VIEWPOINTs

VIEWPOINTS
GUIDELINES oxygen therapy
simulation allows hasdevelopment
been used forofthreatened
these skills,skin grafts
reducing
Viewpoints, pertaining to issues or flaps, osteoradionecrosis, chronic
mistakes, shortening surgical time, and improving re- refractory osteo-
of general interest, are welcome, myelitis, diabetic
sults in vivo. 4
Weulcers, and other
performed conditions.
a surgical
2
simulationUsingex- a
even if they are not related to closed chamber
perimental study, with an elevated
evaluating internaland
traditional atmospheric
modified
items previously published. View- pressure
auricularand oxygen concentration,
templates as guides for the partial
carving earpressure
frame-
points may present unique tech- of oxygen
niques, brief technology up- works on in tissue batatas,
Ipomoea can be increased.
comparing Patients return for
and analyzing thea
dates, technical notes, and so on. set numberresults.
obtained of treatments, depending on the indication.
Viewpoints will be published on Figure 1
The traditional demonstrates
templates were images based of on a sheets
healthy,of
a space-available basis because they are typically less time- nonsmoking, nondiabetic, 31-year-old
paper and sketched lines representing the main struc- woman who
sensitive than Letters and other types of articles. Please underwent
tures of thebilateral
externalprophylactic
ear (i.e., helix, nipple-sparing mas-
antihelix, tragus,
note the following criteria: tectomies
antitragus,with tissue expander
triangular fossa, scaphoidand acellular
fossa, and dermal
con-
• Text—maximum of 500 words (not including matrix reconstruction.
cha) (Fig. 1). The proposed The patient
modified developed
templates mastec-
were F1
references) tomy
• References—maximum of five basedflap necrosis
on paper withwith
sheets, tissue
linesexpander
representing deflation on
the main
• Authors—no more than five postoperative
structures andday 2 (Fig. 1,
markings left). the
detailing Shedepths
was referred
of each to of
• Figures/Tables—no more than two figures and/or one our center
these for 30astreatments
structures follows: whole in thepainted,
hyperbaric oxygen
striped, and
table chamber
unpaintedat(meaning
2.0 atmospheres
deep, notfor deep,90-minute sessions.
and elevated, re-
Authors will be listed in the order in which they appear Figure 1,
spectively).right
Thedemonstrates
striped lines, the result
at the same 6 weeks later.
time, repre-
in the submission. Viewpoints should be submitted elec- Using
sentedhyperbaric
more depthoxygen when drawntherapy alone,
closer the patient’s
together (Fig. 1).
tronically via PRS’ enkwell, at www.editorialmanager.com/ Ipomoeaflaps
mastectomy batatas, also known as sweet potato, was
healed.
prs/. We strongly encourage authors to submit figures in
color. usedIncreasing
because comfort with nipple-sparing
of its similarity in consistency mastec-
and
We reserve the right to edit Viewpoints to meet re- tomy has broadened its indications.
flexibility to human rib cartilage. Each sweet po- Patients
5 with prior
quirements of space and format. Any financial interests breast irradiation
tato model and larger,
was referred tomore
as an ptotic breastscase.
individual now
relevant to the content must be disclosed. Submission of are being offered the procedure.
Five common carving tools with different curves
3,4
Performing this
a Viewpoint constitutes permission for the American So- higher risk procedure in higher risk patients will likely
ciety of Plastic Surgeons and its licensees and assignees to and angles were used to sculpt the models. Eight
lead to increased complication rates. Hyperbaric oxy-
publish it in the Journal and in any other form or medium. novel surgeons were tested; half of them used the
gen therapy is a noninvasive, generally well-tolerated
The views, opinions, and conclusions expressed in the traditional template andmitigate
the other
Viewpoints represent the personal opinions of the indi- available therapy that can the half used the
consequences
modified template. The exercise
of mastectomy and nipple-areola complex necrosis fol- was repeated
vidual writers and not those of the publisher, the Editorial
Board, or the sponsors of the Journal. Any stated views, twice. The
lowing resulting mastectomy.
nipple-sparing auricular sculpturesIt should were eval-
be consid-
opinions, and conclusions do not reflect the policy of any uated based on aesthetic
ered and used in instances of necrosis.results, ranked according
of the sponsoring organizations or of the institutions with to resemblance
DOI: to the real ear
10.1097/PRS.0000000000001229 model, being clas-
which the writer is affiliated, and the publisher, the Edi- sified as poor, fair, or good results.
torial Board, and the sponsoring organizations assume no Michael Alperovich, M.D.
responsibility for the content of such correspondence. Aesthetically different auricular frameworks
Department of Plastic Surgery
were
Helenobtained using
L. and Martin the two
S. Kimmel different
Hyperbaric types of
and Advanced
templates. Better definition ofWound three-dimensional
Healing Center
Viewpoints
Viewpoints New helix,
structures (i.e., York University Langone
antihelix, Medical
tragus, Center
antitragus,
Treatment of Nipple-Sparing Mastectomy scaphoid fossa, triangular fossa, and concha) and
AQ: 1 A Modified
Necrosis Template
Using for Microtia
Hyperbaric OxygenReconstruction
Therapy better aesthetic results wereMarco Harmaty,
obtained usingM.D.
the
Division of Plastic and Reconstructive Surgery
Tested by Surgical Simulation on Ipomoea batatas modified template (n  16).
Sir: Mount Sinai Medical Center

EM
Sir:vidence supporting the oncologic safety of nipple-
icrotiamastectomy
sparing reconstructionhas is a challenge
increased for plastic
its use expo- Ernest S. Chiu, M.D.
surgeons because of its variable
nentially over the past decade. However, the greatestclinical presen- Department of Plastic Surgery
tation and
benefit difficult
of the surgical reconstruction.
technique—preservation of theAlthough
1
nipple- Helen L. and Martin S. Kimmel Hyperbaric and Advanced
severalcomplex
areola reconstructive methods
and entire have
breast been proposed,
envelope—is also Wound Healing Center
reconstruction
the source of the with autologous
most costal cartilage,
complications. With the as elab-
major- New York University Langone Medical Center
orated
ity and modified by
of reconstructions Tanzer, still
nationally Brent, and Nagata,
implant-based, New York, N.Y.
remains theflap
mastectomy bestnecrosis
option with
riskswhich
implantto obtain
exposure,favorable
com-
results with Correspondence to Dr. Chiu
promises thefewer
final complications
aesthetic outcome,than other reconstruc-
and complicates
New York University Langone Medical Center
tive options.
definitive 2
reconstruction. 1
Conservative topical wound 240 East 38th Street, 13th Floor
The three-dimensional
management therapies offer topography of the external
limited benefit. New York, N.Y. 10016
ear In isolated cases
accurately of threatened
reflects the shape mastectomy
of the internal flapscarti-
fol- ernest.chiu@nyumc.org
lowing
laginous nipple-sparing mastectomy,anatomical
skeleton.3 Reproducing patients have been
and struc-
referred to our
tural details of hyperbaric
the external oxygen
ear is therapy program
a challenge in
for any
an attempt to salvage the reconstruction. Hyperbaric
plastic surgeon and requires a high level of surgical skill DISCLOSURE
and training to fulfill the patient’s expectation. Surgical The authors have no financial interest to declare in rela-
Copyright © 2015 by the American Society of Plastic Surgeons tion to the content of this communication.
Copyright ©2012 by the American Society of Plastic Surgeons Fig. 1. Traditional and modified auricular templates.
www.PRSJournal.com 1071e
www.PRSJournal.com 1
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Fig. 1. A 31-year-old woman following bilateral prophylactic nipple-sparing mastectomy with tissue expander and acel-
lular dermal matrix reconstruction. The patient developed postoperative right nipple-areola complex and mastectomy flap
necrosis (left) followed by 30 treatments of hyperbaric oxygen therapy with nearly complete healing of her breast envelope
and nipple-areola complex (right).
REFERENCES
1. Warren Peled A, Foster RD, Stover AC, et al. Outcomes after
total skin-sparing mastectomy and immediate reconstruction
in 657 breasts. Ann Surg Oncol. 2012;19:3402–3409.
2. Friedman HI, Friedman HI, Fitzmaurice M, Lefaivre JF, Vec-
chiolla T, Clarke D. An evidence-based appraisal of the use
of hyperbaric oxygen on flaps and grafts. Plast Reconstr Surg.
2006;117(Suppl):175S–190S.
3. Schneider LF, Chen CM, Stolier AJ, Shapiro RL, Ahn CY,
Allen RJ. Nipple-sparing mastectomy and immediate free-
flap reconstruction in the large ptotic breast. Ann Plast Surg.
2012;69:425–428.
4. Alperovich M, Choi M, Frey JD, et al. Nipple-sparing mastec-
tomy in patients with prior breast irradiation: Are patients
at higher risk for reconstructive complications? Plast Reconstr
Surg. 2014;134:202e–206e.
The Rib Graft Rhinoplasty: Anchoring the
Extended Columellar Strut
Sir:
T he use of an osseocartilaginous rib graft for structural
augmentation of the nasal dorsum and tip has been
widely described. To maintain lasting stability and tip con-
trol, it is necessary to control the caudal end of the graft
at the level of the anterior nasal spine. In this regard, the
classic cantilever construct is often supported caudally by
cartilaginous support: the extended columellar strut.
Fixation of the base of the columellar strut is cru-
cial for maintaining tip control. Drill hole and suture or
Kirschner wire fixation techniques have been described
previously.1 These techniques risk weakening the carti-
lage and/or warping the graft, along with technically
challenging suture placement. Here we describe a sim-
ple, novel technique to secure the base of the extended
columellar strut to the anterior nasal spine without
grossly compromising the integrity of the graft.
The nasal cartilages were exposed through an
open technique and a rib graft construct designed
as described previously.2 A mortice joint secured the
1072e
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2015
cartilage framework at the nasal tip. Cranially, the osseo-
cartilaginous rib graft construct was placed subperioste-
ally over the nasal bones. For placement of the extended
columellar strut, a pocket was made between the medial
crura down to the anterior nasal spine. A Micro Quick­
Anchor (DePuy Mitek, Inc., Raynham, Mass.) was placed
in the anterior nasal spine just lateral to the maxillary
midline to preserve the incisive foramen. In some cases,
the apex of the anterior nasal spine was trimmed to
enable better fixation of the Micro QuickAnchor. The
columellar strut was secured with a simple interrupted
suture using the preloaded 4-0 Ethibond suture (Ethi-
con, Inc., Somerville, N.J.). Then, 5-0 Prolene (Ethicon)
mattress sutures were used to secure the medial crura
footplates to the extended columellar strut (Fig. 1). The
nose was then closed in the traditional fashion. We have
found that this technique provides a stable construct
with excellent tip support achieved through secure fixa-
tion and control of the nasal base with excellent long-
term stability.
DOI: 10.1097/PRS.0000000000001231
David J. Moon, B.Sc.(Hons.), M.B.B.S.(Hons.)
University of New South Wales
Prince of Wales Hospital
Jeremy Hunt, M.B.B.S.
Prince of Wales Hospital
Mark P. Gianoutsos, M.B.B.S., D.M.
University of New South Wales
Prince of Wales Hospital
Sydney, New South Wales, Australia
Correspondence to Dr. Moon
University of New South Wales
Surgical and Orthopaedic Research Laboratory
Prince of Wales Hospital
Barker Street
Sydney, New South Wales 2031, Australia
davidmoon3@hotmail.com