Volume 134, Number 2 • Letters Reply: Use of Polyglycolic Acid Nerve Conduit (Neurotube) to Alleviate Pedicle Kinking in Microvascular Anastomosis Sir:
We appreciate the opportunity to comment on the recent letter by Dr. Sapountzis and colleagues, wherein the authors described a novel technique of preventing kinking in a free flap pedicle by affixing a 4-0 polydioxanone (Ethicon, Inc., Somerville, N.J.) suture to the adventitia of the anastomotic segment using a 9-0 nylon suture. This is an elegant, low-cost solution to pedicle kinking that is effective according to the authors’ series of 11 patients treated with this technique. This adds at least a small degree of technical difficulty and a possible risk of injury to the endothelium, either by suture trauma or increased manipulation of the vessels, which could potentially cause thrombus formation. In addition, the use of polydioxanone suture material as an external “rod” exploits the intrinsic memory of the suture, yet the ex vivo memory may not be generalizable in vivo, because heat, moisture, and mechanical forces will lessen its memory. We recently described a simple technique using a polyglycolic acid nerve conduit (Neurotube; Synovis, Birmingham, Ala.) for the same indication. We split the Neurotube longitudinally and ensheathed the anastomotic segment within the tube with minimal added manipulation of the pedicle. Although compression of the vascular pedicle is theoretically a risk of using this device, we did not appreciate any compression intraoperatively, nor were flap-related complications noted postoperatively. The Neurotube is available in different diameters that can accommodate larger or smaller vessel diameters to address this concern. Increased cost of the device is a legitimate drawback of this technique, but for the right patients, this technique will provide added mechanical support of the pedicle, with minimal clinical risks. Both approaches appear to be viable options for a commonly encountered yet incompletely studied problem. DOI: 10.1097/PRS.0000000000000389
Michael A. Holliday, M.D. MedStar Georgetown University Hospital Washington, D.C.
Steven P. Davison, M.D., D.D.S. DAVinci Plastic Surgery Washington, D.C. Correspondence to Dr. Davison DAVinci Plastic Surgery 3301 New Mexico Avenue, NW #236 Washington, D.C. 20016 [email protected]
DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication.
Nanofat Grafting: Basic Research and Clinical Applications Sir: t was interesting to read the article titled “Nanofat Grafting: Basic Research and Clinical Applications.”1 Clinical application of fat grafting has changed over the years from autologous fat aspirate to adiposederived stem cell therapy. The authors have developed a simple technique of clinically useful adipose-derived stem cell concentrate without the need for complex isolation procedures. This will not only overcome the difficulty in injecting the fat with a fine needle, but also reduces the technical and ethical issues involved with the use of adipose-derived stem cells. However, the scientific validity of the terminology “nanofat grafting” is questionable. We feel “supermicrofat grafting” will be a better term for this innovative technique. Autologous fat grafting has become the standard technique for filling soft-tissue defects using the Coleman technique.2 In this technique, fat is harvested with a 3-mmdiameter cannula with a 2-mm side hole and injected with large cannulas. This macrofat does not allow subdermal injection using small cannulas. Trepsat3 described the microfat graft technique in which fat was harvested with a 2-mm-diameter cannula with 1-mm side holes. Nguyen et al.4 used the microfat technique by multiperforated cannula with 600-μm-diameter holes and injected with a 25-gauge cannula (inner diameter, 260 μm). This facilitated very superficial and subdermal injection of fat. Tonnard et al.1 mechanically emulsified fat and filtered it with a sterile nylon cloth with a 500-μm pore size. The effluent collected is called “ nanofat” and injected with a 27-gauge needle (inner diameter, 210 μm). They have used 70-μm filters for isolation of stem cells (size range, 10 to 15 μm) during cell culture. Because the so-called nanofat is in fact in the micrometer range, we propose the term supermicrofat grafting for this technique to differentiate it from the microfat grafting technique and to avoid confusing it with nanotechnology. We feel the scientific terms should be precise and without any ambiguity. A nanometer is one billionth of a meter. Use of materials at the nanoscale has led to expansion of nanotechnology in various scientific fields, including medicine. There are many diverse perspectives on nanotechnology, which necessitated a common definition for nanoscale. The U.S. government defines nanotechnology as science, engineering, and technology conducted at the nanoscale, which is approximately 1 to 100 nm.5 With this definition, we cannot even include isolated stem cells in the nanoscale. We hope the terminology of supermicrofat will reduce the confusion of equating emulsified fat aspirate to nanotechnology.
I
DOI: 10.1097/PRS.0000000000000333
M. T. Friji, M.S., M.Ch. Department of Plastic Surgery Jawaharlal Institute of Postgraduate Medical Education and Research Pondicherry 605006, India [email protected]
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Plastic and Reconstructive Surgery • August 2014 DISCLOSURE The author has no conflict of interest with respect to this communication. REFERENCES 1. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H. Nanofat grafting: Basic research and clinical applications. Plast Reconstr Surg. 2013;132:1017–1026. 2. Coleman SR. Structural fat grafts: The ideal filler? Clin Plast Surg. 2001;28:111–119. 3. Trepsat F. Midface reshaping with micro-fat grafting (in French). Ann Chir Plast Esthet. 2009;54:435–443. 4. Nguyen PS, Desouches C, Gay AM, Hautier A, Magalon G. Development of micro-injection as an innovative autologous fat graft technique: The use of adipose tissue as dermal filler. J Plast Reconstr Aesthet Surg. 2012;65:1692–1699. 5. Nano.gov. National Nanotechnology Initiative. What is nanotechnology? (Online). Available at: http://www.nano.gov/ nanotech-101/what/definition. Accessed January 25, 2014.
The Best Marketing Strategy in Aesthetic Plastic Surgery: Evaluating Patients’ Preferences by Conjoint Analysis Sir: read with great interest the article published by Marsidi et al. in the January of 2014 issue entitled “The Best Marketing Strategy in Aesthetic Plastic Surgery: Evaluating Patients’ Preferences by Conjoint Analysis.”1 I applaud the authors’ effort in supporting a customer-based business model, which I believe should be considered the criterion standard for marketing and survival of a plastic surgery practice with a high cosmetic surgery clientele. Steve Blank, an entrepreneur, professor, and pioneer of the customer development movement, emphasizes how this novel business model increases the chances of business survival by emphasizing an obsessive pattern of data gathering, and constant interaction with the customers.2 The old product-based model is outdated, and plastic surgeons wanting to stay competitive in the marketplace for cosmetic surgery patients would be well advised to adjust to this modern concept. The authors have documented the relative attribute importance of six variables, including treatment costs, travel time, years in practice, size of the clinic, method of referral, and online presentation. To my surprise, having an online presence had the second lowest attribute importance (9.5 percent).1 Interestingly enough, if you were to ask most graduating plastic surgery residents in the United States going into private practice about the first thing they are going to do for their practice, the answer most likely would be, “I am going to develop my Web site.” I understand this study was performed in The Netherlands and the results might not completely translate to our market, but if we assume that we would see the same results in our country, spending a significant amount of money on developing a Web site is not going to have a significant
impact on your practice. This is how the interpretation of quantitative data analysis such as that described in this study can become very helpful. Although I agree with the concept, I found the process of ranking the likelihood of visiting the cosmetic surgery clinic in the scenario in Figure 1 very confusing. Conjoint analysis as very well depicted in the Discussion has several pitfalls, including the magnitude of scenarios developed to evaluate even the small number of attributes chosen in this article. In an effort to maximize the number of respondents, the authors had to reduce the number of scenarios from 288 to 18 using a random pattern design that could have influenced the results and conclusions. I would not go as far as saying that a conjoint analysis is “the best marketing strategy,” but I definitely agree with the conclusion that a paradigm shift in the business model of cosmetic surgery practices is needed. This new customer-based model should emphasize a continuous effort in gathering patient data to help us tailor our marketing strategies to what our customers want. DOI: 10.1097/PRS.0000000000000332
Jose R. Rodriguez-Feliz, M.D.
Division of Plastic Surgery Albany Medical College 50 New Scotland Avenue, MC-190 Albany, N.Y. 12208 [email protected]
I
334e
DISCLOSURE The author has no financial interest in any of the products or devices mentioned in this communication. REFERENCES 1. Marsidi N, van den Bergh MW, Luijendijk RW. The best marketing strategy in aesthetic plastic surgery: Evaluating patients’ preferences by conjoint analysis. Plast Reconstr Surg. 2014;133:52–57. 2. Blank S. Why the lean start-up changes everything. Harv Bus Rev. 2013;91:63–72.
Reply: The Best Marketing Strategy in Aesthetic Plastic Surgery: Evaluating Patients’ Preferences by Conjoint Analysis Sir:
We would like to thank Dr. Rodriguez-Feliz for his “helicopter” view on customer-based business models in aesthetic plastic surgery. We agree that a customerbased rather than product-based business model should be considered the criterion standard for marketing of an aesthetic surgery clinic. Our study has focused on patients’ decisions and provides several recommendations for customer-based aesthetic plastic surgery marketing.1 We have analyzed the decision making of patients when choosing an aesthetic clinic using conjoint
We appreciate the opportunity to comment on the recent letter by Dr. Sapountzis and colleagues, wherein the authors described a novel technique of preventing kinking in a free flap pedicle by affixing a 4-0 polydioxanone (Ethicon, Inc., Somerville, N.J.) suture to the adventitia of the anastomotic segment using a 9-0 nylon suture. This is an elegant, low-cost solution to pedicle kinking that is effective according to the authors’ series of 11 patients treated with this technique. This adds at least a small degree of technical difficulty and a possible risk of injury to the endothelium, either by suture trauma or increased manipulation of the vessels, which could potentially cause thrombus formation. In addition, the use of polydioxanone suture material as an external “rod” exploits the intrinsic memory of the suture, yet the ex vivo memory may not be generalizable in vivo, because heat, moisture, and mechanical forces will lessen its memory. We recently described a simple technique using a polyglycolic acid nerve conduit (Neurotube; Synovis, Birmingham, Ala.) for the same indication. We split the Neurotube longitudinally and ensheathed the anastomotic segment within the tube with minimal added manipulation of the pedicle. Although compression of the vascular pedicle is theoretically a risk of using this device, we did not appreciate any compression intraoperatively, nor were flap-related complications noted postoperatively. The Neurotube is available in different diameters that can accommodate larger or smaller vessel diameters to address this concern. Increased cost of the device is a legitimate drawback of this technique, but for the right patients, this technique will provide added mechanical support of the pedicle, with minimal clinical risks. Both approaches appear to be viable options for a commonly encountered yet incompletely studied problem. DOI: 10.1097/PRS.0000000000000389
Michael A. Holliday, M.D. MedStar Georgetown University Hospital Washington, D.C.
Steven P. Davison, M.D., D.D.S. DAVinci Plastic Surgery Washington, D.C. Correspondence to Dr. Davison DAVinci Plastic Surgery 3301 New Mexico Avenue, NW #236 Washington, D.C. 20016 [email protected]
DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication.
Nanofat Grafting: Basic Research and Clinical Applications Sir: t was interesting to read the article titled “Nanofat Grafting: Basic Research and Clinical Applications.”1 Clinical application of fat grafting has changed over the years from autologous fat aspirate to adiposederived stem cell therapy. The authors have developed a simple technique of clinically useful adipose-derived stem cell concentrate without the need for complex isolation procedures. This will not only overcome the difficulty in injecting the fat with a fine needle, but also reduces the technical and ethical issues involved with the use of adipose-derived stem cells. However, the scientific validity of the terminology “nanofat grafting” is questionable. We feel “supermicrofat grafting” will be a better term for this innovative technique. Autologous fat grafting has become the standard technique for filling soft-tissue defects using the Coleman technique.2 In this technique, fat is harvested with a 3-mmdiameter cannula with a 2-mm side hole and injected with large cannulas. This macrofat does not allow subdermal injection using small cannulas. Trepsat3 described the microfat graft technique in which fat was harvested with a 2-mm-diameter cannula with 1-mm side holes. Nguyen et al.4 used the microfat technique by multiperforated cannula with 600-μm-diameter holes and injected with a 25-gauge cannula (inner diameter, 260 μm). This facilitated very superficial and subdermal injection of fat. Tonnard et al.1 mechanically emulsified fat and filtered it with a sterile nylon cloth with a 500-μm pore size. The effluent collected is called “ nanofat” and injected with a 27-gauge needle (inner diameter, 210 μm). They have used 70-μm filters for isolation of stem cells (size range, 10 to 15 μm) during cell culture. Because the so-called nanofat is in fact in the micrometer range, we propose the term supermicrofat grafting for this technique to differentiate it from the microfat grafting technique and to avoid confusing it with nanotechnology. We feel the scientific terms should be precise and without any ambiguity. A nanometer is one billionth of a meter. Use of materials at the nanoscale has led to expansion of nanotechnology in various scientific fields, including medicine. There are many diverse perspectives on nanotechnology, which necessitated a common definition for nanoscale. The U.S. government defines nanotechnology as science, engineering, and technology conducted at the nanoscale, which is approximately 1 to 100 nm.5 With this definition, we cannot even include isolated stem cells in the nanoscale. We hope the terminology of supermicrofat will reduce the confusion of equating emulsified fat aspirate to nanotechnology.
I
DOI: 10.1097/PRS.0000000000000333
M. T. Friji, M.S., M.Ch. Department of Plastic Surgery Jawaharlal Institute of Postgraduate Medical Education and Research Pondicherry 605006, India [email protected]
333e
Plastic and Reconstructive Surgery • August 2014 DISCLOSURE The author has no conflict of interest with respect to this communication. REFERENCES 1. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H. Nanofat grafting: Basic research and clinical applications. Plast Reconstr Surg. 2013;132:1017–1026. 2. Coleman SR. Structural fat grafts: The ideal filler? Clin Plast Surg. 2001;28:111–119. 3. Trepsat F. Midface reshaping with micro-fat grafting (in French). Ann Chir Plast Esthet. 2009;54:435–443. 4. Nguyen PS, Desouches C, Gay AM, Hautier A, Magalon G. Development of micro-injection as an innovative autologous fat graft technique: The use of adipose tissue as dermal filler. J Plast Reconstr Aesthet Surg. 2012;65:1692–1699. 5. Nano.gov. National Nanotechnology Initiative. What is nanotechnology? (Online). Available at: http://www.nano.gov/ nanotech-101/what/definition. Accessed January 25, 2014.
The Best Marketing Strategy in Aesthetic Plastic Surgery: Evaluating Patients’ Preferences by Conjoint Analysis Sir: read with great interest the article published by Marsidi et al. in the January of 2014 issue entitled “The Best Marketing Strategy in Aesthetic Plastic Surgery: Evaluating Patients’ Preferences by Conjoint Analysis.”1 I applaud the authors’ effort in supporting a customer-based business model, which I believe should be considered the criterion standard for marketing and survival of a plastic surgery practice with a high cosmetic surgery clientele. Steve Blank, an entrepreneur, professor, and pioneer of the customer development movement, emphasizes how this novel business model increases the chances of business survival by emphasizing an obsessive pattern of data gathering, and constant interaction with the customers.2 The old product-based model is outdated, and plastic surgeons wanting to stay competitive in the marketplace for cosmetic surgery patients would be well advised to adjust to this modern concept. The authors have documented the relative attribute importance of six variables, including treatment costs, travel time, years in practice, size of the clinic, method of referral, and online presentation. To my surprise, having an online presence had the second lowest attribute importance (9.5 percent).1 Interestingly enough, if you were to ask most graduating plastic surgery residents in the United States going into private practice about the first thing they are going to do for their practice, the answer most likely would be, “I am going to develop my Web site.” I understand this study was performed in The Netherlands and the results might not completely translate to our market, but if we assume that we would see the same results in our country, spending a significant amount of money on developing a Web site is not going to have a significant
impact on your practice. This is how the interpretation of quantitative data analysis such as that described in this study can become very helpful. Although I agree with the concept, I found the process of ranking the likelihood of visiting the cosmetic surgery clinic in the scenario in Figure 1 very confusing. Conjoint analysis as very well depicted in the Discussion has several pitfalls, including the magnitude of scenarios developed to evaluate even the small number of attributes chosen in this article. In an effort to maximize the number of respondents, the authors had to reduce the number of scenarios from 288 to 18 using a random pattern design that could have influenced the results and conclusions. I would not go as far as saying that a conjoint analysis is “the best marketing strategy,” but I definitely agree with the conclusion that a paradigm shift in the business model of cosmetic surgery practices is needed. This new customer-based model should emphasize a continuous effort in gathering patient data to help us tailor our marketing strategies to what our customers want. DOI: 10.1097/PRS.0000000000000332
Jose R. Rodriguez-Feliz, M.D.
Division of Plastic Surgery Albany Medical College 50 New Scotland Avenue, MC-190 Albany, N.Y. 12208 [email protected]
I
334e
DISCLOSURE The author has no financial interest in any of the products or devices mentioned in this communication. REFERENCES 1. Marsidi N, van den Bergh MW, Luijendijk RW. The best marketing strategy in aesthetic plastic surgery: Evaluating patients’ preferences by conjoint analysis. Plast Reconstr Surg. 2014;133:52–57. 2. Blank S. Why the lean start-up changes everything. Harv Bus Rev. 2013;91:63–72.
Reply: The Best Marketing Strategy in Aesthetic Plastic Surgery: Evaluating Patients’ Preferences by Conjoint Analysis Sir:
We would like to thank Dr. Rodriguez-Feliz for his “helicopter” view on customer-based business models in aesthetic plastic surgery. We agree that a customerbased rather than product-based business model should be considered the criterion standard for marketing of an aesthetic surgery clinic. Our study has focused on patients’ decisions and provides several recommendations for customer-based aesthetic plastic surgery marketing.1 We have analyzed the decision making of patients when choosing an aesthetic clinic using conjoint
