7
Free style facial artery perforator flap for one stage reconstruction of the nasal ala * S. D’Arpa *, A. Cordova, R. Pirrello, F. Moschella Cattedra di Chirurgia Plastica e Ricostruttiva, Dipartimento di Discipline Chirurgiche ed Oncologiche, Universita`degli Studi di Palermo, Palermo, Italy Received 21 September 2007; accepted 10 June 2008 KEYWORDS Nasal ala reconstruction; Free style flap; Perforator flap; Nose reconstruction; Facial artery Summary The nasolabial skin is the ideal donor site for nasal ala reconstruction. The classic techniques involve a two-stage procedure to reconstruct an aesthetically pleasing nasal ala. A one-stage technique for reconstruction of the nasal ala with a free style nasolabial perfo- rator flap is presented in this article. Patients and methods: The technique has been used in eight patients between November 2004 and June 2007. In most of the cases (seven out of eight) the whole alar subunit was recon- structed. Results: Besides a small distal 2 mm necrosis in one flap e which healed without further treat- ment e all the flaps healed uneventfully with aesthetically pleasing results using the one-stage technique. Conclusions: The free style perforator nasolabial island flap has become the method of choice in the authors’ institution for nasal ala reconstruction, especially when the defect involves the whole subunit. It allows one-stage reconstruction with very similar tissue and a concealed scar in the natural groove. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. The nose is the most commonly affected area by basal and squamous skin carcinomas of the head and neck area. 1 Considering its colour and texture, and the possi- bility of hiding the scar in the nasolabial sulcus, the nasolabial skin is the ideal donor site for nasal ala recon- struction. The only drawback is that reconstruction of an aesthetically pleasing nasal ala usually requires two stages in order to reproduce a normal-looking alar-cheek groove, even when an island subcutaneous pedicle flap is used. As Taylor and Palmer 2 described, perforators always cross tissue planes in fixed areas of the body and the naso- labial sulcus is no exception to this rule (Figure 1). In this article, a perforator-based nasolabial flap is described for one-stage reconstruction of the nasal ala. * Presented in part at: Perforator Flaps: 1 Congresso Italiano sui Lembi Perforanti. Bologna 15e16 Dicembre 2006; 21st EWAPS meeting. Abano Terme, 4e7 July, 2007. * Corresponding author. Via Giovanni Pacini, 12, 90138 e Palermo, Italy. Tel.: þ39 3387475749; fax: þ39 0916553771. E-mail address: [email protected] (S. D’Arpa). 1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.06.057 Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 36e42

Free style facial artery perforator flap for one stage reconstruction of the nasal ala

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Page 1: Free style facial artery perforator flap for one stage reconstruction of the nasal ala

Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 36e42

Free style facial artery perforator flap for one stagereconstruction of the nasal ala*

S. D’Arpa *, A. Cordova, R. Pirrello, F. Moschella

Cattedra di Chirurgia Plastica e Ricostruttiva, Dipartimento di Discipline Chirurgiche ed Oncologiche,Universita degli Studi di Palermo, Palermo, Italy

Received 21 September 2007; accepted 10 June 2008

KEYWORDSNasal alareconstruction;Free style flap;Perforator flap;Nose reconstruction;Facial artery

* Presented in part at: Perforator FlLembi Perforanti. Bologna 15e16 Dmeeting. Abano Terme, 4e7 July, 200

* Corresponding author. Via GiovanniItaly. Tel.: þ39 3387475749; fax: þ39 0

E-mail address: turidarpa@hotmai

1748-6815/$-seefrontmatterª2008Bridoi:10.1016/j.bjps.2008.06.057

Summary The nasolabial skin is the ideal donor site for nasal ala reconstruction. The classictechniques involve a two-stage procedure to reconstruct an aesthetically pleasing nasal ala.A one-stage technique for reconstruction of the nasal ala with a free style nasolabial perfo-rator flap is presented in this article.Patients and methods: The technique has been used in eight patients between November 2004and June 2007. In most of the cases (seven out of eight) the whole alar subunit was recon-structed.Results: Besides a small distal 2 mm necrosis in one flap e which healed without further treat-ment e all the flaps healed uneventfully with aesthetically pleasing results using the one-stagetechnique.Conclusions: The free style perforator nasolabial island flap has become the method of choicein the authors’ institution for nasal ala reconstruction, especially when the defect involves thewhole subunit. It allows one-stage reconstruction with very similar tissue and a concealed scarin the natural groove.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

The nose is the most commonly affected area by basaland squamous skin carcinomas of the head and neckarea.1 Considering its colour and texture, and the possi-bility of hiding the scar in the nasolabial sulcus, the

aps: 1�Congresso Italiano suiicembre 2006; 21st EWAPS7.Pacini, 12, 90138 e Palermo,916553771.

l.com (S. D’Arpa).

tishAssociationofPlastic,Reconstruc

nasolabial skin is the ideal donor site for nasal ala recon-struction. The only drawback is that reconstruction of anaesthetically pleasing nasal ala usually requires twostages in order to reproduce a normal-looking alar-cheekgroove, even when an island subcutaneous pedicle flap isused.

As Taylor and Palmer2 described, perforators alwayscross tissue planes in fixed areas of the body and the naso-labial sulcus is no exception to this rule (Figure 1). In thisarticle, a perforator-based nasolabial flap is described forone-stage reconstruction of the nasal ala.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Page 2: Free style facial artery perforator flap for one stage reconstruction of the nasal ala

Figure 1 Left: fresh cadaver dissection shows a perforating artery (A) and vein (V). They usually lie in a row along the course ofthe facial artery from the mandible to the apex of the nasolabial sulcus and vary in number from four to eight perforators. Theveins are more numerous, as usual, and may lie both laterally and medially to the artery. Right: two perforator flaps harvestedin a fresh cadaver.

Free style facial artery perforator flap for nasal ala reconstruction 37

Patients and methods

From November 2004 to June 2007, the nasolabial perfo-rator flap was used in eight patients in the Plastic andReconstructive Surgery Department of the University ofPalermo. The flap was used in seven cases to reconstructthe whole alar unit and in one case for a partial defect. Thepatients’ ages ranged from 42 to 89 years (mean 75 years),with an equal gender distribution. Three patients (37.5%)were smokers and five patients (62.5%) were diabetics.Seven cases (87.5%) of basal cell carcinomas requiredpartial thickness resection. In one case non-anatomiccartilage strut graft in conjunction with the flap wasneeded. The remaining case was a squamous cell carcinomaand a partial thickness resection was performed in conjunc-tion with full-thickness resection of a portion of the alarrim.

In all the flaps a vein was identified. In five cases (62.5%)the nerves to the skin were preserved. Five flaps (62.5%)were thinned at a subcutaneous level, without reaching thesubdermal plexus. Flap sizes ranged between 0.5� 0.7 cmand 2.2� 1.6 cm (see Table 1).

Table 1 Patient data (BCC: basal cell carcinoma; SCC: squamo

N� Name Age Pathology Defect

1 LNA 42 BCC Whole alar subunit

2 QS 76 BCC Partial alaþ lateral wall3 BG 85 BCC Whole alaþ partial

lateral wall4 DS 83 SCC Whole alaþ full

thickness nostril margin5 GG 72 BCC Whole alar subunit

6 IS 89 BCC Whole alar subunit7 LS 63 BCC Partial alar8 TS 72 BCC Whole alar subunit

Surgical technique

The skin cancers were excised with adequate marginsand the whole alar subunit was resected for optimaloutcome.

A Doppler probe was used to identify the perforator.Even if the underlying facial artery was very superficial, theperforators could easily be distinguished from it witha common hand-held Doppler probe.

The flap is drawn around the perforator with its medialmargin lying in the nasolabial sulcus (Figure 2, upper left).At this point only one margin of the flap, usually the medialone, is raised to look for the perforators, as in any otherfree style flap. This will not impede the harvesting ofa random pattern nasolabial flap, which is always kept asa life-line in case the perforator is accidentally cut.

Perforators usually lie in a row underneath the nasola-bial sulcus. The cranial-most one is normally chosenbecause movement is easier with it. Once the perforatingartery is identified, the flap is incised circumferentially(Figure 2, upper right) in order to identify the vein, whichusually lies laterally.

us cell carcinoma)

Flap design Sensate Complications

Propeller 180� þ nonanatomical cartilagestrut graft

No None

Island transposition No NonePropeller 180� Yes None

Propeller 180� Yes None

Propeller 180� Yes Venous congestionand 2 mm distal necrosis

V-Y advancement No NoneV-Y advancement Yes NonePropeller 180� Yes None

Page 3: Free style facial artery perforator flap for one stage reconstruction of the nasal ala

Figure 2 Upper left: surgical defect and drawing of the flap after excision of a basal cell carcinoma. The ‘X’ indicates the perfo-rator identified with a hand-held Doppler probe. The striped triangle is the area to be excised in order to avoid dog ears. Upperright: once the vessels are identified the flap’s margins may be incised circumferentially. Lower left: flap thickness before trim-ming. Lower right: the flap and the donor site at the end of the operation.

38 S. D’Arpa et al.

The venous branches which lie medially, will be sacri-ficed because they will restrict the arc of rotation. It isimportant during vessel dissection that sensory branches tothe skin are identified and preserved. These branchesusually lie between the artery and the vein e and thus donot normally interfere with rotation e and can easily beidentified with loupe magnification.

Figure 3 Left: venous congestion on the fifth postoperative day,taneously with only a distal 2 mm necrosis. Middle: preoperative lthree-quarter view. This was the only case in which we had a comled to a defect in the converse triangle. The patient, however, did

At this point, further perforator length may be neededto achieve optimal tension-free movement: if the vesselsare not musculocutaneous perforators, they are freed fromthe surrounding tissue and even followed down to the facialvessels, in order to improve the arc of rotation and to avoidkinking or torsion of the pedicle (Figure 2, lower left).When musculocutaneous perforators are present through

caused by excessive trimming (see text), which resolved spon-eft three-quarter view. Right: seven months postoperative leftplication: a venous congestion causing a small necrosis whichnot complain about the result.

Page 4: Free style facial artery perforator flap for one stage reconstruction of the nasal ala

Free style facial artery perforator flap for nasal ala reconstruction 39

the levator labii superioris muscle, they may be easilydissected through the muscle. It is not advisable to harvesta cuff of muscle around the vessels because it may causepedicle torsion or kinking. The flap is then transferred tocover the defect. The vessels, especially the vein, arechecked at this point to avoid deleterious torsion or kink-ing. If kinking or torsion is present, the vessels must befreed further. The flap is eventually inset and sutured tothe defect. The donor site is closed primarily and the shapeof the ala, thanks to the freedom in movement and designof the island flap, may be adequately reconstructed in oneprocedure (Figure 2, lower right).

Care must be taken to reproduce a nice alar-cheekjunction, which is the region that most frequently requiresa second stage when a classic nasolabial flap (either witha skin or a subcutaneous pedicle) is used.

Figure 4 Upper left: two basal cell carcinomas of the tip (closedstruction. Upper middle: intraoperative planning of the flap. The caative view after completion of vessels dissection. One artery (medpedicle is cut. Lower left: 31 months postoperative frontal view.right: 31 months postoperative left three-quarter view.

Results

The follow up of the eight patients ranged between 3 and31 months (mean 16 months).

All the flaps were based on a single arterial and a singlevenous perforator.

A perforating vein lying medial to the artery was usedonly in one case (12.5%), whilst in the remaining sevencases (87.5%) the vein lateral to the artery was considered.

The flaps were harvested as a propeller 180� flap in fivecases (67.5%), a V-Y advancement flap in two cases (25%),and a simple island transposition in one case (12.5%).

Most of the flaps (seven out of eight) healed unevent-fully. One flap had a 2 mm distal necrosis and this was dueto overzealous thinning of the flap with injury to thesubdermal venous plexus. This (Figure 3, left) led to a small

primarily) and of the ala requiring subunit resection and recon-udal triangle is the area to be excised. Upper right: intraoper-

ial) and one vein (lateral) are identified before the cranial skinThis result has been obtained with only one operation. Lower

Page 5: Free style facial artery perforator flap for one stage reconstruction of the nasal ala

40 S. D’Arpa et al.

necrosis causing a lack of tissue in the converse triangle(Figure 3, right). Despite this, the patient was pleasedwith the final result.

A slight pin cushioning effect was observed only in onecase (12.5%) a month post reconstruction but it hasspontaneously resolved within 3 months.

No revisions to improve aesthetic outcome were neededin this case series.

Aesthetic results were satisfactory in all cases asdeemed by both surgeons and patients (Figures 3 and 4).

In five cases, the nerves were preserved and painsensitivity (pain at pinprick) was present from the firstpostoperative day. At 3 months, the sensitivity was presentin the innervated flaps and not in the non-innervated ones.While in the first period there is an advantage of innervatedflaps over non-innervated, at 1 year follow up sensitivity is,both in cases of innervated and non-innervated flaps,comparable (it has the same two point discriminationresult), to the contralateral ala and to the ipsilateral cheek(which is the donor site) (Table 2). It is worthy of note thatpatients who had innervated flaps were not able to

Table 2 Sensitivity testing. In patient no. 2 the flap was too small tered. Patients 3,4,5,7 and 8 had a sensate flap. The advantage of haviWithin one year, probably due to reinnervation and thanks to their l

Patient Day 1 Region tested

1 No pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

2 No pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

3 Pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

4 Pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

5 Pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

6 No pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

7 Pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

8 Pain sensation inthe flap at pinprick

FlapIpsilateral cheekContralateral alaContralateral cheek

distinguish between the reconstructed ala and the donorsite: when touched in the reconstructed ala (flap), theystated they were being touched in the cheek (donor site).After 3 weeks, they were able to tell the differencebetween sensation in the reconstructed ala (flap) and thedonor site.

Average operating time was 90 min (range 75e120 min),which included excision, planning and reconstruction.

Discussion

The nasolabial flap has been described for nose reconstruc-tion from as early as 1840.3 Since then, with all its modifi-cations, it is the workhorse for nasal ala reconstruction. Itprovides skin of similar texture and colour allowing primaryclosure of the donor site and a concealed scar in a naturalfold. Furthermore, due to the laxity of cheek tissues, thereis enough tissue to reconstruct the whole ala. The possi-bility of concealing the scar makes this flap much moreappealing to the patient than the forehead flap.

o measure two point discrimination. The patient was not consid-ng the flap sensate seems to be evident only during the first year.imited size, even non-sensate flaps seem to recover well

Two-point discrimination at3 months (in mm)

Two-point discrimination at1 year (in mm)

Not present 1518 1813 1312 12Too small to measure Too small to measure

6 66 64 46 64 46 64 46 66 66 66 66 6

Not present 88 88 86 6

10 109 10

12 1212 126 68 86 68 8

Page 6: Free style facial artery perforator flap for one stage reconstruction of the nasal ala

Free style facial artery perforator flap for nasal ala reconstruction 41

The only drawback of the flap is that it usually requiresa second operation to resect the pedicle to improve shapeand aesthetics. Even when harvested as an island subcuta-neous pedicle flap, the arc of rotation and mobility are notsufficient to allow one-stage reconstruction.

In this era of perforator flaps, thorough knowledge ofskin vascularisation is available and, therefore, randomflaps should be avoided whenever possible.

The vessels are the only pivot which makes the flap veryversatile and the reconstruction safer and more elegant.

Even if, in some cases, harvesting a perforator flap maybe unnecessary, there are several advantages to usinga perforator flap for nasal ala reconstruction.

The first and most important reason is that the operationbecomes a one-stage procedure.

Second, the sensory nerve to the flap may be identifiedand preserved. Sensitivity will never fade in these casesand the reconstruction will be more functional from thebeginning. After 1 year, no significant advantage has beenobserved between innervated and non-innervated flaps interms of two point discrimination.

Third, the free style design makes it possible to havethe highest freedom in designing the flap shape and itsarc of rotation, making it possible to choose the bestdesign needed to cover the defect without compromisingprimary closure. The pivot of the flap is determined onlyby the perforating vessels, which will give the leastrestriction of movement when compared to cutaneousor subcutaneous pedicle flaps. As a consequence, distor-tions and cosmetic defects due to excess rotation andpedicle bulk are not observed with this flap. In ourexperience, the best results are achieved with a propeller180� design.

Lastly, careful dissection always allows identificationof at least one vein which will drain the skin flapthrough subcutaneous venous plexus and avoids harvest-ing a bulky pedicle. The pedicle may thus be freed inorder to give the flap the widest arc of rotationpossible. Dissection may also be carried out all theway down to the facial vessels in order to furtherimprove the arc of rotation. In the formerly describedsubcutaneous pedicle nasolabial flap,4,5 the lateral nasalartery nasolabial island flap6 or even in the facial arteryperforator flap,7 the flap relied on a random venousoutflow carried by the subcutaneous tissue surroundingthe pedicle, as in digital island flaps.8

We prefer this technique over the classic nasolabialflap and its modifications4,5,9e14 because it is a one-stage procedure and the flap has by far a wider arc ofrotation.

The only drawbacks of this flap are the operatingtime, which can be longer when compared to non-perforator options, and the need for perforator dissec-tion. These are not relevant at all in our opinion,because with this technique, the second stage of a classicnasolabial flap is avoided. Perforator vessel dissection canbe very straightforward with or without the aid of loupemagnification.

An alternative surgical option may be the forehead flapwhich, besides being at least a two-stage operation, alsogives a forehead scar which is not always accepted by thepatient.

We have no experience with the zygomatic flapdescribed by Gardetto et al.,15 which could be a valuableoption. We have never used it because venous outflow isunclear to us and so is the arc of rotation and the applica-bility to defects of the nasal ala.

The lateral nasal artery pedicle nasolabial flap6 relies ona subcutaneous venous outflow and mandates division ofthe levator labii superioris and zygomaticus minor muscles,which is not needed with the nasolabial perforator flapdescribed in this paper.

All the local options that use flaps harvested from thenose are of less value, especially when the whole subunitrequires reconstruction, as they cause scarring of the noseand distortion of the reconstructed ala due to the poorlaxity of the nasal skin.

Whether it is correct or not to call this flap a perforatormay be subject to debate. As to the Gent ConsensusConference,16 a perforator should pierce the deep fasciabefore reaching the skin. As there is no deep fascial layerin the face, and as the vessels pierce the superficialmuscular aponeurotic system (SMAS) layer before reachingthe skin (sometimes requiring intramuscular dissection),we believe that this flap may have the right to be calleda perforator flap.

In conclusion, due to its reliable vascularisation, thepossibility of performing a safe one-stage technique withsensation preservation but at the expense of anincreased operating time, the free style nasolabialperforator flap has become the method of choice fornasal ala reconstruction in our institution. Its idealapplication is the reconstruction of the whole subunitof the nasal ala.

References

1. Kopf AW. Computer analysis of 3531 basal-cell carcinomas ofthe skin. J Dermatol 1979;6:267e81.

2. Taylor G, Palmer J. The vascular territories (angiosomes) of thebody: experimental study and clinical applications. Br J PlastSurg 1987;40:113e41.

3. Wesser DR, Burt Jr GB. Nasolabial flap for losses of the nasal alaand columella. Case report. Plast Reconstr Surg 1969;44:300e2.

4. Herbert DC, DeGeus J. Nasolabial subcutaneous pedicle flaps.Br J Plast Surg 1975;28:90e6.

5. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicleflaps. Br J Plast Surg 1975;28:85e9.

6. Turan A, Kul Z, Turkaslan T, et al. Reconstruction of lower halfdefects of the nose with the lateral nasal artery pedicle naso-labial island flap. Plast Reconstr Surg 2007;119:1767e72.

7. Hofer SO, Posch NA, Smit X. The facial artery perforator flapfor reconstruction of perioral defects. Plast Reconstr Surg2005;115:996e1003 [discussion: 1004e1005].

8. Adani R, Busa R, Scagni R, et al. The heterodigital reversedflow neurovascular island flap for fingertip injuries. J HandSurg [Br] 1999;24:431e6.

9. Cameron RR, Latham WD, Dowling JA. Reconstructions of thenose and upper lip with nasolabial flaps. Plast Reconstr Surg1973;52:145e50.

10. Guerrerosantos J, Dicksheet S. Nasolabial flap with simulta-neous cartilage graft in nasal alar reconstruction. Clin PlastSurg 1981;8:599e602.

11. Kroll SS. Nasal alar reconstruction using the nasolabial turnoverflap. Laryngoscope 1991;101:1127e31.

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42 S. D’Arpa et al.

12. McLaren LR. Nasolabial flap repair for Alar Margin defects. Br JPlast Surg 1963;16:234e8.

13. Rohrich RJ, Conrad MH. The superiorly based nasolabial flap forsimultaneous alar and cheek reconstruction. Plast ReconstrSurg 2001;108:1727e30. quiz 1731.

14. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flapfor reconstruction of lateral alar defects. Plast Reconstr Surg1987;79:915e20.

Figure 1 (a) The figure shows how after opening the peri-ostium/pericondrium the Backhaus’s tips have to be posi-tioned before applying pressure on it. (b) The figure showsthe bone’s segment removed by using the instruments.

15. Gardetto A, Erdinger K, Papp C. The zygomatic flap:a further possibility in reconstructing soft-tissue defectsof the nose and upper lip. Plast Reconstr Surg 2004;113:485e90.

16. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The ‘‘Gent’’consensus on perforator flap terminology: preliminary defini-tions. Plast Reconstr Surg 2003;112:1378e83. quiz 1383,1516; [discussion: 1384e1377].

SURGICAL TIP

Exposure of the IMA made easy

Internal mammary arteries and veins are commonly usedas recipient vessels for free-flap breast reconstruction.1,2

The dissection technique, in some cases, may requirethe removal of a small segment of a rib, for adequateexposure of the vessels. The rib is usually removed usinga bottoming drill, or is ‘grabbed’ with a Luer. In thelatter case, we used a Backhaus instrument to break andremove the rib.

After opening the periostium, we used the Backhausforceps to hold the rib and noticed that it could bebroken easily.

While gently pulling upwards, and applying pressure onthe Backhaus eye-ring at the same time (Figure 1a), it waspossible for the tips of the instrument to enter the rib andremove the costal cartilage gently - and with ease e allow-ing a small section of the rib to be taken (Figure 1b).

Using this technique, we carefully removed the bone,and preserved the internal periostium/pericondrium of

the rib, thus allowing the continuation of thevessels’harvest.

The direct view of Backhaus entrance points on therib, made the cartilage removal easy.

This method may be useful, as it was in this case,whenever appropriate instruments are not available.

References

1. Clark C.P., Pittman C.E., Rohric R.J., et al. The internalmammary vein: an anatomic study. Presented at the 10thAnnual Meeting of the American Society for the Reconstruc-tive Microsurgery, Marco Island, Fla., January 1995.

2. Dupin CL, Allen RJ, Glass CA, et al. The internal mammaryartery and vein as a recipient for free-flap breast reconstruc-tion: a report of 110 consecutive cases. Plast Reconstr Surg1996;98:685.

Emanuele CignaDepartment of Plastic Surgery, ‘‘La Sapienza’’

University, Rome, Italy

Diego RibuffoSection of Plastic Surgery, Cagliari University Hospital,

Cagliari, ItalyE-mail address: [email protected]

Federico CorriasDepartment of Plastic Surgery, ‘‘La Sapienza’’ Univer-

sity, Rome, Italy

Francesco SerratoreSection of Plastic Surgery, Cagliari University Hospital,

Cagliari, Italy

Nicolo ScuderiDepartment of Plastic Surgery, ‘‘La Sapienza’’

University, Rome, Italy

ª 2008 British Association of Plastic, Reconstructive andAesthetic Surgeons. Published by Elsevier Ltd. All rightsreserved.

doi:10.1016/j.bjps.2008.06.026