Plastic and Reconstructive Surgery • May 2017

proved to result in better and stable outcomes for body

contouring.
DOI: 10.1097/PRS.0000000000003319
Javier Vera Cucchiaro, M.D.
Horacio Lostia, M.D.
Patricia Velazquez, M.D.
Elizabeth Liska, M.D.
Clinic Aesthetic Surgery
Salta, Argentina

Correspondence to Dr. Javier Vera Cucchiaro

Private Clinic of Aesthetic and Laser
Avenida Entre Rios 220
Salta capital, Argentina
jvc@centrocirugiaestetica.com
Fig. 1. A-plasty scar revision technique. The red line is the inci-
sion line and the blue line indicates the final outcome.
DISCLOSURE
The authors have no financial interest to declare in rela-
tion to the content of this communication.

REFERENCES
1. Ribeiro RC, Matos WN Jr, Cruz PFS. Modified lipoabdomino-
plasty: Updating concepts. Plast Reconstr Surg. 2016;138:38e–
47e.
2. Pontes R. Abdominoplastia: Resección en bloque y su apli-
cación en el lifting de cadera y en la torsoplastia. Caracas,
Venezuela: AMOLCA; 2005:25–54.
3. De Souza Pinto EB. Our experience in liposuction. Ann Cong
Bras Plast Surg. 1983;1:9.
4. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture
prevent seroma in abdominoplasty? Plast Reconstr Surg.
2007;119:1060–1064; discussion 1065.
5. Motura AA. Local anesthesia for abdominoplasty, lipo-
suction, and combined operations. Plast Reconstr Surg. Fig. 2. Preoperative drawing for a scar revision on the face.
1994;94:227–228.
6. Pollock H, Pollock T. Progressive tension sutures: A tech-
nique to reduce local complications in abdominoplasty. Plast
keloid scars, effective adjuncts to excision include cortico-
Reconstr Surg. 2000;105:2583–2586; discussion 2587. steroids, mitomycin C, bleomycin, and radiation therapy.
7. Baroudi R, Ferreira CA. Seroma: How to avoid it and how to The appearance and symptoms of established
treat it. Aesthet Surg J. 1998;18:439–441. hypertrophic scars may be improved with injection of
8. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al. substances that cause scar atrophy, pulsed-dye laser
Lipoabdominoplasty with selective and safe undermining. treatment, pressure garments, and scar massage. We
Aesthetic Plast Surg. 2003;22:322–327. can choose nonsurgical treatment or surgical treat-
ment to achieve the purpose of repair and reconstruc-
tion of scar contracture deformity after considering the
Surgical Scar Revision with A-Plasty factors of function and appearance.2
Sir: In our opinion, surgical treatment should be taken

W e read with great interest the article from Khansa

et al. entitled “Evidence-Based Scar Manage-
ment: How to Improve Results with Technique and
Technology.”1 The authors performed a literature
review of high-level studies analyzing methods to pre-
vent or improve hypertrophic scars, keloids, and striae
distensae.
They conclude that, for the treatment of existing
hypertrophic scars, silicone, pulsed-dye laser, carbon
dioxide laser, corticosteroids, 5-fluorouracil, bleomy-
cin, and scar massage have high efficacy, whereas onion
extract and fat grafting seem to have low efficacy. For
into consideration by the plastic surgeon. In general,
surgical revision of scars should be delayed for at least
12 months.3
The various surgical techniques of revising the
scar are as follows: fusiform elliptical excision, Z-plasty,
S-plasty, W-plasty, geometric broken-line closure, and
V-Y and Y-V advancement techniques.4 The plastic
surgeon should be experienced with each of the sur-
gical revision technique and apply these methods as
appropriate.5
With this letter, we propose our personal sur-
gical technique (the A-plasty) to revise the scar, in

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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 139, Number 5 • Letters
alternative to the previously described techniques, with
a different drawing (Fig. 1). The initial drawing repre-
sents “A” along the excision line; subsequently, the A
is deprived of its triangular component, and only the
design of trapezoids along the excision line is kept.
We commonly perform the A-plasty in scar revision.
Among the reasons why it is useful in scar revision is its
ability to make the revised scar not lie in or parallel to
a crease line or relaxed skin tension line, as opposed to
a W-plasty or Z-plasty.
The A-plasty could be an excellent alternative, to
avoid a zig-zag incision, especially in delicate anatomi-
cal areas, such as the face (Fig. 2). The technique is very
easy to execute and can be used in both web and linear
contractures. It offers a new option for the correction of
linear scar contracture that is safe, simple, and effective.
As with any technique, careful preoperative planning
and meticulous execution lead to great results.
DOI: 10.1097/PRS.0000000000003312
Nicola Freda, M.D.
Alessandro Giacomina, M.D.
Gian Luca Gatti, M.D.
Plastic and Reconstructive Surgery
Santa Chiara Hospital
Pisa, Italy
Correspondence to Dr. Freda
Plastic and Reconstructive Surgery
Santa Chiara Hospital
Via Roma 69
Pisa 56010, Italy
nicolafreda64@gmail.com
DISCLOSURE
None of the authors has a financial interest in any of the
products, devices, or drugs mentioned in this communication.
REFERENCES
1. Khansa I, Harrison B, Janis JE. Evidence-based scar manage-
ment: How to improve results with technique and technol-
ogy. Plast Reconstr Surg. 2016;138(Suppl):165S–178S.
2. Garg S, Dahiya N, Gupta S. Surgical scar revision: An over-
view. J Cutan Aesthet Surg. 2014;7:3–13.
3. Jones N. Scar tissue. Curr Opin Otolaryngol Head Neck Surg.
2010;18:261–265.
4. Sharma M, Wakure A. Scar revision. Indian J Plast Surg.
2013;46:408–418.
5. Shockley WW. Scar revision techniques: Z-plasty, w-plasty,
and geometric broken line closure. Facial Plast Surg Clin
North Am. 2011;19:455–463.
Regional Oxygen Saturation Index: A Novel
Criterion for Free Flap Assessment Using Tissue
Oximetry
Sir:
W e read the article entitled “Regional Oxygen Sat-
uration Index: A Novel Criterion for Free Flap
Assessment Using Tissue Oximetry” by Akita et al.1 with
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
great interest. The authors succeeded in detecting vas-
cular compromise in postoperative free flaps with high
accuracy by monitoring the regional oxygen saturation
index (the ratio of regional oxygen saturation on the
flap and the control nondissected portion), using the
two probes of a TOS-OR (Fujita Medical Instruments
Co., Ltd., Tokyo, Japan) near-infrared spectroscopy
device. We agree with the authors about the usefulness
of the near-infrared spectroscopy device in monitoring
the free flap based on our own experience and the vast
experiences of other authors in using another near-
infrared spectroscopy device (Tissue Oximeter; ViOp-
tix, Inc., Newark, Calif.).2–5 However, we would like to
point out two potential problems with the authors’
method of flap monitoring.
First, the necessity of measuring the control non-
dissected portion is questionable. The value of tissue
oxygen saturation is usually stable if the probe is set
on the same position in normal tissue. Accordingly, the
denominator (the control nondissected portion) of
the regional oxygen saturation index is considered sta-
ble, and the change in the regional oxygen saturation
index mostly depends on the numerator (the regional
oxygen saturation of the flap). To improve the ease of
application by co–medical staff, it would seem advan-
tageous to use the absolute tissue oxygen saturation
value on the flap or its decrease from the initial value.
Moreover, because most other near-infrared spectros-
copy devices have one probe, the simultaneous moni-
toring of two sites would require two devices.
Second, the rationale for monitoring the regional
oxygen saturation of the area that has been stained earlier
in indocyanine green angiography is unclear. Of course,
every free flap has areas of high and low perfusion, and
the ischemic or congestive changes in cases of vascular
compromise usually appear first in areas of low perfu-
sion. Thus, we wonder whether monitoring the regional
oxygen saturation level in the area with delayed staining
would be more appropriate for detecting vascular com-
promise at an earlier stage. We would be interested to
hear the authors’ opinions regarding these issues.
DOI: 10.1097/PRS.0000000000003313
Yu Kagaya, M.D.
Shimpei Miyamoto, M.D.
Division of Plastic and Reconstructive Surgery
National Cancer Center Hospital
Tokyo, Japan
Correspondence to Dr. Kagaya
Division of Plastic and Reconstructive Surgery
National Cancer Center Hospital
5-1-1 Tsukiji, Chuo-ku
Tokyo 104-0045, Japan
mkagayakson@yahoo.co.jp
DISCLOSURE
The authors have no financial interest to declare in rela-
tion to the products or devices mentioned in this communica-
tion. No funding was received for this communication.
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