhazi P, Saban Y, Journel B. The lower nasal base: An anatomical study. Aesthet Surg J. 2013;33:222–232. 5. de Souza Pinto EB. Relationship between tip nasal muscles and the short upper lip. Aesthetic Plast Surg. 2003;27: 381–387. 6. DeSouza Pinto EB, Rocah RP, Filho WQ, et al. Anatomy of the median part of the septum depressor muscle in aesthetic surgery. Aesthetic Plast Surg. 1998;22:111–115. 7. Letourneau A, Daniel RK. The superficial musculoaponeurotic system of the nose. Plast Reconstr Surg. 1988;82:48–57.
www.PRSJournal.com
Volume 134, Number 3 • Letters 8. Saban Y, Polselli R. Atlas d’Anatomie Chrirurgicale de la Face et du Cou. Firenze, Italy: SEE Editrice; 2009. 9. Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An anatomical study of the nasal superficial musculoaponeurotic system: Surgical applications in rhinoplasty. Arch Facial Plast Surg. 2008;10:109–115. 10. Kosins AM, Lambros V, Daniel RK. The plunging tip: Illusion and reality. Aesthet Surg J. 2014;34:45–55.
Zhibo Xiao, Ph.D.
Department of Plastic Surgery The Second Hospital of Harbin Medical University 194 Xuefu Road Harbin, People’s Republic of China 150086 [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.
A Novel Murine Model of Hypertrophic Scarring Using Subcutaneous Infusion of Bleomycin Sir: was pleased to read the article entitled “A Novel Murine Model of Hypertrophic Scarring Using Subcutaneous Infusion of Bleomycin” (Plast Reconstr Surg. 2014;133:69–78). This article focused on an animal model of hypertrophic scarring. The authors created the methods about bleomycin infusion for stimulating dermal fibroproliferation and building reproducible murine scars. They also analyzed histologic features and collagen content and organization, transforming growth factor-β, and cellularity for this model tissue. They concluded that the bleomycin model represents a promising technique for studying scar formation and testing new antiscarring therapies. According to the information from this article, I think this model has not solved the root of the problem about the hypertrophic scar model. As you know, apart from the animal model mentioned in this article, some other animal models can also produce the hypertropic scar and meet all of the characteristics of fibroblasts and tissue of scar collagen hypertrophy, for example, the nude mouse model1 and the rabbit ear model.2 This model does not have unique advantages compared with the other models published before. It was not perfect, and although it suggests a new method for a hypertrophic scar model, there exists a serious problem. As we all know, hypertrophic scarring is a genetic disease with different incidence rates and different susceptibilities in different human races, different families, and different individuals. Thus, the ideal model should reflect genetic characteristic of human hypertrophic scars to some extent, which is the key to the perfect animal model. It is very difficult to find a perfect animal model that includes the genetic characteristic. Without genetic characteristic of human hypertrophic scars, no model can provide precise results for a study of hypertrophic scarring. Like the animal models published before, this model does not reflect the genetic characteristics of hypertrophic scars and does not include any information regarding the genetic characteristics of scars. Nevertheless, this model does not give any consideration regarding this important factor. Therefore, I think this model may be no more significant in the area of hypertrophic scar research than other animal models before.
I
DOI: 10.1097/PRS.0000000000000480
REFERENCES 1. Momtazi M, Kwan P, Ding J, et al. A nude mouse model of hypertrophic scar shows morphologic and histologic characteristics of human hypertrophic scar. Wound Repair Regen. 2013;21:77–87. 2. Kloeters O, Tandara A, Mustoe TA. Hypertrophic scar model in the rabbit ear: A reproducible model for studying scar tissue behavior with new observations on silicone gel sheeting for scar reduction. Wound Repair Regen. 2007;15(Suppl 1):S40–S45.
Distal Digital Replantation Sir:
W
e read with great interest the article by Leila Jazayeri et al.1 entitled “Distal Digital Replantation.” However, as microsurgical reconstructive surgeons, we wonder whether there is another approach in addition to leech therapy, heparin injection, or nail-bed scrubbing for the venous drainage problems in zone IA, IB, and IC. Therefore, we also reviewed the following studies. The articles we refer to covered several interesting and important points. They discuss the use of arteriovenous anastomoses,2 venocutaneous fistulas,3 or even delayed venous repairs.4 These methods may increase the replantation success rate. To successfully make a very distal digital replantation, we usually harvest a vein graft and interposition it between injured vessels. Besides pulling a tortuous vessel straight, we also can apply the reverse digital arterial arch, because the digital arteries run on both sides of the digit and form an arch near the fingertip. Therefore, we can ligate the artery on the opposite side of the digit, mobilize the arch, and make a transfer for anastomosis to the distal amputated artery (Fig. 1). As the traumatic amputation level is above the digital arterial arch, with this method we can avoid using a vein graft. Another important issue is the ideal ischemic time. Some case reports5 have shown that successful digital replantation can take place after 42 hours of warm ischemia. Also, three successful digital replantations have been performed in patients after 84, 86, and 94 hours of cold ischemia time. Therefore, patients and surgeons should not give up the
481e
