Partially tubulized U-shaped supraclavicular flap: An excellent option for reconstruction of circumferential pharyngeal defects

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Correspondence and Communications

Autologous breast reconstruction surgery outcomes in patients with autoimmune connective tissue disease

^R

DearSir,

Autologousbreastreconstructionfollowing mastectomy remainsanintegralcomponentinthemanagementofthese patients. Those with pre-existing medical conditions re- quire specialconsideration, suchaspatientswithautoim- muneconnectivetissuediseases(CTDs).AutoimmuneCTDs include a group of disorders with a wide spectrum of clinical manifestations that may adversely affect surgical outcomes.¹ Due to these factors, surgeons may be reluc- tanttoperformautologousbreastreconstructionsinthese patients, particularly using free tissue transfer. However, whetherthepresenceofCTDssigniﬁcantlyincreasestherisk for adverse outcomes in autologous breastreconstruction remainsunsettled.

Methods

WeconductedaretrospectiveanalysisoftheNationwideIn- patient Sample (NIS2008–2011) toevaluate postoperative outcomes of autologous breast reconstruction in patients withCTD.Patientsthatunderwentautologousbreastrecon- struction were identiﬁedusing International Classiﬁcation ofDiseases,NinthRevision,(ICD-9)codes.Cohortsconsisted ofpatientswithandwithoutautoimmuneCTDs.

Patient demographic factors, comorbidities, and in- hospital postoperative outcomes were analyzed. Mi- crovascular complications weredeﬁnedasthose requiring re-interventionidentiﬁed usingICD-9 procedure codes, as describedpreviously.²WeemployedPearsonchi-squaretest forcategoricalvariablesandtwo-tailedstudent’st-testfor continuous data. Multivariate logistic regression analyses were performed to evaluate independent risk factors for complications following autologous breast reconstruction.

Pvaluesof<0.05wereconsideredstatisticallysigniﬁcant.

ThisstudywasexemptfromfullreviewbytheInstitutional

R Previously presentedas an oral presentation atResident Ab- stractsession,PlasticSurgeryTheMeeting(ASPS)2016,September 24th,2016,LosAngeles,California.

ReviewBoardattheUniversityofMiami LeonardM. Miller SchoolofMedicine.

Results

Therewere 56,522autologous breastreconstructions per- formedduringthestudyperiod.Ofthese,830(1.5%)were performedonpatientswithautoimmuneCTDs. Amongau- toimmune CTDs, rheumatoid arthritis (RA) was the most commondiagnosis(50.8%)followed bysystemiclupusery- thematosus (SLE) (24%), Raynaud’s syndrome (7.1%), Sjo- gren’s disease (8.7%), scleroderma (7%), and psoriatic arthritis (2.4%). Patients with CTD had higher rates of co-morbidities than non-CTD group (Table 1). Majority of patients underwent pedicled flap breast reconstructions (Table 1). However, CTD patients underwent free flaps less frequently than non-CTD patients (43.6% vs. 48.6%, p<0.01). Postoperatively, patients withCTD experienced woundcomplicationsmorefrequentlythanpatientswithout CTD(10.6%vs.7.4%,p<0.01).Amongpatientsthatunder- wentfreeflap-basedbreast reconstructions,therewasno differenceinrateofmicrovascularcomplicationsbetween CTDandnon-CTDgroups(2.5%vs.2.3%,p=0.61).

Rateof pulmonary embolismwassigniﬁcantlyhigherin CTDgroup(1.2%vs.0.2%,p<0.01).Overallmedical com- plicationratewas8.3%inpatientswithCTD,comparedto 5.2%innon-CTDgroup(p<0.01).However,onlyrespiratory complicationsweresigniﬁcantlyhigheramongpatientswith CTDcomparedtonon-CTDgroup (6.6%vs. 4.3%,p<0.01) (Table2).

On risk-adjusted multivariate analysis controlling for patient characteristics, comorbidities, and reconstruction type,CTDwasindependentlyassociatedwithincreasedrisk ofwoundcomplications(OR1.4095%CI1.1–1.8)andmajor medical complications (OR 1.54 95% CI1.2–2.0). CTD sta- tuswasnotassociatedwithincreasedriskofmicrovascular complications.

Discussion

Toourknowledge,thisrepresentsthelargeststudyofautol- ogousbreastreconstructionoutcomesinpatients withau- toimmuneCTD.OurresultssuggestthatpatientswithCTDs areatincreasedriskofpostoperativewoundcomplications andmajor medical adverse events. However,results indi- catethat CTDsdidnotincrease therate ofmicrovascular freeﬂapcomplications.

ThereareseveralfactorsinpatientswithCTDthatmay compound the risk of wound complications. CTDsare associated with systemic inﬂammation resultingin compro-

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Table1 Characteristicsofpatientswithandwithoutconnectivetissuediseases(CTD)thatunderwentautologousbreastrecon- struction(NIS2008–2011).

Overall(n=56,522,100%) Non-CTD(n=55,692,98.5%) CTD(n=830,1.5%) Pvalue

Meanage(SD) 51.2(9.8) 51.2(9.8) 54.2(9.1) <0.01

Race <0.01

White 72.4% 72.4% 68.5%

Black 11.7% 11.6% 17.4%

Hispanic 9.8% 9.8% 10.2%

Asian 2.9% 2.9% 1.2%

NativeAmerican 0.3% 0.3% 0%

Other 3% 3% 2.7%

Comorbidities

Diabetesmellitus 7.1% 7.0% 10.6% <0.01

Hypertension 25.8% 25.6% 39.5% <0.01

Congestiveheartfailure 0.4% 0.4% 1.7% <0.01

Chroniclungdisease 8.0% 7.9% 15.4% <0.01

Renalfailure 0.3% 0.3% <1% 0.20

Liverdisease 0.5% 0.5% 2.9% <0.01

Peripheralarterialdisease 0.4% 0.3% 1.2% <0.01

Obesity 7.6% 7.6% 7.7% 0.90

Immediatereconstruction(vsdelayed) 40.7% 40.7% 41% 0.89

Freeﬂap(vspedicled) 48.5% 48.6% 43.6% <0.01

Typeofreconstruction

Latissimusdorsimyocutaneousﬂap 30.4% 30.3% 33.3% 0.12

PedicledTRAMﬂap 19.6% 19.6% 21.6% 0.053

FreeTRAMﬂap 17.9% 17.9% 19.7% 0.07

FreeDIEPﬂap 26.7% 26.7% 20.9% <0.01

FreeSIEAﬂap 1.3% 1.3% 2.7% <0.01

FreeGAPﬂap 0.7% 0.7% 0.0% 0.02

FreeNOSﬂap 3.4% 3.5% 1.8% 0.01

NIS,NationwideInpatientSample;CTD,connectivetissuedisease;SD,standarddeviation;TRAM,transverserectusabdominismyocuta- neous;DIEP,deepinferiorepigastricarteryperforator;SIEA,superﬁcialinferiorepigastricartery;GAP,glutealarteryperforator;NOS,not otherwisespeciﬁed.

Table2 In-hospitalpostoperativeoutcomesofpatientswithandwithoutconnectivetissuediseases(CTD)thatunderwentau- tologousbreastreconstruction(NIS2008–2011).

Outcome Total(n=56,522,100%) Non-CTD(n=55,692,98.5%) CTD(n=830,1.5%) Pvalue

In-hospitalmortality 0.1% 0.1% 0% 0.50

Woundcomplications 7.4% 7.4% 10.6% <0.01

Hematoma 2.4% 2.4% 2.5% 0.86

Delayedhealing 1.2% 1.1% 2.3% <0.01

Seroma 1.1% 1.0% 2.4% <0.01

FatNecrosis 0.9% 0.9% 3.8% <0.01

Hemorrhage 0.5% 0.5% 1.2% <0.01

Dehiscence 0.8% 0.8% 1.2% 0.24

Infection 1.3% 1.3% 2.3% <0.01

Microvascularﬂapcomplications 2.3% 2.3% 2.5% 0.61

Venousthromboembolism 0.6% 0.6% 1.2% 0.04

Pulmonaryembolism 0.2% 0.2% 1.2% <0.01

Deepvenousthrombosis 0.4% 0.4% 0% 0.06

Bloodtransfusion 10.2% 10.2% 11.3% 0.30

Medicalcomplication 5.3% 5.2% 8.3% <0.01

Myocardialinfarction 0.1% 0.1% 0% 0.48

Stroke 0% 0% 0% 0.79

Pulmonary 4.3% 4.3% 6.6% <0.01

Acutekidneyinjury 0.5% 0.5% 0.5% 0.82

Meanlengthofstay,days(SD) 4(3.2) 4(3.2) 4(2.3) 0.85

NIS,NationwideInpatientSample;CTD,connectivetissuedisease;SD,standarddeviation.

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misedwoundhealing.Inaddition,chronicimmunosuppres- sant therapyfor thesediseases mayfurtherimpairwound healing. Results from small studies have also reported arelativehighrateofwoundcomplicationsinpatientswith CTDundergoingautologousbreastreconstructions.^3,4

As expected, our CTD cohort had signiﬁcantly higher rates ofcomorbidities comparedtopatientswithout CTD.

Postoperatively,patientswithCTDexperiencedhigherrates of pulmonary complications and VTE. Hypercoagulability is a associated with autoimmune CTDs, particularly patients with SLE with concomitant antiphospholipid syndrome. Given the risk of this complication, preoperative risk-stratiﬁcationandadherence toVTEpreventionguide- linesisessential.

OurresultsindicatethatpatientswithCTDsdidnotexpe- riencehigherratesofmicrovascularfreeﬂapcomplications.

Evenafterrisk-adjustedanalysis,CTDstatuswasnotfound tobeanindependentriskfactorformicrovascularfreeflap complications.InothersmallerstudiesonCTDpatientsthat underwent autologous breast reconstructions, there were noreportedcasesoffreeflapfailure.^4,5Together,thesere- sultssuggestthatfreetissuetransferbreastreconstructions are feasible with low risk of flap failure in patients with CTDs. However, these results should be interpreted with caution.Microvascularcomplicationsweredefinedasthose requiringreintervention.Hence,resultsmayunderestimate thiscomplicationrate.

Insummary,autologousbreastreconstructions,including freeﬂaps,maybefeasible inpatientswithunderlyingau- toimmuneCTD.However,reconstructivesurgeonsshouldbe awareoftheincreasedriskofpostoperativewoundcompli- cations,pulmonary complicationsandVTE.It isimportant toconveythisinformationtothepatientsduringconsulta- tions and incorporate these discussions into theinformed consent.

Conﬂict of interest statement

None

Funding

None

Acknowledgments

AuthorswouldliketothankMs.LienMorcateforherassis- tanceindatacollectionforthisstudy.

References

1.TsaiDM,BorahGL.Implicationsofrheumaticdiseaseandbiolog- icalresponse-modifyingagentsinplasticsurgery.PlastReconstr Surg2015;136:1327–36.

2.TuggleCT,PatelA,BroerN,PersingJA,SosaJA,AuAF.Increased hospitalvolumeisassociatedwithimprovedoutcomesfollowing abdominal-basedbreastreconstruction.JPlastSurgHandSurg 2014;48:382–8.

3.ChinKY,ChalmersCR,BrysonAV,Weiler-Mithoff EM.Breastre- constructioninthehighriskpatientwithsystemicconnective tissue disease: a case series. J Plast Reconstr Aesthet Surg 2013;66:61–6.

4.WangTY,SerlettiJM,KolasinskiS,LowDW,KovachSJ,WuLC.A reviewof32freeﬂapsinpatientswithcollagenvasculardisor- ders.PlastReconstrSurg2012;129:421e–427e.

5.ShuckJ,PatelKM,FranklinB,FanKL,HannanL,NahabedianMY. Impactofconnectivetissuediseaseononcologicbreastsurgery andreconstruction.AnnPlastSurg2016;76:635–9.

GustavoA.Rubio DeWittDaughtryFamilyDepartmentofSurgery, UniversityofMiamiLeonardM.MillerSchoolofMedicine, Miami,FL,UnitedStates

ChristieS.McGee UniversityofMiamiLeonardM.MillerSchoolofMedicine, UnitedStates

SethR.Thaller DivisionofPlastic,Aesthetic,andReconstructiveSurgery, UniversityofMiamiLeonardM.MillerSchoolofMedicine, Miami,ClinicalResearchBuilding(CRB),1120N.W.14th Street,Room410,FL,UnitedStates

Correspondingauthor:SethR.Thaller,MD,DMD,FACS, ProfessorofSurgery,DivisionofPlastic,Aesthetic,and ReconstructiveSurgery,DeWittDaughtryFamily DepartmentofSurgery,UniversityofMiamiLeonardM.

MillerSchoolofMedicine,ClinicalResearchBuilding(CRB), 1120N.W.14thStreet,Room410,Miami,FL33136.

E-mailaddress:[email protected](S.R.Thaller)

https://doi.org/10.1016/j.bjps.2018.12.038

The use of ultrasound guidance for foreign body removal

DearSir,

Patients with implanted subcutaneous foreign bodies (FB)areacommonpresentationtoPlasticSurgeryservices.

This implantation may be accidental, inflicted or part of aself-embeddingbehaviour.RemovalofFBposesmultiple risksincludingthe usualrisks of anoperation, which may includeageneralanaesthetic andtourniquet.Inaddition, therearerisksposedbyremovalofFBinparticular.Theyare oftensharp,posinganeedlestickrisktothesurgeon.They arealsousuallysmall,makingidentificationpotentiallydif- ficult,lengthyandoccasionallyunsuccessful.

Manydepartmentsusepre-operativeimaging,eitherul- trasoundorx-ray,todiagnosethesite,sizeandnumberof FBpriortoattempting removal.¹ Some surgeons mayalso use an image intensiﬁer to check position. However, this

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involves a radiation dose topatients, and does not allow imagingofradiolucentFB.²

Pointofcareultrasound(POCUS)mayallowtherisksto patientandsurgeontobereduced.InrecentyearsPOCUS hasincreasedinuseacrosshealthcare,inthehandsofclin- icians without formal trainingasa Radiologist.³ It can be employedfordiagnosis,suchastheFASTscan.Itcanalsobe usedfortreatmentthroughimage-guidedprocedures,such asnerveblocks.Althoughwidelyemployedinsomemedical specialties,particularlyAnaesthetics,thishasnotyetbeen adoptedinPlasticSurgery.

Inappropriatelytrainedhands,POCUSrepresentsanop- tionforguidingtheremovalofFB.Thiscanbeintheform of intraoperative localisation or image-guided removal. I wouldliketopresentaseriesofultrasound-guidedforeign bodyremovaltoillustratethebeneﬁtsofthistechnique.

Toperformthis,theFBshouldbevisualisedusingahigh frequencyultrasoundprobe,optimisingdepth,gain,orien- tation andposition.Dopplerandanisotropismcanbeused todelineatebloodvesselsandnerves.Localanaestheticis injected aroundtheobjecttohelpseparatetissueplanes, thenastabincisionismadedownontotheobject.Forceps or aneedleholdercanthenbeinsertedunderguidanceto removeit.

13 patients presented to the Plastic surgery department at Cambridge University Hospital with a total of 34implantedFB.54%ofthesewereorganic,withtheothers beingamixofneedles,glassandfibreglassshards.69%were removedunderlocalanaestheticinfiltrationalone,withall butoneofthegeneralanaestheticcasesbeingchildren.A tourniquetwasnotrequiredin69%.Inthreecasesadditional objects were removedwhich hadnotbeen identifiedpre- operatively.Onlyoneproceduretooklongerthanonehour, duringwhichtime14objectswereremoved.

Allidentifiableforeignbodieswereremoved,andPOCUS allowed confirmation of this.It wasnot required for very superficial objects(<0.5cmdeep),whichareusuallypal- pable and too close to the probe to allow image-guided removal.

Ultrasound can improve theaccuracy and efﬁciencyof foreignbodyremoval.Increasedfamiliarityinitsusecanbe ofbeneﬁtnotonlyinthissetting,butalsoinothersituations suchasjointinjections.

Conﬂict of interest

None.

Funding

None.

References

1.GinsburgMJ,EllisGL,FlomLL.Detectionofsoft-tissueforeign bodiesbyplainradiography,xerography,computedtomography, andultrasonography.AnnEmergMed1990;19(6):701–3. 2.Anderson MA, NewmeyerWL3rd,Kilgore ESJr. Diagnosisand

treatmentof retained foreignbodies inthe hand.Am JSurg 1982;144(1):63–7.

3.MooreCL,CopelJA.Point-of-careultrasonography.NEnglJMed 2011;364(8):749–57.

JohnKiely PlasticSurgery,CambridgeUniversityHospitals E-mailaddress:[email protected](J.Kiely)

A novel modification of keystone flap for superficial defects repair

DearSir,

In2003,Behan¹wasthefirsttoreporttheKeystoneDe- sign PerforatorIslandFlap(KDPIF). TheKDPIF hasthe advantages of simple design, convenient operation, certain perforatorblood supply,adjacent tissue,goodappearance andnearbytexture.Therefore,ithasbeenwidelyapplied torepairingskinsofttissuedefectscausedbytrauma,tu- morresection,andscars.^2,3However,theKDPIFhascertain issuessuchasexcessivetension,constraintontheclosure ofthedonorarea,^4,5 andskincontracturesduetostraight line scars across the joints in repairing large-size defects ofthe trunk,thejointsor other movingareas.To address theseproblems,onthebaseofKDFIP,wedesignedanextra Vshapeonthelateralcurveoftheflap.Becausethewhole appearanceoftheflaplikeaboat,wealsocalledthismod- ifiedKDPIFasaBoat-ShapedFlap.Theadded“V” likeasail is thekeypointtoreduce thetensionof theflapandthe surroundingsofttissues.

A Boat-Shaped Flap is designed beside the defect as shown in Figure 1: two perpendicular straight lines, AA1 andBB1,aredesignedonbothendsofthearc-shaped“bot- tomof theboat(A1B1)” nexttothefusiform wound. The arcthatis farfromthewoundandparallel tothebottom oftheboatis the“deck(AB)”.The width(H)between AB andA1B1≈1–1.5timesthewidthofthewound(H1).Then thepositionof point O,the“head ofthe sail”,is located at the midpointof AB, and theheight is thesame asthe maximumdiameterofthedefect.Along withࢬαandࢬβ, 3 V-Y advancement flaps are formed, advancing together to the wound and maximally reduce the tension. If the tensionistoomuch,thedeepfasciaisincisedtoincrease the degree of movement of the flap.Compared with the traditionalKeystoneFlapwhichonlyseparatesa2cmarea outsidetheflap,¹ourseparationrangeaddstheareaunder thefascia(shadedpartinFigure1).Also,abluntseparation with a scissor is needed provide an adequate degree of movement.Thetightconnectionofthefasciaisopenedup longitudinally,andmultipletunnelsareseparateduntilthe entire shaded areabeneath theflapis opened up.During

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Figure1 showsthedesignofBoat-ShapedImprovedKeystoneDesignPerforatorIslandFlap.Incisetheskinandthesubcutaneous tissue.ThensepratetheshadedpartunderthefasciaandpushtheﬂaptowardsthewoundviathreeV-Yadvancementdirection.

this process, the vessels that perforate upward from the muscleandmuscleseptumneedtobeprotected.Thenthe flapis pushed towards thecenter of the wound via three V-Y advancemovements. The extraportion of the flap is trimmed,andabsorbablethreadisusedtoperformsubcu- taneoussutures. Negativepressuresuctioncanbeusedto formthepressureofabout100mmHg,andaflapmonitoring windowis indwelledtofacilitate observationof theblood supply.

Aftertheresectionofthebasalcellcarcinomaina73- year-oldfemale,a3×4.5cm²wound wasformed,anda Boat-ShapedFlapwasdesignedonthelateralofthewound torepairthedefectsuccessfully(Figure2,Supplementary Figure1). We have done the operation for 31 patients to repairthedefectsonthetrunk,face,andlimbjoints.Most patientsweresatisﬁedwiththemorphologyandfunctionof theirrepairs.

ComparedwiththetraditionalKDPIF,themodifiedKDPIF addsanewV-shapedesign(sail)ontheoutsidearc,forming a third V-Y advancement flap, and the region between the “sail” and “hull” is opened to form an open tunnel (Figure1).Accordingtoourclinicalexperience,thesizeof theࢬδtriangleismoreflexiblebetween30°and60°,with thegeneralprinciplebeingthatthetriangleshouldbelarge ratherthan smallonthebasis ofsatisfyingthe releaseof tension.Inaddition,whentheheightofthe“sail” h=H,it cansatisfytherepairofmosttensionedwounds.Ourwork suggeststhenewV-shape dispersesthetensionof theflap andreducesskin tensionof thedonorregion,which plays animportantroleinthehealingoftheincision. Especially in moving areas, suchas limb joints, the improved KDPIF also ingeniously changes the straight line of the incision that crosses the joint to a curvedline, which effectively preventsscartractionatthejointandprotectsthemotion function. In a word, The Boat-Shaped Flap reduce and dispersethetensionoftheflapanddonorareawithbetter effects in function and aesthetics, which can be widely applied in the reconstruction of the extensive superficial defects.

Figure2 showsaBoat-ShapedImprovedKeystoneDesignPer- foratorIsland Flap repair the defecton the righttemporalis immediatelyafterthesurgery.

Acknowledgment

WeowegreatgratitudetoallthecolleaguesintheDepart- mentofPlasticandReconstruction.Theyhavebeenofgreat helptoourwork.Thereisnoconﬂictofinterest.Thisstudy

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wassupportedbythegrantfromtheNationalNaturalSci- enceFoundationofChina(81701923).

Supplementary materials

Supplementarymaterialassociatedwiththisarticlecanbe found,intheonlineversion,atdoi:10.1016/j.bjps.2018.12.

041.

References

1.BehanFC.TheKeystoneDesignPerforatorIslandFlapinrecon- structivesurgery.ANZJSurg2003;73(3):112–20.

2.ShayanR,BehanFC.Re:the"keystoneconcept’:timeforsome science.ANZJSurg2013;83(7–8):499–500.

3.Behan FC, Paddle A, Rozen WM, et al. Quadriceps keystone island ﬂap for radical inguinal lymphadenectomy: a reliable locoregional island ﬂap for large groin defects. ANZ J Surg 2013;83(12):942–7.

4.RaoAL,JannaRK.Keystoneﬂap:versatileﬂapforreconstruction oflimbdefects.JClinDiagnRes2015;9(3):PC05–7.

5.Hessam S,SandM, BecharaFG. Thekeystoneﬂap:expanding thedermatologicsurgeon’sarmamentarium.JDtschDermatol Ges2015;13(1):70–2.

ShuoFang¹,WeiyaTang DepartmentofPlasticandReconstruction,Shanghai ChanghaiHospitalAfﬁliatedtoSecondMilitaryMedical University,Shanghai,People’sRepublicofChina

YingliLi DepartmentofPlasticandReconstruction,General HospitalofJinanMilitaryRegion,People’sRepublicof China

WeiyeZhu,WeiZhuang,XinXing,ChaoYang DepartmentofPlasticandReconstruction,Shanghai ChanghaiHospitalAfﬁliatedtoSecondMilitaryMedical University,Shanghai,People’sRepublicofChina

1Theseauthorscontributedtotheworkequallyandshould beregardedasco-ﬁrstauthors.

E-mailaddresses:[email protected](S.Fang), [email protected](W.Tang),[email protected](Y.

Li),[email protected](W.Zhu),[email protected] (W.Zhuang),[email protected](X.Xing), [email protected](C.Yang)

Partially tubulized U-shaped supraclavicular ﬂap: An excellent option for reconstruction of

circumferential pharyngeal defects

DearSir,

Reconstructionofcircularpharyngeal defectsis achal- lenging procedure forboth itsfunctional involvementand theexposuretosalivaanddigestiveenzymes.Radialfore- arm flap, anterolateral thigh flap (fasciocutaneous flaps) andjejunalflaparecommonly usedforpartial orcircum- ferential pharyngeal defects.¹ Nevertheless,microsurgical reconstruction may be severely hampered in cases of ir- radiated or infected surgical fields, or contraindicated in patientswithpoorclinicalconditions.Inrecentyears,there hasbeenanincreasinginterestintheuseofsupraclavicular flap in head and neck reconstruction,²^,³ especially for oropharyngealdefects.However,fartoolittleattentionhas been paidtotheuseofthis flapfor thereconstructionof circumferentialpharyngealdefects.

We would like to share our experience in this field describingourfavouritetechniquetorepaircircumferential pharyngealdefectsusingaU-shapedsupraclavicularartery island flap. In actual fact, it has become our preferred workhorse flap for many head and neck defects. In our department five patients underwent circumferential pharyngeal reconstruction between May 2016 and December 2017 withaU-shaped supraclavicularflap.Three of them had previously been treated with chemoradiotherapy. In all cases the supraclavicular artery was identified preop- eratively by means of an Eco Doppler device. A flap of approximately 7–8×18–22cm, with a 7×10cm skin paddle was harvested using the distal-to-proximal technique describedbyPalluaandDemir.⁴

The flap was then rotated 180°, superficial to the sternocleidomastoid muscle and the skin of the flap was orientatedtobecometheinnersurfaceoftheneopharynx.

Afterthecircumferentialdefectwascreated,theposterior walls of the native pharynx and esophagus were sutured totheprevertebralfascia topreventleakage.The lateral edgesoftheflapwerethensecuredtothelateralprever- tebral fascia conferring theflap intoa “U” shape usinga round needle 3.0 silk suture, asdescribed by Spriano for pectoralismajormuscleflap⁵(Figure1).The distalendof thesupraclavicularflapwasthensecuredtothebaseofthe tongueorpharynxanterolaterallyandtheproximalendwas suturedto the anterolateral native esophagus. This technique produces a neopharynxwith the anterolateral 270° madeupofthepediclesupraclavicularflapandaposterior wall that is prevertebralfascia (Figure2). The procedure required approximately 60 minutes. None of the patients presentedsignificantfunctionallimitationsoftheshoulder.

Thedefectofthedonorareawasclosedwithadirectclo- sureinallpatientswithouttheneedforskin graft.Follow

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Figure1 Theﬂapisinsertedandsuturedtotheprevertebralfascia,andtothepharyngealandtheesophagusremnants.

Figure2 Theneopharynxaspectafterreconstruction.

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uprangedbetween10and30months.Onecaseofseroma was observed, and with respect to major complications one case of pharyngocutaneous fistula was conservatively managed with pressure dressing and botulinum toxin injection(50units)intothesubmandibularglandstoreduce sialorrhea.Beforestartingoral feeding,thepatients were fedthroughanasogastrictubefor3weeks(untillmodified bariumswallowshowednoleaks).Sequentlyoraltolerance wasstarted,beginningwithliquidswithagradualadvance indiet.Indeed,allthepatientshavebeenabletomaintain nutritionbyoralintakeduringthefollow-up.Theprincipal advantage of the U-shape technique is that if a partially tubulizedflapisperformed,a6–7cmwideflapissufficient tocreateapermeable neopharynxandadirectclosureof the donor area is possible without the interposition of a skin graft. In fact,thedirect closureof thedonorareais possiblewithflapsofupto8cmwide.

Usingatotallytubulizedsupraclavicularﬂap,askinpad- dle of about 9–10cmin length and 2× π×R (ray of the circumference=1.5cm)wide(3×π=9.42cm)isrequired aswellaskingrafttoclosethedefectofthedonorarea.

Circumferentialpharyngealreconstructionisachalleng- ing procedure. Regional flaps such as pectoralismajor or deltopectoralmayresultinsignificantfunctionalmorbidity andmicrosurgicalreconstructionmaybeseverelyhampered incasesofirradiatedsurgicalfields.Thesupraclavicularflap presentsseveraladvantages.Itisathinandmoldableflap, idealforpharyngealreconstruction,anditisharvestedeas- ily,quickly,withminimaldonor-sitemorbidityandwithout theneedtocreatetwooperativefields.Finally,itsreduced weight and mass decreasethe risk of leakage at superior suturewiththebaseofthetongue.

Thesmallnumberofpatientslimitthepossibilityofper- formingastatisticalanalysisoftheresultsbutweconsider thattheU-shapedsupraclavicularﬂapisanexcellentalter- native procedurefor thereconstructionofcircumferential pharyngealdefects.

Financial disclosure

None ofthe authors hasa ﬁnancialinterest in any of the products,devices,ordrugsmentionedinthismanuscript.

Conﬂict of interest

The authorsdeclarethattheyhavenoconﬂictofinterest.

This researchreceivednospeciﬁc grant fromanyfunding agency,commercialornot-for-proﬁtsectors.

Ethical approval

Ethicalapprovalwasnotrequiredforthisstudy.Noexperi- mentwithhumansoranimalswasperformed.

References

1.MurayDJ,NovakCB,NeliganPC.Fasciocutaneousfreeﬂapsin pharyngolaryngoesophagealreconstruction:acriticalreviewof theliterature.JPlastReconstAesthSurg2008;61:1148–56.

2.Granzow JW, Suliman A, Roostaeian J, et al. Supraclavicu- lar arteryislandﬂap (SCAIF)vsfreefasciocutaneousﬂaps for head and neck reconstruction. Otolaryngol Head Neck Surg 2013;148:941–8.

3.ZhangS,ChenW,CaoG,DongZ.Pedicledsupraclavicularartery islandflapversusfreeradialforearmflapfortonguereconstruc- tionfollowinghemiglossectomy.JCraniofSurg2015;26:527–30. 4.PalluaN,DemirE.Postburnheadandneckreconstructioninchil- drenwiththefasciocutaneoussupraclaviculararteryislandflap.

AnnPlastSurg2008;60:276–82.

5.SprianoG,PiantanidaR,PelliniR.Hypopharyngealreconstruc- tionusingpectoralismajormyocutaneousﬂapandprevertebral fascia.Laryngoscope2001;111:544–7.

C.Carnevale M.Tomás-Barberán P.Sarría-Echegaray D.Arancibia-Tagle M.García-Wagner J.Miralles-Cuadrado G.Til-Pérez OtolaryngologyHeadandNeckSurgeryDepartment,Son EspasesUniversitaryHospital,CarreteraValldemosa,79, 07210PalmadeMallorca,IllesBalears,Spain E-mailaddress:[email protected](P.

Sarría-Echegaray)

Use of Integra Flowable Wound Matrix for nasal dorsum reconstruction or augmentation: A series of 6 cases

DearSir,

The nasal dorsum is oneof themajor componentsof the nose’sarchitectureanditsesthetics.Resectionorreduction proceduresaremuchmorecommonthatprojectionproce- dures.However,bydeﬁnition,addingvolumeismorecom- plicatedthanremovingitasnewmaterielmustbeaddedto obtainthisprojection.Therearemanypublishedstudieson thistopic.^1–5

The Integra^® Flowable Wound Matrix,which is derived from the Integra^® Dermal Regeneration Template, is a bovinecollagen matrixthat canberevascularizedand re- populatedbyhostﬁbroblaststorecreatedermaltissue.Af- terthismatrixisrehydrated,ithasapasteconsistencythat allowsthesurgeontoshapeitasdesired.Wereportourex- perienceusingtheIntegra^®Flowablematrixforaugmenting thenasalprojection.

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Figure1 Femalepatient(31y/o)whorequestedanaugmentationofthedorsalprojection.(A)Three-quarterviewbeforesurgery.

(B)Three-quarterviewatthe1-yearfollow-upafterFlowableinjection.

Whileclassicrhinoplastyis stillrelevant,aless aggres- siveapproachformoretargetedproblemshasbeendevel- oped.Theinjectionofresorbable(hyaluronicacid)²orper- manent dermal ﬁllers (adipose tissue)³ is one element of thislessinvasivecare.

The Integra^® Flowable Wound Matrix competes with these products because it has several advantages: immediate and unlimited availability, immediate visualization of theresult,potential for secondary shaping,permanent productthatwillberevascularized.

The procedure was performed under local anesthesia whenonlythedorsumwasbeingoperatedon.Inallcases, diluteadrenalizedxylocainewasinjectedat thesite.This injectionwasdoneatleast10minbeforehandtoensurethe anesthetichadenoughtimetoresorb,soastonotinterfere withFlowabledispersion.

The theoretical lateraldefect wasoutlined withafelt pen oneither side of the dorsum. A 1.5-cm incision was done at the glabella and the tissues detached with ﬁne scissors to the previously marked boundary. This dissec- tion should be limited to the desired projection area to avoid diffusion of the product (particularlyonthe lateral sides).TheFlowablematrixwaspreparedaccordingtothe manufacturer’s recommendations, with one change: the productwasdilutedslightlymorebyusing6cm³ ofliquid instead of the recommended 5 cm³. The paste was then injected through the glabellar incision, in a retrograde mannerstartingfromthedistalportionofthedetachment, withthesurgeonpositionedatthepatient’shead.Regular lateral views are taken to stop the injection when the desired projection has been obtained. The injection was done with a CATHLON^® 16G I.V. catheter in order to be moreaccurate.Over-correctionisnotnecessarybecauseno productresorptionisexpected.Atthispoint,theFlowable matrix can be shaped as needed to correct any imper- fections or asymmetry. The injection wasthen restricted withstripsandanasalcastwasadded.Thecastwassolely protectiveanddidnotapplypressuretotheinjectedarea to avoid modifying the initial result obtained during the injection and shaping. The cast was removed on the 5th postoperativeday,butwornatnightforupto10days.

Patientswerereviewedat5days,2monthsand1yearto assesstheﬁnaloutcome.

Thistechniquewasperformedin 6patients.Mostwere women(5patients)andblackpatientswhowantedtoEu- ropeanizetheirnose(Figure1).Thedorsum(glabella/tipof nose)wasseparatedinthreethirds:superior,middle,infe- rior.Thephotographsweremagniﬁed3×andthedifference inprojectionmeasuredinthecenterofthesuperiorthird.

Theﬁnalresultwasevaluatedbyscalingtheprojectiondif- ferencebacktoanormalscale.

Patientsatisfactionwasassessedonascaleof1–10dur- ingthe1-yearfollow-upvisit.

Therewerenocomplications.Theprocedurewaspurely estheticinﬁvecases.Forthesixthcase,reconstructionwas carried out becauseof excessive resectionduring a prior rhinoplastyprocedure.A3–7mmprojectionwasachieved.

Patient satisfactionwas relatively high, as it averaged 7.8andrangedfrom6to10.Noretouchingwasproposedby thesurgeonorrequestedbythepatients.

TheresultsobtainedwiththeFlowablematrixinourcase seriesarestableovera1-yearperiod.Italsoconfersarela- tivenaturalfeelwhentouched.Thecreationofneodermis leadstothedorsumhavingaﬁrm,physiologicalappearance (likecartilage),incontrasttotheresultsobtainedwithadi- posegraftsthataresofterandwithouttonus.

The ability toaugment the projection is an important factor,butitisnottheonlyfactor.TheabilityofFlowableto beshapedaftertheinjectionisveryvaluableasthisallows thesurgeontomake thedorsumasphysiological aspossi- blewithaverygradual,thus natural,connectionwiththe othernasalstructures.Becauseoftheproduct’splasticity, thedorsumcanbereshapedasneededtomakeitmoreor lesspointedbasedontheclinicalsituationandthepatients’

andsurgeons’wishes.

Conﬂict of interest

None.

Funding

None.

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References

1.DuronJB.CartilaginousgraftinRhinoplasty.AnnChirPlastEs- thet2014;59:447–60.

2.Jallut Y, NguyenPS. Rhinoplastyand dermalﬁllers. Ann Chir PlastEsthet2014;59:542–7.

3.Nguyen PS, BaptistaC,CasanovaD, BardotJ, MagalonG. Au- tologus fat grafting and rhinoplasty. Ann Chir Plast Esthet 2014;59:548–54.

4.GunterJP, RohrichRJ.Augmentationrhinoplasty:dorsalonlay graftingusingshapedautogenousseptalcartilage.PlastRecon- strSurg1990;103:1003–14.

5.KellyMH,BulstrodeNW,WaterhouseN.Versatilityofdicedcar- tilage-fasciagraftsindorsalnasalaugmentation.PlastReconstr Surg2007;120:1654–9.

FranckDuteille,HadrienTillietLeDentu DepartmentofPlastic,AestheticandReconstructive Surgery,BurnCenter,HôtelDieu,CHUdeNantes,44093 NantesCedex01,France

MichaelAtlan DepartmentofPlastic,AestheticandReconstructive Surgery,HôpitalTenon,AP-HP,75020Paris,France

PierrePerrot^∗ DepartmentofPlastic,AestheticandReconstructive Surgery,BurnCenter,HôtelDieu,CHUdeNantes,44093 NantesCedex01,France

∗Correspondingauthor.

E-mailaddresses:[email protected](F.

Duteille),[email protected](P.Perrot)

The inﬂuence of social

media on women undergoing immediate breast

reconstruction

^R

Introduction

Withnearlyfour-fifthsoftheUnitedStatespopulationuti- lizingsocialmedia,thesenetworksarequicklybecominga tool for physiciansto disseminateandpatients tofindin- formation.¹Whileitislikelythatsocialmediaisoneofthe sourcesthroughwhichbreastreconstructionpatientsseek andobtain information,thishasneverbeenassessed.The goalofthisstudywastodeterminewhich,ifany,socialmedia sourceswereinfluencingwomen’schoicein breastre-

R Theauthorshavenodisclosuresorconﬂictsofinterest.

Figure1 Assessing ifawoman hadaninitial preferencefor whichtypeofreconstructiontopursue.

constructionandwhichwerethemostinﬂuentialsourcesof information.

Methods

Consecutive women undergoing immediate breast reconstruction at our institution with any staff member were presentedtheoptiontocompleteananonymoussurveyon themorningof surgeryuntil50patients hadparticipated.

Thissurveyqueriedmultipleaspectsofawoman’sdecision- makingprocess.

Results

50 women, withan average age of 50 years (range21–70 years)participated.Themajorityofwomen(42,84%)iden- tiﬁed asWhite/Caucasian. The highest level of education wasgraduateschool(19,38%),college(23,46%),andhigh school(8,16%).

31 (63%) ofwomen initially preferredprosthetic based reconstruction (Figure1). Most (40, 80%) women strongly agreed/agreed they had the ability tochoose which type of reconstruction to pursue and identified herself as the primary decision maker. Support networks were statisti- callymoreinfluential onthedecisionmakingprocessthan spouse/significantother(p<0.001).

Forinitialreconstructivepreference,age,educationand racewerenotindependentpredictors(p>0.05).Therewas a trend towards younger women having an initial preference(p=0.08). Mostwomendid notcite social media or supportgroups as beinginﬂuential and age hadnoeffect onthedegreeofsocialmedialutilization.Mostwomenwho hadaninitialreconstructivepreferencedidnotuseTwitter (p=0.106),Facebook (p=0.091)or Pinterest (p=0.043).

Supportgroupsandsocialmediausagewerenotpredictive of initial reconstructive preference (p>0.005). 33 (66%) womenindicatedtheirphysicianasthemostinfluentialfac- torontheirreconstructivechoice.Therewasa significant differencebetweeninitialreconstructivepreferenceandfi- nalreconstructiveplan(p=0.032)(Figure2).90%ofwomen strongly agreed/agreed that theyunderstood their procedure and92% ofwomen stronglyagreed/agreed thatthey

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Figure2 Changesfrominitialreconstructivepreferencetoﬁnalreconstructivedecision.

understoodtheoutcomesandtypeofsecondaryprocedures thatwouldberequired.

Conclusion

Socialmedia’seffectonpatientsseekingplasticsurgeryhas beenlargelyunreported.Whiletherearereputablesources onsocialmedia,therearealsoforums,blogsandsiteswith misinformationthatiseasilyaccessibletopatients.Astudy surveying women seeking breastaugmentation found that morethanhalf ofthepatients startedtheirsearchfor in- formationontheinternet,while only11%soughtaplastic surgeon’swebsite,andonly10%ﬁrstwenttoaplasticsur- geon.²Thus,whenpatientsﬁrstpresentforaconsultation, theymayhaveunrealisticexpectations,goalsorfearsbased onmisinformationthatmustbeaddressed.

In our study, social media did not appear to inﬂu- encepatients’reconstructivedecisions.Althoughoursam- ple encompassed a wide range of ages, and prior studies have demonstrated age discrepancies in utilization of various types of social media,¹ we did not ﬁnd the utilization of social media to bedependent onage, race or education.

Thelackofsocialmediautilizationinourstudymaybe duetothevastnumberofresourcesthatareavailableon- line forbreastcancer patients,aswellasthefactthatin general, breast cancer patients are older than aesthetic surgerypatients. As opposedtoaestheticbreastpatients, reconstructivepatientsaretypicallytreatedinthecontext ofacancerdiagnosiswiththefocusoncareinatimelyfash- ion,andthus,thispatientpopulationmaybelesslikelyto spendtimeseekingoutsideinformation.

Importantly,themajority ofpatients wesurveyed indi- catedthattheirphysicianwastheprimaryinﬂuenceontheir reconstructivedecision.Thisinofitselfmayindicatease- lection bias, indicating that physicians who are well pre- paredforconsultation regardingbreastreconstructionob- viatetheneedforoutsideinformation.Thus,thesurgeon’s

abilitytoconveythenecessaryinformationandreassurance seemstosupersedeexternalinﬂuences.

Thelimitationsofthisstudyincludeitssmallsamplesize andthe restriction to asingle-center. Although thestudy resultswere blinded, patients mayhave been hesitant to answer questions honestly. As surveys were delivered the morningofsurgery,theremayhavebeenadegreeofrecall bias.Also, we didnot capture patients whoopted for no reconstruction.

This is the first survey to assess how women who are undergoingbreast reconstruction receive information and make their reconstructive decision. Although final recon- structivechoiceis likelyacumulativeeffectofphysician, personal,andextraneousinfluences,thisstudyemphasizes theinfluence that physicians have in helpingpatients un- derstandtheiroptionsanddeterminethemostappropriate reconstructivedecision.

Conﬂict of interest

None.

Funding

None.

References

1.SoriceSC,LiAY,GilstrapJ,etal.SocialMediaandthePlastic SurgeryPatient.PlastReconstrSurg2017;140:1047–56. 2.Walden JL, PanagopoulousG, Shrader SW. Contemporary de-

cisionmaking andperceptionin patientsundergoingcosmetic breastaugmentation.AesthetSurgJ2010;30:395–403.

RebeccaKnackstedt,PaulAdenuga,JoshLandreneau DepartmentofPlasticSurgery,ClevelandClinic, Cleveland,OH,UnitedStates

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JamesGatherwright DivisionofPlasticSurgery,MetroHealth,Cleveland,OH, UnitedStates

AndreaMoreira,GrahamSchwarz,StevenBernard, RaymondIsakov,Rafﬁ Gurunluoglu,RisalDjohan^∗ DepartmentofPlasticSurgery,ClevelandClinic, Cleveland,OH,UnitedStates

∗Correspondingauthor.

E-mailaddress:[email protected](R.Djohan)

Bio-Alcamid complications: A 10 year review

DearSir,

HIVrelatedlipoatrophyisanadverseeffectoftheuseof antiretroviral therapy.Doctorssought toimprove thecos- metic appearance of these patients with the use of syn- thetic ﬁllers.Bio-Alcamidisa non-biodegradablehydrogel polymerthatwasinitiallypopulardue toitslongevityand resistance to hydrolysis. In 2010 the Edinburgh unit pub- lished their experience with eighteen patients with HIV- associatedlipoatrophywhoweretreatedwithBio-Alcamid betweenSeptember2005andSeptember2007.Itwasfound thatoftheeighteenpatients,sevenexperiencedcomplica- tions.Atenyearreviewhasshownthattwopatientswere losttofollowup,onepatientwasdeceasedandtwelvehad experiencedcomplications;onlythreepatientswerefound tohavenocomplications.Belowisasummaryofcomplica- tionsandrecommendationsformanagement.

Complications

Oftheoriginalsevenpatients,fourexperiencedfurtherlate complicationswithanaverageonsetofnineyears.Thecom- plicationsincludedmigration,capsuleformationandrecur- rentabscesses.Oftheninepatientswhohadlateremoval ofBio-Alcamid,ﬁvedevelopedatleastoneepisodeofpost- operative infectionrequiringfurtherwashout.Allpatients hadsatisfactoryHIVhaematologicalparametersthroughout theirtreatment(Table1).

Discussion

SinceBio-Alcamidcameontothemarketin2001,earlyre- sults were promising, however long-term follow up high- lightedmuchhighercomplicationrates.^2,3 Nadarajahetal showedthatof267patientstreatedwithBio-Alcamid,19%

developedinfectionsassociatedwiththeimplant.⁴Thiswas in spite of antibiotic prophylaxis and strict adherence to manufacturerrecommendations. Atthe 12thInternational Workshop on Adverse Drug Reactions and Co-morbidities in HIV, 6 November 2010, it was recommended that Bio- Alcamidnolongerbeofferedasatreatmentforfaciallipoa- trophy.InMarch2012NICEpreparedanoverviewbasedon rapidreview ofthemedical literatureandspecialistopin- ions,althoughtheInterventionalProceduresAdvisoryCom- mitteehasnotmadeanyformalrecommendations.

Management recommendations

Once thedecision toremove theproducthasbeen made, there is a signiﬁcant risk to the patient of postoperative infection. Inour review of latecomplications, ﬁveout of ninepatients developedapost-operativeinfection, inthe formofanabscess,requiringatleastonefurtherwashout.

The difficulty with removal of the filler is that complete clearancecannotbeguaranteed andany fillerleftbehind tends tobecomeinfected following a removalprocedure.

Theotherissueisthatfollowingremovaltheencapsulated pocketﬁllswithexudate,whichalsohasatendencytobe- come infected. These infections aredifﬁcult to eradicate

Table1 SummaryofpatientstreatedwithBio-AlcamidintheEdinburghUnit.

Summaryofpatients(Total15)

Earlycomplications Intermediatecomplications Latecomplications

Onset Within6months 6monthsto5years 5–10years

Complication

Infection 3/15 Capsuleformation 1/15 Capsuleformation 2/15 Asymmetry 4/15 Inferiormigration 2/15 Inferiormigration 4/15 Capsuleformation 1/15 Extrusion 1/15 Recurrentabscesses 3/15

Chronicinﬂammation 1/15

Total 8/15 5/15 9/15

Incidence 53.3% 33.3% 60%

10yearoverallcomplicationrate:12/15(80%).

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andoftenrequireaperiodofinpatientstay,intravenousan- tibiotics and either aspiration or formalwash out in the- atre.Duetothehighriskofpost-operativeinfectionnoted followingremoval,ithasbeentheseniorauthor’spractice touseprophylacticantibioticsperiandpostoperatively,as well asadrainfor 24h. Variousmethodstoattemptcom- pleteremovalofthefillerhavebeendescribed.Kirkpatrick andForoglou⁵advocatetheuseofpre-operativeMRIscans with contrasttodelineate the plane of the filler, aswell as the degree of encapsulation. Options for removal in- cludestabincisions andexpressionaswellasanopen approach;thetwomaybecombinedasrequired.Ifan open approach is to beused, the upper face may be accessed viabiocoronal incisions,mid faceviaalowerlid transcon- junctivalincisionand thelateralcheek via afacelift incision.Kirkpatrickalsoemploystheuseofintraoperativeul- trasoundtohelpguidetheplacementofstabincisionsand alsotodemonstratethedegree offiller removal.Thereis alsosomedebateastowhethertheproductshouldbere- movedelectivelyinasymptomatic patients.Thereasoning behindthisistoavoidthesignificantscarringandaesthetic deformitythatensueonceaninfectionhasdeveloped.The argument against doing so is the high risk of postoperative infection oncean attempt at filler removalhas been made.

Conclusion

DespiteearlypromisingresultswiththeuseofBio-Alcamid in our unit,extended follow up has ledus todiscontinue it’s use for HIV associated lipoatrophy. We also strongly caution against its use in this group of patients who are potentiallyimmunocompromisedandarethusmoresuscep- tibletoinfections,especiallyfollowinganyinterventionre- quired to remove the Bio-Alcamid. Bitter experience has dissuadedusfromtheuseofpermanentsyntheticinjectable fillers inany part of the body.Unacceptably high complication ratesaswellasdifficulties associatedwithinsuring completeextractionmaketheseproductsunsafe,thisisin contrasttosolidimplants,whichcanbefullyremovedwith confidence.

Conﬂict of interest

Nonedeclared.

Funding

None.

References

1.Nelson L, Stewart KJ. Early and late complications of polyalkylimidegel(Bio-Alcamid)®.JPRAS2011;64:401–4. 2.Karim RB, Hage JJ, van Rozelaar L, et al. Complications of

polyalkylimide4%injections(Bio-Alcamid):areportof18cases.

JPRAS2006;59:1409–14.

3.GoldanO, GeorgiouI, Grabov-NardiniG, etal.Earlyand late complicationsafteranonabsorbablehydrogelpolymerinjection:

aseriesof14patientsandnovelmanagement.DermatolSurg 2007;33:199–206.

4.NadarajahJT, Collins M, Raboud J, Su D, RaoK, Loutfy MR, Walmsley S. Infectious complications of Bio-Alcamid ﬁlled used for HIV- related facial lipoatrophy. Clin Infectious Dis 2012;55(11):1568–74.

5.Kirkpatrick, N, Foroglou, P. Treating permanent dermal ﬁller complications. https://aestheticsjournal.com/feature/

treating-permanent-dermal-ﬁller-complications

MaiRostom DepartmentofPlasticandReconstructiveSurgery, StJohnsHospital,HowdenRoadWest,Howden,Livingston EH546PP,Scotland,UK

LisaBrendling BrightonandSussexUniversityHospitalsNHSTrust,Elm Grove,BrightonBN23EW,UK

KenStewart DepartmentofPlasticandReconstructiveSurgery, StJohnsHospital,HowdenRoadWest,Howden,Livingston EH546PP,Scotland,UK E-mailaddress:[email protected](M.Rostom)

Patient satisfaction after levator aponeurosis surgery for the treatment of

involutional blepharoptosis

DearSir,

Levatoraponeurosissurgery,inwhichthelevatorisreat- tachedoradvancedtothetarsus,isawidelyusedtechnique forthetreatment ofinvolutionalblepharoptosis.Although thissurgicaltreatmentcanachievegoodresultsbothfunc- tionallyandaesthetically,fewstudieshaveanalyzedpatient satisfaction after this surgical treatment. In the present study,weinvestigatedthepatientsatisfactionafterlevator aponeurosissurgerybyaskingpatientstocompleteapostal questionnaire,andwe analyzedthefactorsaffecting their satisfaction/dissatisfaction.

ThestudywasapprovedbytheEthicsCommitteeatKy- orinUniversity Schoolof Medicine. We retrospectivelyre- viewedthe cases of 448 patients who underwent levator aponeurosissurgeryfor bilateralinvolutionalblepharopto- sisbetweenJanuary2010 andDecember2016.We mailed aquestionnairetothepatients,andthepatientsreturned

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Table1 Thequestionnairedistributedtothepatientsand theresults.

Question1:Pleaserateyouroverallsatisfactionwith blepharoptosissurgery.

5:Verysatisﬁed 35.5%

4:Satisﬁed 39.8%

3:Neutral 3.5%

2:Dissatisﬁed 17.0%

1:Verydissatisﬁed 4.2%

Question2:Ifyouchose5(verysatisﬁed)or4(satisﬁed), pleasechoosethereasonsforsatisfaction(multiple answersallowed).

1.Aestheticimprovement 61.3%

2.Easinessineyelidopening 73.7%

3.Enlargementofvisualﬁeld 59.3%

4.Relieffromstiff neck 14.9%

5.Relieffromheadache 13.4%

6.Decreasedforeheadwrinkle 18.0%

7.Other 4.6%

Question3:Ifyouchose2(dissatisﬁed)or1 (verydissatisﬁed),pleasechoosethereasonsfor dissatisfaction(multipleanswersallowed).

1.Aestheticproblem 67.3%

2.Insufﬁcientimprovementofptosis 49.1%

3.Dryeye 21.8%

4.Lacrimation 14.5%

5.Glare 18.2%

6.Painduringoperation 18.2%

7.Painafteroperation 20.2%

8.Other 36.4%

thequestionnairetogetherwithaninformedconsentforthe analysisoftheirdata.Thequestionnaireaskedthepatient about hisor hersatisfactionwithafive-pointLikertscale, from1(verydissatisfied) to5(verysatisfied).Thereasons for the satisfaction or dissatisfaction were also explored with multiple-choice questions. The average duration be- tweenthesurgeryandthesurveywas3.3±2.0years.

The response rate of the questionnaires was 57.8%

(259/448 patients). Ninety-two patients(35.5%) scored 5, 103patients(39.8%)scored4,ninepatients(3.5%)scored3, 44patients(17.0%)scored2,and11patients(4.2%)scored 1.Amongthereasonsforthesatisfaction,‘easinessineyelidopening’wasthemostcommonreason(73.7%),followed by ‘aesthetic improvement’ (61.3%) and ‘enlargement of visual ﬁeld’ (59.3%). Among the reasons for the dissatisfaction, ‘aestheticproblem’wasthemostcommonreason (67.3%), followed by ‘insufﬁcient improvement of ptosis’

(49.1%) (Table 1). Some dissatisﬁed patients reported de- tailedreasonssuchas‘asymmetryofeyelids’(19patients),

‘unexpected double eyelid’ (12 patients), ‘unnatural appearance’ (eightpatients),‘moreswellingthan expected’

(sevenpatients),‘largersubcutaneoushemorrhagethanex- pected’(threepatients),and‘operativescar’(onepatient).

Theageofthepatientsdidnotaffectthesatisfactionscore;

nordidthepatients’sex.Elevenplasticsurgeonswithvar- ious numbersof yearsofexperiencewereinvolved in this

patientpopulation.Allsurgeonsperformedlevatoraponeu- rosis surgery by means of a transcutaneous approach, as described previously.¹ There wasnosignificant difference in the satisfaction score amongthe 11 surgeons. The patients with severe blepharoptosis, defined as a marginal reflex distance <0mm, showed significantly higher satis- factionscores (4.13±1.08)comparedtothepatientswith non-severeblepharoptosis(3.71±1.22)(p=0.017).Among the 259 patients, 68 patients (26.3%) underwent a reoperation. The patients without reoperation showed significantly higher satisfaction scores (3.97±1.31) than those withreoperation(3.51±1.14)(p=0.006).Thereoperation ratein thedissatisfied group(score1,2)wassignificantly higher than that in the satisfied/neutral group (score 3, 4,5)(38.1%vs23.0%,p=0.024).

Questionnaireshavebeenusedbeforeforthepostoper- ativeevaluationofeyelidsurgery,buttherehavebeenfew studiesaboutpatientsatisfactionafterlevatoraponeurosis surgery.²^,³ No studies have analyzed the factors affecting the patientsatisfaction afterlevator aponeurosis surgery.

Since75.3%ofthepatientsin ourpresentstudyweresat- isfied(35.5%verysatisfiedand39.8%satisfied),thelevator aponeurosis surgery seems tobe satisfactory. Taherian et al.reportedpatientsatisfactionwithathree-stepgrading system, and stated that 59.3% of the patients scored the resultsasgood,8.7%assuboptimal,and32%aspoor.³ The satisfactionscoresarethussimilartothoseobtainedinour present investigation. Therewere nosignificant between- groupdifferencesinthepatientageorsexorthesurgeons inourstudy.Mehtaetal.describedthattherewasnosignif- icantdifferenceinblepharoptosisrepairoutcomesbetween trainees and experienced staff surgeons.⁴ Our previous study revealed thatthere wasnosignificant differencein therateof reoperationamongsurgeons.¹We believethat evenexperiencedsurgeonsencounter unexpectedandun- favorableresultsin levatoraponeurosissurgery.Here,the patients with severe blepharoptosis showed significantly highersatisfaction thanthose withnon-severeblepharoptosis.Amongthereasonsforthesatisfactionoftheformer group,functionalimprovementssuchas‘easinessineyelid opening’ and ‘enlargement of visual field’ were major reasons.Thepatientswithsevereptosisweremorelikelyto feelthefunctionalimprovementspostoperatively.Therate ofreoperationafterlevatoraponeurosissurgeryvariedfrom 8.7% to32.5%in previous reports,¹ andthecorresponding rate was 26.3% in this study. Although reoperation after levatoraponeurosissurgeryisunavoidabletosomeextent, we need to realize that the reoperation affects patient satisfaction, asshownby ourpresentfindings. Webelieve thatthebalancebetweentherightandleftsidesshouldbe carefullyadjustedintraoperativelytodecreasetherateof reoperation.

Funding

None.

Conﬂict of interest

None.

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References

1.SugaH,Ozaki M,NaritaK,etal.Preoperative asymmetryisa riskfactorforreoperationininvolutionalblepharoptosis.JPlast ReconstrAestheticSurg2017;70:686–91.

2.MahrooOA,HysiPG,DeyS,etal. Outcomesofptosissurgery assessedusingapatient-reportedoutcomemeasure:Anexplo- rationoftimeeffects.BrJOphthalmol2014;98:387–90. 3.TaherianK,AtkinsonPL,ShekarchianM,ScallyAJ.Comparative

studyofthesubjectiveandobjectivegradingofptosissurgery outcomes.Eye2007;21:639–42.

4.MehtaVJ,PerryJD.Blepharoptosisrepairoutcomesfromtrainee versusexperiencedstaff astheprimarysurgeon.AmJOpthal- mol2013;155:397–403.

DaisukeSato HirotakaSuga MineOzaki KeigoNarita TomohiroShiraishi KiyonoriHarii AkihikoTakushima DepartmentofPlasticSurgery,KyorinUniversitySchoolof Medicine,Tokyo,Japan E-mailaddress:[email protected](H.Suga)