Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71, 1664–1678

Correspondence and Communications

The foot fillet flap for ischial

pressure sore
reconstruction: A new
indication

Dear Sir,

Pressure ulcers in paraplegic and tetraplegic patients

pose a significant problem with an estimated lifetime risk of
>70% and a prevalence of up to 33%.1 Even with adequate
care and preventive measures, pressure ulcers tend to re-
cur and may need repeated reconstruction. First choice for
reconstruction are perforator flaps - that have far greater
arcs of rotation compared to the equivalent musculocuta-
neous flaps. When local and regional flaps are exhausted,
the total thigh musculocutaneous flap (TTF) is an operation
of last resort. In order to avoid the upper leg amputation
associated with a TTF, we performed a pedicled foot fillet
flap (FFF) in four patients with recurrent ischial ulcers. In-
dications for the pedicled FFF are similar to the TTF: pa-
tients affected by extensive and recurrent pressure sores in
the sacral and/or ischial region and local or regional recon-
structive options are exhausted or cannot allow sufficient
coverage. The only difference in indications is the absolute
need of sufficient vascularization and absence of vascular
disease of the lower extremities in these patients.
The flap is designed to include the entire foot sole with
an extension on the medial side of the lower leg from the
ankle up to the knee along the course of the greater saphe-
nous vein (Figure 1). Flap dissection starts on the lateral
side of the foot, where the first muscle encountered is Figure 1 Flap design: notice harvesting of the entire sole of
the abductor digiti minimi. Dissection continues deep to the foot on the posterior tibial vessels.
the flexor digitorum brevis where the lateral plantar artery
digitorum longus. The two teams will meet along the course
is encountered, clipped and divided. The medial plantar
of the posterior tibial vessels. If only one team is available,
artery is encountered deep to the abductor hallucis and di-
dissection continues proximally until the popliteal fossa is
vided as distally as possible. The entire foot sole is incised
reached. Once the flap is ready, the knee is disarticulated.
and the posterior tibial pedicle is included in the flap. The
In cases of very high ulcers, an above the knee femoral am-
flap is not entirely islanded but a skin bridge is preserved
putation might be required to lengthen the pedicle. For flap
along the course of the greater saphenous vein: inclusion of
inset, a longitudinal incision is made on the posterior sur-
the vein provides additional venous drainage and inclusion
face of the thigh to fit the skin bridge. Wounds are closed
of the skin bridge and more tissue to be re-advanced shall
on suction drains to facilitate tissue adhesion (Figure 2). The
the ulcer recur. If two teams are working at the same time,
average operating time was 245 min. All patients were kept
the second team can start at the level of the popliteal artery
in an air-fluidized bed for two weeks and progressed well
and vein. The anterior tibial artery and fibular artery are di-
during their post-operative course; healing time varied from
vided at their origin, and dissection continues to include the
12 to 29 days. No wound dehiscence, hematomas or other
posterior tibial artery, posterior tibial muscle and the flexor
complications were observed.
Correspondence and Communications 1665

Conflict of interest
None.

References
1. Tadiparthi S, Hartley A, Alzweri L, Mecci M, Siddiqui H. Improv-
ing outcomes following reconstruction of pressure sores in spinal
injury patients: a multidisciplinary approach. J Plast Reconstr
Aesthet Surg 2016;69(7):994–1002.
2. Sameem M, Au M, Wood T, et al. A systematic review of com-
plication and recurrence rates of musculocutaneous, fasciocu-
taneous and perforator-based flaps for treatment of pressure
sores. Plast Reconstr Surg 2012;130(1) 67e-77e.
3. Cheng PT, Adams BM, Chunilal A. Modified total thigh musculo-
cutaneous flap: ’operation of last resort’ for massive pressure
ulcers. J Plast Reconstr Aesthet Surg 2014;67(2):260–3.
Figure 2 After performing a through knee amputation the
4. Lazar CC, Auquit-Auckbur I, Milliez PY. The total thigh flap
wounds are closed on suction drains to facilitate tissue adhe- in reconstructive surgery. Ann Chir Plast Esthet 2007;52(2):
sion. 144–147.
5. Ghali S, Harris PA, Khan U, et al. Leg length preservation with
pedicled fillet of foot flaps after traumatic amputations. Plast
Reconstr Surg 2005;115(2):498–505.

K. Peters
Many reconstructive options are available to reconstruct
B. Colebunders
pressure ulcers: perforator flaps, such as SGAP and IGAP,
S. Brondeel
lumbar artery perforator, PAP, ALT and TFL flaps, the pos-
S. D’Arpa∗
terior thigh flap, the gluteal musculocutaneous rotation
S. Monstrey
flap and the hamstring V-Y musculocutaneous advancement
Department of Plastic Surgery, Gent University Hospital,
flap are possible options. Recent studies show no differ-
De Pintelaan 185, 2K12C, B-9000 Gent, Belgium
ence regarding complications and recurrence rates among
musculocutaneous, fasciocutaneous or perforator flaps.2 ∗
Corresponding author.
After several recurrences, some patients have no local or E-mail address: salvatore.darpa@uzgent.be (S. D’Arpa)
regional options left to provide reliable coverage: the TTF
might be the last chance in these cases.3 The musculo- © 2018 British Association of Plastic, Reconstructive and Aesthetic
cutaneous tissues of the thigh, pedicled on the femoral Surgeons. Published by Elsevier Ltd. All rights reserved.
vessels, are degloved from the femur and used as flap to
cover the pressure sore after coxofemoral disarticulation.4 https://doi.org/10.1016/j.bjps.2018.07.009
We believe that the FFF is a valuable alternative to a
TTF for the most severe cases.3 This flap is an established
technique to achieve primary stump closure in patients
with insufficient soft-tissue coverage after traumatic lower
leg amputation5 and avoid an above-knee amputation. The
thick, glabrous, plantar skin, the shock-absorbing fibrofatty
subcutaneous tissue and the underlying muscles of the Negative-pressure wound
heel pad have obvious advantages in terms of durability therapy: An effective
for stump coverage.5 The same principles can be applied
to pressure sores surgery. In our opinion, this flap provides adjunctive treatment to
durable coverage that can theoretically (since it is made assist flap survival and
to bear weight when standing) tolerate pressure, shear and
friction forces better than skin from other body areas. Fur- wound closure
thermore, the patient avoids coxofemoral disarticulation,3
thus can keep his upper leg, important for stability while
sitting. Both procedures compromise the body integrity, Dear Sir,
however we believe the FFF might be psychologically more
acceptable for the patient since the upper leg is spared and The skin flap is widely used in surgery for closing large
a prosthesis can be used to restore limb length. Through wounds. Color, texture, and function after repair are all re-
this operation patients can be transformed from desperate ported to be markedly better with skin flap transplant than
candidates for a total thigh, as a last chance, into patients with skin transplantation. During flap formation and trans-
that still have three resources for the treatment of their fer, it is crucial to ensure that the flap is kept alive and func-
pressure sore: foot-fillet flaps, re-advancement of the foot tional. Negative-pressure wound therapy (NPWT) is a novel
fillet, and eventually still the total thigh. method that can promote the healing of wounds caused by
1666 Correspondence and Communications

trauma, infection, or tumor resection. Experimental studies

Table 1 Basic information of enrolled patients.
and clinical experience have provided abundant evidence
of the benefits of NPWT in wound treatment.1,2 In animal NPWT Conventional dressing
models, it has been proved to promote tissue regenera- Value (%) Value (%) p
tion, reduce edema, and increase neovascularization, lead-
Age, year
ing to accelerated wound healing.3,4 These features should
Mean ± SD 43 ± 12 46 ± 15
contribute to facilitating recovery after reconstruction with
Range 2–80 2–76 0.163
flap.
Sex
We compared wound healing and complications in two
Male 89(55) 56(60)
groups of patients: those who received NPWT immedi-
Female 78(45) 38(40) 0.327
ately after surgery followed by conventional dressing (NPWT
Primary cause
group; n = 167) and those who received conventional dress-
Tumor resection 125(75) 74(79)
ing only (conventional dressing group; n = 94). Patients in
Traumatic 42(25) 20(21) 0.480
this study had skin defects resulting from either soft-tissue
Anatomical location
tumor resection or debridement of traumatic wounds. Tu-
Upper limb 33(20) 20(21) 0.770
mor excision was performed with histologically clear mar-
Lower limb 25(15) 19(20) 0.277
gins and bases, as confirmed by intraoperative frozen patho-
Inguen 30(18) 10(11) 0.115
logic section. Debridement was carried out following the
Trunk 45(27) 25(27) 0.951
general principles of this procedure. Skin flap design was
Scalp 6(4) 7(7) 0.169
based on the location and size of the defect, and drainage
Face 10(6) 9(10) 0.284
tubes were inserted after wound closure with the flap.
Neck 18(11) 4(4) 0.069
In the conventional dressing group, the wound was
covered with multiple layers of common gauze. Dressing
changes were on the first postoperative day and then every
3 days. In the NPWT group, after flap closure, the site was Table 2 Outcomes.
covered with petrolatum gauze (Coloplast A/S, Humlebaek,
NPWT Conventional dressing
Denmark). The InfoV.A.C. Therapy System (KCI Inc., San An-
tonio, TX, USA) was used for NPWT. Patients in the NPWT Value (%) Value (%) p
group did not receive any dressing change until the device Length of stay (days) 7.11 ± 0.72 10.97 ± 0.68 0.013
was removed on the 5th–7th postoperative day; in those pa- Time for drainage 2.19 ± 0.45 3.87 ± 0.57 0.001
tients who needed NPWT for >7 days, the NPWT device was tubes to be
removed for a dressing change on the 7th or 8th day and removed (days)
then reapplied. After completion of NPWT, wound dress- Complications
ing in the NPWT group was the same as in the conventional Hematoma 6(4) 15(16) <0.001
dressing group. The negative pressure applied during NPWT Seroma 4(2) 11(12) 0.002
differed with the anatomical site, as follows: inguinal re- Wound dehiscence 2(1) 9(10) 0.001
gion, −150 mmHg; scalp, upper limb, lower limb and trunk, Swelling 9(5) 25(27) <0.001
−125 mmHg; and neck and face, −100 mmHg. Wound heal- Infection 1(1) 5(5) 0.015
ing status was compared between the two groups at the Necrosis
time of NPWT removal and then at regular intervals over Overall 4(2) 20(21) <0.001
6–12 months. In both groups, drainage tubes were removed Entire 0(0) 1(1) 0.182
when drainage decreased to less than 10 mL/24 h. The t Major 2(1) 4(4) 0.114
test, Mann-Whitney U test, and chi-square test were used, Minor 2(1) 15(16) <0.001
as relevant, to compare variables between the two groups.
Demographic characteristics, causes of the primary
wounds, and anatomical locations of the wounds (Table 1)
were comparable between the two groups. The incidence the flap and the wound edge. Second, wounds in the up-
of major complications was low in both groups, with no per or lower limbs can be immobilized with plaster; this
statistically significant difference between the groups. All will facilitate wound healing and increase the flap survival
other complications were significantly less common in the rate. Third, the negative pressure may have to be decreased
NPWT group than the conventional dressing group. Duration in certain patients, for example, in children or in patients
of hospitalization and the time to removal of drainage tubes who have poor tolerance. Pain can be reduced by lowering
were significantly shorter in the NPWT group than in the the pressure by 25 mmHg within the recommended effec-
conventional dressing group (Table 2). NPWT patients ex- tive pressure range. Fourth, the application of NPWT after
hibited more satisfactory wound healing than conventional lymph node dissection in the axilla or inguinal region can
dressing patients. During dressing changes, the flaps in the help reduce the likelihood of development of lymphatic fis-
NPWT group were more likely to have normal color and less tula.
likely to be congested and swollen (Figure 1). Our study had some limitations. First, because of the ret-
In the light of our experience with NPWT, we would like rospective design we did not have detailed information on
to mention a few techniques to maximize the benefits of several variables (e.g., the condition of the wound bed) that
NPWT. First, the NPWT sponge should extend at least 1 cm could affect the flap survival rate. Second, we did not use an
beyond the flap margins; this helps reduce congestion of objective measure for assessing the wound healing process.
Correspondence and Communications
Figure 1 Typical cases of conventional dressing group and negative pressure wound therapy group. Conventional dressing group:
skin defect of the breast: (a) Immediate after operation; (b) Flap condition during dressing changing, congestion of the flap; (c) the
congestion became worse, holes were made to improve the condition; (d) Flap condition during follow up. Negative pressure wound
therapy group: skin defect on face: (e) Wound immediately after operation; (f) The flap covered by the NPWT device; (g), (h) the
frontal and lateral view of the flap 10 days after surgery.
Nevertheless, our study does show definite benefits with the
use of NPWT as an adjunctive therapy in flap transplant pa-
tients. Its effectiveness is likely to improve with the contin-
uing developments in interface dressing, solution delivery,
and portable equipment.
Financial disclosure statement
None of the authors has a financial interest in any of the
products or devices mentioned in this article.
Conflict of interest
All authors have no conflict of interest to report regarding
the presented study.
Acknowledgments
This study was supported by Shanghai Municipal Commission
of Health and Family Planning Clinical Research Program
(20184Y0113) and Changhai Science Foundation for Youth
Scholars Program (CH201812). This manuscript was edited
by a professional language editing service provider (Inter-
national Science Editing).
References
1. Huang C, Leavitt T, Bayer LR, Orgill DP. Impact of negative
pressure wound therapy on wound healing. Curr Probl Surg
2014;51:301–31.
2. Alexandra Condé-Green, Chung TL III LHH, et al. Incisional
negative-pressure wound therapy versus conventional dressings
1667
following abdominal wall reconstruction: a comparative study.
Ann Plast Surg 2013;71:394–7.
3. Labler L, Rancan M, Mica L, Har̈ter L, Mihic-Probst D, Keel M.
Vacuum-assisted closure therapy increases local interleukin-
8 and vascular endothelial growth factor levels in traumatic
wounds. J Trauma 2009;66:749–57.
4. Daigle P, Despatis M, Grenier G. How mechanical deformations
contribute to the effectiveness of negative-pressure wound ther-
apy. Wound Repair Regen 2013;21:498–502.
Minliang Wu1
Mengyan Sun2
Haiying Dai
Jianguo Xu
Rui Guo
Yuchong Wang
Chunyu Xue
Department of Plastic Surgery, Changhai Hospital, Second
Military Medical University, Shanghai, People’s Republic of
China
1
The first two authors contributed to the work equally and
should be regarded as a co-first authors.
2
Wang Yuchong and Xue Chunyu contributed equally to this
work as co-corresponding authors.
E-mail addresses: drwangyc@163.com (Y. Wang),
xcyfun@sina.com (C. Xue)
© 2018 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2018.07.021
1668
Inferior portion of the
perpendicular plate of the
ethmoid as a suitable
grafting material in
rhinoplasty and septoplasty
proceduresR,RR
Dear Sir,
Rhinoplasty and septoplasty for nasal deviation are of
great importance to patients with functional or aesthetic
nasal problems. The nasal septal cartilage, as the primary
option for grafting materials, is regarded as an essential
element in ensuring a satisfying surgical effect. However, in
some circumstances, it can also be weak or insufficient, thus
necessitating a complementary donor site. In recent years,
surgeons consider the perpendicular plate of the ethmoid
(PPE) to be an ideal bone grafting material supplement
in nasal procedures.1–3 Nevertheless, improper harvesting
of the PPE not only results in a rough shape but can also
possibly lead to complications, including cerebrospinal fluid
rhinorrhea and saddle nose.4 Based on our long-term clinical
observations and reconstruction estimation, we hypothe-
sized that the grafting focus should be on the inferior por-
tion of the PPE, which is the area surrounded by the inferior
side, posterior side, lower third of the anterior side, and the
side connecting the lower trisecting point of the anterior
side and the superior point of the posterior side (Figure 1).
To evaluate the ideal grafting material, we conducted
a study consisting of 104 Chinese patients who underwent
paranasal sinus CT scanning from July 2015 to July 2016.
Using the Mimics medical software (ver. 17.0 research;
Materialise, Leuven, Belgium), we reconstructed the cor-
responding three-dimensional (3D) images utilizing the CT
scanning images. To describe the characteristics of the
inferior portion of the PPE precisely, the following items
were defined: the anterior side of the PPE, the anterior
side of the inferior portion of the PPE, the inferior side of
the PPE, the posterior side of the PPE, the superior side of
the inferior portion of the PPE, the area of the PPE, the
area of the inferior portion of the PPE, anterior and inferior
thicknesses of 1, 2, and 3 (i.e., the thickness of the anterior
and inferior sides, respectively, at the point of their 1/6,
1/2, and 5/6 sites), and the ratio of the inferior portion of
the PPE. Through the reconstructed 3D images, the items
were measured and analyzed for the clinical evaluation
using SPSS 22.0.0.0 (IBM, Armonk, NY, USA) (Figure 1).
R The paper has not been presented in any meeting.
RR The study design was approved by the ethical committee of
Peking University Third Hospital and informed consent was obtained
from all patients.
Correspondence and Communications
The area of the inferior portion of the PPE was
480.47 ± 110.19 mm, and the ratio of the inferior portion
of the PPE was 0.45 ± 0.07. Therefore, the observed fo-
cused area occupied nearly half of the PPE (Figure 1). An-
terior thickness 1, 2, and 3 were 3.14 ± 0.69, 3.13 ± 0.79,
and 1.76 ± 0.55 mm, respectively. The inferior thickness 1,
2, and 3 were 1.91 ± 0.63, 1.96 ± 0.71, and 1.85 ± 0.66 mm,
respectively. When analyzing the differences between
males and females, results suggested that the anterior side,
inferior side, PPE area, and the area and ratio of the inferior
portion of the PPE were significantly larger in males than in
females (Table 1). Results indicated that PPE anterior thick-
ness 1, 2, and 3, PPE inferior thickness 1, the inferior side
of the PPE, the PPE area, and the anterior side and area of
the inferior portion of the PPE gradually increased with age,
but some results did not reach significance (Table 1).
With the progress in rhinoplasty surgeries, PPE is
now considered a potential grafting material with ideal
resorption rate,1,2 except when traditional grafts like
costal, auricular, and nasal septal cartilages are used.
However, during the procedure to harvest PPE, surgeons
should cater not only to the final cosmetic and functional
outcome, but also to the stabilization of the structural
framework to avoid iatrogenic complications. Therefore,
a regulated harvesting procedure is needed to instruct
surgeons on the method by which enough graft material can
be obtained. The inferior portion of the PPE was found to be
a suitable option for rhinoplasty or septoplasty surgeries.
According to clinical observations and CT reconstruction,
the PPE structure is similar to a plate, wide at the top and
narrow at the bottom, which narrows down sharply at the
inferior trisecting point. Korean septal cartilage thickness
was previously measured to range from 1.04 to 1.71 mm.5 In
our study, the inferior portion was found to have a thickness
similar to the septal cartilage, whereas the superior portion
was approximately double the size. With proper tools, the
inferior portion of the PPE was harvested along the bound-
ary dividing the thickness variations. Besides, utilizing the
inferior portion as the grafting material avoids potential
adverse effects on the base of the skull and the keystone
area, thus preventing the occurrence of cerebrospinal fluid
rhinorrhea and saddle nose.
In the present study, the 25.98 ± 5.72-mm-long and
10.22 ± 2.41-mm-wide material, which was a comparatively
regular quadrangle, can be an ideal grafting alternative
because the harvested inferior portion of PPE can be of
proper size, thickness, and quality, with little opportu-
nity for serious complications, which serves as a guide-
line to surgeons and helps in ensuring a satisfying nasal
appearance.
Conflict of interest
None.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Correspondence and Communications 1669

Figure 1 Measurements of the PPE and the definition of borders. (A) anterior side of the PPE: border between the PPE and the
nasal septal cartilage; (B) anterior side of the inferior portion of the PPE: side between the lower point trisecting the anterior side
and the bottom of the anterior side; (C) inferior side of the PPE: border between the PPE and the vomer; (D) posterior side of the
PPE: border between the PPE and the sphenoid sinus; E, superior side of the inferior portion of the PPE: side between the lower
point trisecting the anterior side and the top point of the posterior side.

Table 1 Sex and age differences in PPE measurements.

Sex difference

Male Female P value

Anterior side (mm) 29.97 ± 3.07 28.07 ± 3.03 0.0019

Anterior side of the inferior portion (mm) 10.26 ± 2.35 10.18 ± 2.49 0.86
Inferior side (mm) 27.70 ± 4.96 24.25 ± 5.96 0.0018
Posterior side (mm) 20.46 ± 2.95 19.84 ± 3.10 0.30
Superior side of the inferior portion (mm) 36.56 ± 6.20 34.45 ± 6.01 0.082
PPE area (mm) 1101.26 ± 179.90 1000.06 ± 149.41 0.0026
Area of the inferior portion (mm) 506.90 ± 111.96 454.04 ± 102.77 0.013
Anterior thickness 1 (mm) 3.11 ± 0.78 3.19 ± 0.63 0.67
Anterior thickness 2 (mm) 3.06 ± 0.73 3.21 ± 0.86 0.36
Anterior thickness 3 (mm) 1.74 ± 0.59 1.78 ± 0.51 0.69
Inferior thickness 1 (mm) 1.89 ± 0.59 1.93 ± 0.58 0.75
Inferior thickness 2 (mm) 1.95 ± 0.75 1.96 ± 0.67 0.93
Inferior thickness 3 (mm) 1.85 ± 0.60 1.86 ± 0.73 0.89
Ratio of the inferior portion (mm) 0.46 ± 0.06 0.45 ± 0.07 0.0013
Overlap length (mm) 7.33 ± 2.34 7.44 ± 2.71 0.53
(continued on next page)
1670 Correspondence and Communications

Table 1 (continued)

Age differences

20–29 Years 30–39 Years 40–49 Years 50–59 Years

Anterior side (mm) 29.51 ± 3.11 29.54 ± 2.84 28.52 ± 3.03 28.50 ± 3.48
Anterior side of the inferior portion (mm) 9.25 ± 1.62 11.19 ± 2.78 10.09 ± 1.93 10.37 ± 2.67
Inferior side (mm) 23.12 ± 3.83 25.70 ± 5.83 27.03 ± 5.49 28.09 ± 6.13
Posterior side (mm) 20.49 ± 2.39 19.46 ± 2.26 20.50 ± 3.62 20.18 ± 3.43
Superior side of the inferior portion (mm) 32.51 ± 5.79 35.30 ± 6.16 37.13 ± 5.55 38.38 ± 5.88
PPE area (mm) 946.74 ± 167.75 1040.53 ± 143.35 1099.90 ± 163.77 1129.30 ± 183.94
Area of the inferior portion (mm) 454.21 ± 98.03 471.50 ± 95.81 472.25 ± 103.01 523.94 ± 126.40
Anterior thickness 1 (mm) 2.67 ± 0.72 3.01 ± 0.55 3.45 ± 0.73 3.52 ± 0.57
Anterior thickness 2 (mm) 2.83 ± 0.96 3.02 ± 0.64 3.35 ± 0.68 3.36 ± 0.73
Anterior thickness 3 (mm) 1.56 ± 0.47 1.67 ± 0.49 1.90 ± 0.57 1.92 ± 0.59
Inferior thickness 1 (mm) 1.81 ± 0.73 1.90 ± 0.46 1.95 ± 0.61 1.99 ± 0.69
Inferior thickness 2 (mm) 2.04 ± 0.62 2.09 ± 0.77 1.96 ± 0.79 1.76 ± 0.61
Inferior thickness 3 (mm) 1.98 ± 0.72 1.52 ± 0.47 2.02 ± 0.61 1.91 ± 0.70
Ratio of the inferior portion (mm) 0.42 ± 0.06 0.46 ± 0.07 0.52 ± 0.05 0.46 ± 0.08
Overlap length (mm) 8.19 ± 2.39 7.67 ± 2.83 7.33 ± 2.45 6.77 ± 2.35
Values are mean ± standard deviation.

Acknowledgements https://doi.org/10.1016/j.bjps.2018.07.005

We would like to acknowledge Peking University Third Hos-

pital for its general support.

Aspect of brow position

References
1. Dini GM, Iurk LK, Ferreira MC, Ferreira LM. Grafts for
straightening deviated noses. Plast Reconstr Surg 2011;128:
529e–537e.
2. Kayabasoglu G, Yilmaz MS, Altundag A, Cayonu M, Varlı AF, Gu-
ven M. Bone grafts as a recyclable material in nasal surgeries.
Auris Nasus Larynx 2015;42:24–8.
3. Apaydin F. Bone recycling in nasal septal reconstruction. Facial
Plast Surg 2013;29:473–8.
4. Cochran CS, Landecker A. Prevention and management of rhino-
plasty complications. Plast Reconstr Surg 2008;122:60e–67e.
5. Pochat VDD. The role of septal cartilage in rhinoplasty: cadav-
eric analysis and assessment of graft selection. Aesthet Surg J
2011;31:891–6.
Yang An1
Xiao Yang1
Hongyu Xue
Lifeng Xie
Bolin Pan
Xin Yang
Dong Li
Department of Plastic Surgery, Peking University Third
Hospital, No. 49, Huayuanbei Road, Haidian District,
Beijing, China
1
Yang An and Xiao Yang are co-first author and contributed
equally.
E-mail address: lidong9@sina.com (D. Li)
© 2018 Published by Elsevier Ltd on behalf of British Association of
Plastic, Reconstructive and Aesthetic Surgeons.
changes after bilateral ptosis
correction surgery
Dear Sir,
Increased tonicity of the frontalis muscle lifts the brow to
elevate the lid margin to compensate for the drooping eye-
lid in ptosis. Surgical intervention can alleviate the need to
keep the brows elevated with the use of the frontalis mus-
cle. Some studies have reported changes in brow position
after ptosis surgery.1,2 However, this is not a universal phe-
nomenon and some patients experience the persistence of
brow elevation even after ptosis surgery1 . This study was
aimed at evaluating the prevalence of brow elevation be-
fore and after ptosis surgery and analyzing the change in
brow position in each patient.
The Institutional Review Board of Kim’s Eye Hospital in
Seoul, Korea, approved this study.
98 patients who underwent ptosis surgery from January
2011 to December 2012 were evaluated retrospectively.
Patients were divided into two groups; Group 1 (symmet-
ric bilateral ptosis) and Group 2 (asymmetric bilateral pto-
sis). Symmetric bilateral ptosis is defined as less than 1 mm
differences between the palpebral fissure height of the two
eyes (Supplementary Figure 1A) and asymmetric bilateral
ptosis as more than 1 mm differences between the palpe-
bral fissure height of the two eyes (Supplementary Figure
Correspondence and Communications 1671

Table 1 Changes of brow elevation in group 1 (symmetric bilateral ptosis).

Preoperative brow elevation
Bilateral brow elevation (30/37, 81.1%)
Unilateral brow elevation (7/37, 18.9%)
Symmetric brow elevation (19/30, 63.3%)
Asymmetric brow elevation (11/30, 36.7%)
Right brow elevation (4/7, 57.1%)
Left brow elevation (3/7, 42.9%)
Postoperative brow elevation
Right brow elevation (1/9, 5.3%)
Asymmetric brow elevation (1/11, 9.1%)
Right brow elevation (2/11, 18.2%)
Left brow elevation (2/11, 18.2%)
Left brow elevation (2/3, 66.7%)

Table 2 Changes of brow elevation in group 2 (asymmetric bilateral ptosis).

Preoperative brow elevation
Bilateral brow elevation
(23/38, 60.5%)
Unilateral brow elevation
(15/38, 39.5%)
Postoperative brow elevation
Symmetric brow elevation (7/23, 30.4%)
Asymmetric brow elevation More ptotic side brow More ptotic side brow
(16/23, 69.6%) elevation (11/16, 68.6%) elevation (4/11, 36.4%)
Less ptotic side brow elevation
(1/11, 9.1%)
Less ptotic side brow Less ptotic side brow elevation
elevation (5/16, 31.3%) (2/5, 40%)
More ptotic side brow elevation (13/15, 86.7%) More ptotic side brow
elevation (5/13, 38.5%)
Less ptotic side brow elevation (2/15, 13.3%) Less ptotic side brow elevation
(1/2, 50%)

1B). The brow position was evaluated by comparing it to
the normal position of the brow (Supplementary Figure 2). It
was analyzed by drawing a straight line (Supplementary Fig-
ure 2 blue line). The changes in brow position were analyzed
by comparing preoperative and postoperative photographs
obtained at the last follow-up visit. The photographs were
reviewed in a standard manner using Image J (National In-
stitutes of Health, Bethesda, Maryland).
This study included 53 women and 45 men with an aver-
age age of 45.0 ± 25.0 years. The mean follow-up period was
19.8 weeks. Fifty-one patients showed symmetric bilateral
ptosis and 47 had asymmetric bilateral ptosis.
In Group 1, 30 patients (81.2%) showed bilateral brow
elevation and 7 (18.9%) showed unilateral brow elevation
preoperatively. Postoperatively, 7 patients (87.5%) showed
unilateral brow elevation, and 1 (12.5%) showed asymmet-
ric bilateral brow elevation. In 6 patients, the reason for
postoperative brow elevation could not be determined. One
patient showed under-correction of dermatochalasis and 1
showed under-correction of ptosis. (Table 1)
In Group 2, 23 patients (48.9%) showed bilateral brow
elevation and 15 (31.9%) showed unilateral brow elevation
preoperatively. Postoperatively, 13 patients (34.2%) showed
asymmetric brow elevation. In 10 patients, the reason of
postoperative brow elevation could not be determined. One
patient showed under-correction of dermatochalasis and 2
showed browptosis. (Table 2)
In both groups, most patients with postoperative brow
elevation maintained the patterns seen preoperatively. Only
2 patients showed changes in the pattern of brow elevation,
of which 1 was caused by under-correction of ptosis and in
the other, the reason remained unknown.
In this study, the levator muscle function didn’t influence
the brow position post-surgery. All 8 patients in Group 1
and 11 in Group 2 who retained brow elevation post-surgery
showed the same levator function in both eyes. In Group 2,
only 2 patients showed some differences in the levator func-
tion. In these 2 patients, levator function was measured to
3 mm and 4 mm, respectively, in the eye with more ptosis
and 10 mm and 8 mm, respectively, in the eye with lesser
ptosis.
Lee et al.1 reported that patients who underwent leva-
tor advancement showed a significant reduction of an aver-
age of 4 mm in the central brow position. Rootman et al.3
reported a significant decrease in brow height after ptosis
surgery. Lee et al.4 reported a positive linear correlation
between the magnitude of eyebrow elevation and height of
the palpebral fissure. These studies, however, analyzed the
overall quantitative average change in brow position and
not the change in brow position in each individual patient.
In a study that analyzes the average change in brow po-
sition, even if some patients do not show change in brow
position postoperatively, the overall average value appears
to change significantly. Therefore, the results of the cur-
rent study are particularly significant since it analyzed the
change of brow position in individual patients.
The cause of retained brow elevation was supposed
through the study of Karacalar A et al.5 , which reported that
some cadavers showed partial or no interdigitation between
the frontalis muscle and the orbicularis oculi muscle. If pa-
tients with brow elevation have partial or no interdigitation,
brow elevation would be retained even after a successful
ptosis surgery.
However, there are a few limitations to this study, as it
did not consider the severity of the ptosis, effects of ocu-
lar dominance, and the daily undulations in ocular aperture
that are known to play a role in the change in brow position
in ptosis.
1672
In conclusion, in this study, all ptosis patients did not
show preoperative brow elevation. Those who did, retained
the elevation even after corrective ptosis surgery, the cause
for which could not be determined by the surgeons.
Conflict of interest
The author has no financial or conflicting relationships to
disclose.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2018.07.
013.
References
1. Lee JM, Lee TE, Lee H, Park MS, Baek SH. Change in brow position
after upper blepharoplasty or levator advancement. J Craniofac
Surg 2012;23:434–6.
2. Rootman DB, Karlin J, Moore G, Goldberg R. The effect of ptosis
surgery on brow position and the utility of preoperative phenyle-
phrine testing. Ophthal Plast Reconstr Surg 2016;32:195–8.
3. Ezure T, Amano S. The severity of wrinkling at the forehead is
related to the degree of ptosis of the upper eyelid. Skin Res
Technol 2010;16:202–9.
4. Lee EI, Kim NH, Park RH, Park JB, Ahn TJ. The relationship be-
tween eyebrow elevation and height of the palpebral fissure:
Should postoperative brow descent be taken into consideration
when determining the amount of blepharoptosis correction. Arch
Aesthetic Plast Surg 2014;12:20–5.
5. Karacalar A, Korkmaz A, Kale A, Kopuz C. Compensatory brow
asymmetry: anatomic study and clinical experience. Aesthetic
Plast Surg 2005;29:119–23.
Ji Sun Baek
Department of Ophthalmology, Kim’s Eye Hospital,
Myung-Gok Eye Research Institute, Konyang University
College of Medicine, Seoul, South Korea
Jung Hye Lee
Department of Ophthalmology, Hyemin Eye Hospital,
Seoul, South Korea
Hye Sun Choi, Sung Joo Kim, Jae Woo Jang
Department of Ophthalmology, Kim’s Eye Hospital,
Myung-Gok Eye Research Institute, Konyang University
College of Medicine, Seoul, South Korea
E-mail address: jjw@kimeye.com (J.W. Jang)
© 2018 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2018.07.013
Correspondence and Communications
Reconstruction of columellar
defects: Which surgical
technique to choose? A
retrospective study of 18
patients
Dear Sir,
We reviewed our experience with 18 cases of columellar
reconstruction cases included partial reconstructions and
reconstruction as part of a greater nasal reconstruction. The
nasal columella has always been a difficult subunit to re-
pair because of its unique contours, limited availability of
adjacent skin, and tenuous vascularity. Several reconstruc-
tion techniques have been described in the literature. These
include chondrocutaneous composite auricular grafts, local
flaps, pedicled flaps harvested from the forehead and free
flaps. To our knowledge, theses reconstruction techniques
have not been evaluated and compared.
Eighteen patients (9 women and 9 men) underwent col-
umellar reconstruction from 1999 to 2014 in our university
center of facial reconstruction and were included in our ret-
rospective study. The average age was 53 years. The follow-
up period was 4 years on average (1 to 10 years). Four in-
dependent plastic surgeons were shown the patients’ pho-
tographs before and after reconstruction of the columella.
Patients and Plastic surgeons evaluated the aesthetic result
on a 10 cm visual analogue scale (0 = the worst appearance,
10 = the best). Patients evaluated their satisfaction regard-
ing the procedure using a 4-point scale: “very satisfied”,
“satisfied”, “dissatisfied”, “very dissatisfied”.
The analysis of the 18 columellar defects reported 3
partial defects (1 congenital columellar malformation, 1
trauma and 1 congenital naevus), 1 total defect limited to
the columella (tumor excision) and 14 total defects exceed-
ing the columella (12 tumor excisions, 1 congenital columel-
lar malformation and 1 post-rhinoplasty skin necrosis) (Sup-
plemental Digital Content Figure 1).
Three 3–7 mm chondrocutaneous composite auricular
grafts (CCG) were performed for partial columellar defects
in one-stage procedure. A secondary Z plasty was required
for one patient. Three bilateral nasolabial flaps (NLF) were
performed for total columellar defects extended to the su-
perior lip and the tip nose in two-stage procedure. Two to
four additional debulking and/or reshaping procedures were
required. Two flaps got into a ball initially. General anaes-
thesia was performed for the first step in two patients. For
the third patient, all procedures were performed under lo-
cal anaesthesia. Five ipsilateral Paramedian Forehead Flaps
(PFF) were performed in three-stage procedure for total de-
fects exceeding the nose. Six Scalping Forehead Flaps using
the Converse technique1 (SFFc) and one using the Raulo’s
variation2 (SFFr) were performed in two-stage procedure for
total defects exceeding the nose. All SFFc patients required
secondary fat grafting of the harvest site. A third proce-
dure was required to debulk and to reshape the scalping
Correspondence and Communications
Figure 1 Reconstruction of partial defect of the columella
with chondrocutaneous skin graft in a 8 years-old child. Postop-
erative photography after 6 month follow up: columellar view.
flaps. No necrosis of chondrocutaneous grafts nor flaps was
reported.
The post-operative outcomes were assessed after 4 years
of follow-up on average [10 months–15 years]. Surgeon and
patient aesthetic evaluations were respectively: 7.9 (8.3)
/10 for the CCG group; 6.1 (6.7) /10 for the NLF group; 6.9
(7.3) /10 for the PFF group; 3,7 (4,5) /10 for the SFFc group
and 6,1 (6,3) /10 for the SFFr group. Eleven patients were
very satisfied: 3/3 CCG patients, 1/3 NLF patients and 4/5
PFF patients. Six patients were satisfied: 2/3 NLF patients,
1/5 PFF patient, 3/6 SFFc patients and the SFFr patient. Two
SFFc patients were unsatisfied.
In our study, the reconstruction by composite graft pro-
vided the best outcomes (Figure 1, details in Supplemen-
tal Digital Content Figure 2). We used this technique to re-
pair defects smaller than 10 mm. However successful 15 mm
composite grafts were reported in the litterature.3 We rec-
ommend its use in patients with healthy tissue all around
the defect or in complement to flaps. Nasolabial flaps pro-
vided the worst initial results. However, after reshaping
procedures, patients and surgeons were satisfied (Supple-
mental Digital Content Figure 3). Furthermore, this tech-
nique could be performed under local anesthesia.4 Burget
and Menick recommended the use of nasolabial flaps only
for isolated alar defects.5 However, we suggest to extend
those indications to columellar defects in elder patients. In
our series, we performed forehead flaps only for defects ex-
tended to the tip nose (Supplemental Digital Content Figure
4). The analysis of the aesthetic evaluation and satisfac-
tion showed better results for reconstructions by PFF than
for SFF (Supplemental Digital Content Figure 5). The mor-
bidity of the SFFc donor site and the psychological trauma
secondary to scalp plication seems to be responsible of the
bad SFF outcomes. Raulo’s technique9 was used only for one
patient (Supplemental Digital Content Figure 6). However,
in cases of median nasal defect up to 4 cm wide, this self-
closing flap seems very interesting.
1673
We summarized our experience in an algorithm based on
the size of the columellar defect, its extension and the pa-
tient’s characteristics (Figure 2). When it was possible, com-
posite grafts provided the most satisfaction. Raulo’s and
paramedian forehead flaps provided the most satisfaction
for defects extending to the tip nose. Nasolabial flaps were
the most adapted for patients with contraindications to gen-
eral anesthesia.
Substantial contributions
1. BERGEL Claire: First Writer, conception, drafting, final
approval, agreement to be accountable for all aspects of
the work
2. AL SHUKRY Abdallah: second writer, illustration, draft-
ing, final approval, agreement to be accountable for all
aspects of the work
3. KERFANT Nathalie: conception, revision, final approval,
agreement to be accountable for all aspects of the work
4. PHILANDRIANOS Cecile: drafting, revision, final approval,
agreement to be accountable for all aspects of the work
5. BARDOT Jacques: design, revision, final approval, agree-
ment to be accountable for all aspects of the work
6. CASANOVA Dominique: design, revision, final approval,
agreement to be accountable for all aspects of the work
7. BERTRAND Baptiste: conception, revision, final approval,
agreement to be accountable for all aspects of the work
Financial disclosures
There is no conflict of interest nor funding for this work.
“None of the authors has a financial interest in any of the
products, devices, or drugs mentioned in this manuscript.”
Additional Figure 1
Patients and reconstructions data
Additional Figure 2
Reconstruction of partial defect of the columella with
chondrocutaneous skin graft in a 8 years-old child.
A. Preoperative view
B. Peroperative view with the chondrocutaneous skin
graft
C. Postoperative photography after 6 month follow up:
front view
Additional Figure 3
Reconstruction of complete defect of the columella ex-
tended to the lip and the septum with two nasolabial flaps
in a 71-years-old woman.
A. Peroperative view of the defect
B. Postoperative photography after 6 month follow up:
columellar view
C. Postoperative photography after 6 month follow up:
front view
Additional Figure 4
Total reconstruction of the nose with 2 paramedian fore-
head flaps in a 64-years-old man
A. Preoperative view
B. Peroperative view with the first paramedian flap for
the internal lining and the drawing of the second parame-
dian flap for the external lining
1674
Figure 2 Algorithm to identify the optimal columellar reconstruction to use according to the size of the defect, it extension and
the patient’s characteristics.
C. Per operative columellar view
D. Postoperative photography after 2 years follow up:
front view
Additional Figure 5
Reconstruction of complete defect of the columella ex-
tended to the tip, the dorsum and the right alar nose with
scalping forehead flap in a 69-years-old woman.
A. Peroperative view of the defect
B. Peroperative view of the flap markings
C. Postoperative columellar view after 2 years follow up
D. Postoperative lateral view after 2 years follow up
E. Postoperative front view after 2 years follow up
Additional Figure 6
Reconstruction of complete defect of the columella ex-
tended to the tip and the dorsum with scalping flap using
Raulo’s modification in 31-years-old women.
A. Preoperative view
B. Peroperative view of the defect
C. Peroperative view with drawing of scalping flap using
Raulo’s modification
D. Postoperative photography after 15 years follow up
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2018.07.
019.
Correspondence and Communications
References
1. Converse JM. Reconstruction of the nose by the scalping flap
technique. Surg Clin North Ameri 1969;39:259–335.
2. Raulo Y, Baruch J. Nasal reconstruction by frontal flaps.
Chirurgie. 1993 1994;119(9):493–6.
3. Parkhouse N, Evans D. Reconstruction of the ala of the nose
using a composite free flap from the pinna. Br J Plast Surg
1985;38:306–13.
4. Farina R, Mion D, Baroudi R, Golcman B. Comparative advan-
tages of frontal flaps and nasogenial in the substitution of nasal
substance. Ann Chir Plast 1960;5(4):279–86.
5. Burget GC, Menick FJ. Aesthetic reconstrucion of the nose.
Philadelphia: Mosby; 1994.
Claire Bergel, Abdullah Alshukry
Department of Plastic Surgery and Recontructrive
Surgery, La Conception Hospital, Assistance Publique-
Hôpitaux de Marseille, Aix-Marseille Université, 147,
Boulevard Baille, 13005 Marseille, France
Nathalie Kerfant
Department of Plastic Surgery and Reconstructive Surgery,
CHRU de Brest, 2, avenue Foch, 29200 Brest, France
Cecile Philandrianos, Jacques Bardot, Dominique Casanova,
Baptiste Bertrand∗
Department of Plastic Surgery and Recontructrive
Surgery, La Conception Hospital, Assistance Publique-
Correspondence and Communications
Hôpitaux de Marseille, Aix-Marseille Université, 147,
Boulevard Baille, 13005 Marseille, France
∗
Corresponding author.
E-mail address: baptiste.bertrand@ap-hm.fr (B. Bertrand)
© 2018 Published by Elsevier Ltd on behalf of British Association of
Plastic, Reconstructive and Aesthetic Surgeons.
https://doi.org/10.1016/j.bjps.2018.07.019
Extended chest wall based
flap and lipofilling for
immediate breast
reconstruction for obese
patients
Dear Sir,
Introduction
Increasing rates of obesity in the general population have
coincided with increased rates of obese patients with
breast cancer1 . Breast reconstruction in the overweight
population represents a challenge for the plastic surgeon.
Multiple studies have shown very high complication rates
for both prosthetic and autologous reconstruction in these
patients. Obesity confers independent risk of perioperative
medical and surgical morbidity in breast reconstruction pop-
ulation2 .
Analyzing the overall characteristics of these patients, it
is possible to observe that they commonly have consider-
able lateral tissue in the upper trunk, and this extra tissue
forms the usually called “back rolls”. In patients who have
achieved massive weight loss these significant areas of re-
dundant skin and subcutaneous tissue are treated with der-
molipectomy procedures3 . The concept of the utilization of
this tissue to enhance breast shape has been described by
Hurwitz and colleagues in 2016. The spiral flap technique
for breast reshaping of massive weight loss patients confers
a very reliable and stable option for auto augmentation in
patients referring for mammoplasty procedures4 . We have
previously published some experience using a similar tech-
nique5 .
We present details of a surgical technique combining
the extended chest wall based flap with intramuscular and
subcutaneous lipofilling for immediate breast reconstruc-
tion following nipple skin sparing mastectomy procedures
in obese patients.
Patients and method
Until the present moment, we used the extended
chest wall based flap associated with lipofilling on
1675
15 patients for immediate breast reconstruction after
mastectomy.
Patient markings are done in the standing position (See
“Supplementary Material” – Content 1 illustrates the skin
markings). We proceed to decide the new nipple position
along the ideal mammary nipple line, and a narrow-angled
“keyhole” pattern is drawn, using the Lejour maneuver to
estimate the amount of tissue to resect. The spiral flap is
drawn in the lateral trunk, including all available extra tis-
sue in this area.
All skin markings are initially deepithelialized to facili-
tate access to the breast tissue for the oncology surgeon
performing the mastectomy (See “Supplementary Mate-
rial” – Content 1 illustrates all skin markings deepithelial-
ized). After finishing the resection, intramuscular and sub-
cutaneous lipofilling are also performed in order to enhance
the upper pole projection and total breast volume (Figure
1A). A minimum of 200–300cc of graft is usually done. Then,
all this fasciocutaneous flap extensions of a Wise pattern
mastopexy are rotated to the central axis of the breast
mound and sutured together (Figure 1B). The lateral tho-
racic and perforating intercostal and pectoral vasculature
supply this flap3 .
Discussion
The higher rate of complications for immediate breast re-
construction in the obese population has been urged the
reconstructive surgeon to look for new options2 . The possi-
bility utilization of an autologous option with minimal mor-
bidity is something very useful to manage this population.
It has been previously published, but the lipofilling was not
included in the procedure. Fat grafting tends to resorb ap-
proximately 30%. There numerous factors that can influ-
ence volume gain. For example, the vascularization of tis-
sue bed is also important: the intramuscular resorption is
smaller6 .
The extended chest wall based flap associated with intra-
muscular and subcutaneous lipofilling is a feasible and com-
monly available option for autogenous tissue augmentation,
providing enough tissue for adequate breast mound recon-
struction. The association with lipofilling provides an extra
source of volume, and the possibility of managing possible
irregularities that are common in postmastectomies recon-
structions.
Conclusions
The obese patient poses a significant postmastectomy re-
constructive challenge and the utilization of the spiral flap
and lipofilling represents a new option for autologous breast
reconstruction with minimal additional morbidity and low
complications rates.
1676 Correspondence and Communications

Figure 1 A) After finishing the ressection by the Breast Surgeon, intramuscular and subcutaneous lipofilling are performed. B)
The fasciocutaneous flap extensions of a Wise pattern mastopexy are rotated to the central axis of the breast mound and sutured
together.

Financial disclosure
None of the authors has a financial interest in any of the
products, devices, or drugs mentioned in this manuscript.
flap associated with a loop of pectoralis muscle. Aesthetic Plast
Surg 2008;32(2):371–4. doi:10.1007/s00266- 007- 9062- 1.
6. Hamza A, Lohsiriwat V, Rietjens M. Lipofilling in breast cancer
surgery. Gland. Surg 2013;2:7–14.

Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2018.07.
027. Maria Cecilia Closs Ono∗
Ruth Maria Graf
Dayane Raquel de Paula
References Fabiola Grigoletto Lupion
Renato da Silva Freitas
1. Mastectomy SchwartzJ-CGoldilocks. Plast Reconstr Surg - Glob
Department of Plastic and Reconstrucive Surgery, Federal
Open 2017;5(6):e1398. doi:10.1097/GOX.0000000000001398.
University of Parana, Clinics Hospital, 181 General
2. Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanch-
wala S. Impact of obesity on outcomes in breast reconstruction: Carneiro Street, Curitiba, Paraná 80060900, Brazil
analysis of 15,937 patients from the ACS-NSQIP datasets. J Am ∗
Coll Surg 2013;217(4):656–64. doi:10.1016/j.jamcollsurg.2013. Correspondence to: Maria C. Closs Ono, 190 Rosa Kaint
03.031. Nadolny Street, Curitiba, Parana 81200-525, Brazil.
3. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmenta- E-mail address: mccono@gmail.com (M.C.C. Ono)
tion after massive weight loss: the intercostal artery perforator
(ICAP) flap. Ann Plast Surg 2006;57(4):361–5. doi:10.1097/01. © 2018 Published by Elsevier Ltd on behalf of British Association of
sap.0000222569.59581.d9. Plastic, Reconstructive and Aesthetic Surgeons.
4. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast
reshaping: the spiral flap. Ann Plast Surg 2006;56(5):481–6. https://doi.org/10.1016/j.bjps.2018.07.027
doi:10.1097/01.sap.0000208935.28789.2d.
5. Graf RM, Mansur AEC, Tenius FP, Ono MCC, Romano GG, Cruz GA.
Mastopexy after massive weight loss: extended chest wall-based
Correspondence and Communications 1677

Potential of performing a
microvascular free flap
reconstruction using solely a
3D exoscope instead of a
conventional microscope

Dear Sir,

Since the introduction of the operating microscope in

the mid of the 20th century reconstructive microsurgery has
emerged and pushed its boundaries continuously.1 , 2 Figure 1 Snap shot of the surgical procedure. The Exoscope
In 2012 Cheng et al.3 reported the use of a three- was positioned above the surgical field, coming from the foot
dimensional stereoscopic monitor system in combination section of the patient.
with a conventional microscope to perform free flap surgery.
On the 29th of November 2017 the authors of this com-
munication performed a microvascular free flap for autolo-
gous breast reconstruction using solely an Exoscope (Vitom®
3D, Karl Storz) equipped with three-dimensional imaging;
hence, without the use of a conventional microscope.
The aforementioned Exoscope has previously been tested
during neurosurgical procedures,4 , 5 but to date this was the
first time the system has been applied to perform a mi-
crovascular free flap reconstruction.
The Exoscope was chosen for this procedure because the
authors foresee an enormous potential in the use of the Ex-
oscope for this kind of reconstructive surgery.

Materials and methods
The Exoscope concerns an ultra high definition 3D camera
with a high zoom range. This makes it a possible game
changer in the field of reconstructive microsurgery. Its ver-
satility and its compactness are two of the main advantages
compared to a standard microscope, which is normally used
for this type of surgery. Another advantage is that the scrub-
nurse is also embedded in the 3D experience and therefore
has a better understanding for the difficulties of the pro-
cedure. In the current setting the camera was positioned
coming from the foot section of the patient (see Figures 1
and 2). Two microsurgeons (A.P. and X.K.) performed the
surgery, assisted by a resident (R.S.).
Three 3D monitors were used during this surgery while
the whole surgical team wore 3D polarisation glasses. This
setting enabled all surgeons and nurses to see the operation
performed in 3D.
During the operation, which was a direct breast recon-
struction with a bilateral DIEP-flap, one side was performed
using only the Exoscope and the contralateral side using a
conventional microscope (Zeiss).
First the Exoscope was used for dissection of the left
mammary artery and vein. Subsequently the microvascular
venous anastomosis was performed (Synovis MicroCoupler 2–
0 mm) followed by the arterial anastomosis (hand-sewn end-
end Ethilon 9–0). Then the right side of the bilateral DIEP re-
construction was performed using the aforementioned tra-
ditional microscope.
Figure 2 Snap shot of the surgical procedure. Three 3D moni-
tors were used during the surgery while the whole surgical team
wore 3D polarisation glasses. This setting enabled all surgeons
and nurses to see the operation performed in 3D.
Results
On both sides the microvascular anastomosis was success-
fully completed. No severe events or complications oc-
curred while using either the Exoscope or the microscope.
The time for the microvascular venous and arterial anas-
tomosis was in total 57 min for the flap done with the Exo-
scope and 29 min for the flap done with the microscope.
Discussion
The Exoscope provides a potential alternative way to per-
form a secure microsurgical anastomosis. The difference in
operating time can be attributed to the lack of experience
with the Exoscope, as well as a couple of shortcomings of
the system at the moment.
The most precarious part of the Exoscope is the lower
depth of field compared to a microscope. Furthermore, in
high magnifications a part of the details are lost. This is
probably due to the use of a digital zoom instead of an op-
tical as used in a traditional microscope.
1678
Currently the use of the Exoscope in plastic surgery is
equivalent to the use of surgical loupes. The comfort and
especially the resolution while using higher magnifications
is at the moment not good enough to use the Exoscope as a
standard alternative to the use of a microscope in microvas-
cular reconstructive surgery.
The authors do however feel that the Exoscope could em-
body the future of reconstructive microsurgery since it is
smaller and more versatile than a conventional surgical mi-
croscope. Therefore the ergonometric advantage is clearly
on the side of the Exoscope.
Especially if you are looking at the future of surgery you
can see that the trend is going towards robotic surgery.6
The Exoscope might accelerate the development of robotic
microsurgery, also lifting it away from the restrictions of a
microscope.
Envision the combination of the Exoscope with a robotic
arm and an ultra-high speed Internet connection: perform-
ing a microsurgical intervention from behind your desktop
computer becomes a possible future.
In conclusion, the report illustrates that the Exoscope
can, in its current state, already be used for performing free
flap surgery. Nevertheless, given its zoom capability and the
low depth of field it does not (yet) reach the performance of
a good quality microscope at the moment. When further im-
provements to the hardware are made the Exoscope could
be an absolute game changer in the field of microsurgery.
Conflict of interest
N/A.
Funding
N/A.
Correspondence and Communications
Financial disclosure
N/A.
References
1. Armstrong MB, Masri N, Venugopal R. Reconstructive micro-
surgery: reviewing the past, anticipating the future. Clin Plast
Surg 2001;28:671–86 vi.
2. Miller MJ, Wei FC. Supplement: advances in reconstructive mi-
crosurgery. Plast Reconstr Surg 2009;124:1983–4.
3. Cheng HT, Ma H, Tsai CH, Hsu WL, Wang TH. A three-dimensional
stereoscopic monitor system in microscopic vascular anastomo-
sis. Microsurgery 2012;32:571–4.
4. Oertel JM, Burkhardt BW. Vitom-3D for exoscopic neurosurgery:
initial experience in cranial and spinal procedures. World Neu-
rosurg 2017;105:153–62.
5. Rossini Z, Cardia A, Milani D, et al. VITOM 3D: preliminary expe-
rience in cranial surgery. World Neurosurg 2017;107:663–8.
6. Ibrahim AM, Dimick JB, Joseph A. Building a better oper-
ating room: views from surgery and architecture. Ann Surg
2017;265:34–6.
Andrzej A. Piatkowski
Xavier H.A. Keuter
Rutger M. Schols
René R.W.J. van der Hulst
Department of Plastic, Reconstructive and Hand Surgery,
Maastricht University Medical Center+, Maastricht, The
Netherlands
E-mail address: rutger.schols@mumc.nl (R.M. Schols)
© 2018 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2018.07.032