Plastic and Reconstructive Surgery • February 2014 Numerous studies have documented significant risks associated with combined breast augmentation and mastopexy.1–3 Even studies that have advocated combined augmentation/mastopexy have also reported rather prohibitively high morbidity rates.4–6 This large study shows that the two-stage option may prove beneficial to many women seeking primarily volume increase. Analysis of outcome in cosmetic surgery is based on the assumption that patients will return for secondary surgery rather than go elsewhere. With this in mind, adopting a policy of breast augmentation as an initial treatment strategy works well and is acceptable for most women with breast ptosis. Variations in patient demographic profiles and cultural diversity determine how postoperative ptosis is perceived or accepted by patients. In our practice, a two-stage breast augmentation/mastopexy policy has meant breast augmentation with no further surgery for most of our patients. In view of the increased morbidity rate of the combined procedure, we believe it is important not to deny women who are primarily seeking an increase in volume the option of augmentation alone, and we suggest offering delayed mastopexy at a reduced cost in order to reassure patients that they will not lose out financially. The high revision rate7 for one-stage breast augmentation/mastopexy may also offset the apparent cost savings of this procedure. In conclusion, offering breast augmentation in women with ptosis may result in fewer mastopexies being performed and reduced morbidity rates while remaining aesthetically acceptable. DOI: 10.1097/01.prs.0000434414.63088.56

Bassem Nathan, F.R.C.S. Riverside Hospital London, United Kingdom

Mark Mikhail Imperial College London London, United Kingdom

Zachary Nash Lawrence Mascarenhas, M.D. Guy’s and St Thomas’s Hospital London, United Kingdom Correspondence to Dr. Nathan Riverside Hospital Great West Road London TW8 9DR, United Kingdom [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this article and received no funding for this study. REFERENCES 1. Eagan SL, Atashroo DA, Puckett CL, Henry, SL. Concurrent Podium Paper Sessions: Scientific Session 5C: Clinical Research Outcomes 68C: Combined augmentation mastopexy. Plast Reconstr Surg 2010;125:50.


2. Codner MA, Mejia JD, Locke MB, et  al. A 15-year experience with primary breast augmentation. Plast Reconstr Surg. 2011;127:1300–1310. 3. Spear SL, Boehmler JH, Clemens MW. Cosmetic augmentation/mastopexy: A 3-year review of a single surgeon’s practice. Plast Reconstr Surg 2006;118:136S–147S. 4. Scheer J, Patel A, Blount A, et  al. One-stage augmentation and mastopexy: A review of outcomes in a large patient population. Plast Reconstr Surg. 2012;130(Suppl 5S-1):85–86. 5. Seify H, Ismail K, Evans G. Primary augmentation/mastopexy using large implants: Is it a safe technique? A 4-year single surgeon review. Plast Reconstr Surg. 2010;126:67. 6. Stevens WG, Freeman ME, Stoker DA, et al. One-stage mastopexy with breast augmentation: A review of 321 patients. Plast Reconstr Surg; 2007;120:1674–1679. 7. Adams WP. Discussion: Simultaneous augmentation mastopexy: A retrospective 5-year review of 332 consecutive cases. Plast Reconstr Surg. 2013;131:157–158.

Swine Sign: A Valuable Audible Sign in Liposuction Sir: iposuction is a very commonly used procedure in plastic surgery. In general, this procedure is used to contour and thin certain areas of the body without taking out too much, as this may lead to unwanted irregularities and depressions. The result is determined not by the amount of fat sucked out but by the amount of fat left behind and the even distribution of it. However, in some procedures, liposuction is used to get rid of as much fat as possible (e.g., in the planned area of a dermolipectomy of an arm or leg, where skin excision can be performed only after thorough liposuction of the planned redundant area; or in the lower abdominal region beneath the Scarpa fascia, so that the Scarpa fascia can be saved without too much fat left beneath in the liposuction abdominoplasty procedure).1 The problem in these examples might be determining the endpoint of liposuction, when almost all fat has been sucked out; thus, the question during such a procedure will be what the right moment is at which to stop liposuction without leaving too much fat. During such procedures, we always noticed an audible sign that helped us in making the decision to stop liposuction because of an ample amount of remnant fat: this audible sign is a sound made by the liposuction cannula when there is almost nothing left to suck anymore in the treated area. This sound resembles the sound of a child that is finishing his or her soft drink with a straw, or the sound of a pig or a swine that is eating from a trough. When this sound is heard, we stop the liposuction procedure in these specific indications, and always have observed that there is almost no fat left that should have been sucked. Because of this experience, we would like to advise that this “swine” sign be used as a cue during the specific liposuction procedures to help deciding when one has reached the moment to finish the procedure when almost all fat has been sucked out. (See Video, Supplemental Digital Content 1, which demonstrates the swine sign, a


Volume 133, Number 2 • Viewpoints

Video. Supplemental Digital Content 1 demonstrates the swine sign, a valuable audible sign in liposuction, http://links.lww. com/PRS/A939.

valuable audible sign during liposuction, http://links. DOI: 10.1097/

Berend van der Lei, M.D., Ph.D. Marije Smittenberg, M.D. University Medical Centre Groningen Groningen, The Netherlands Correspondence to Dr. van der Lei University Medical Centre Groningen Groningen, The Netherlands [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Brauman D, Capocci J. Liposuction abdominoplasty: An advanced body contouring technique. Plast Reconstr Surg. 2009;124:1685–1695.

Fig. 1. Standard Moberg flap with a composite triangular segment including the distal phalanx and nail bed is flipped into the contralateral defect.

distal phalanx and nail bed matrix in reconstructing these defects. A Moberg flap is designed and raised under general anaesthesia with tourniquet control. A small triangular segment of distal phalanx and nail bed matrix from the contralateral side of injury is included in the advancement flap and “flipped” into the defect (Fig.  1). The nail bed is repaired with a fine absorbable suture and the surrounding skin is trimmed to fashion a well-rounded tip and secured with nonabsorbable sutures. Excellent sensitivity and functionality are seen 12 months after surgery, with preservation of thumb length and normal nail growth. We have found this simple and elegant modification of the standard Moberg flap to be an excellent choice when faced with reconstructing complex injuries of the thumb tip. DOI: 10.1097/01.prs.0000437237.46047.c0

Nanda Kandamany, M.R.C.S.

The Composite Moberg Flap for Reconstruction of Complex Thumb Tip Injuries Sir:


artial or complete amputation of the thumb is extremely common and leads to significant impairment of hand function.1 Reconstruction is often challenging, and preservation of length, restoration of sensation, and stable soft-tissue coverage remain the goals of any reconstructive procedure. In 1964, Moberg described the palmar advancement flap to meet these goals.2 This flap was then later described for the coverage of defects less than or equal to 2 cm in longitudinal diameter at the palmar tip of the thumb,3 along with various modifications mainly to extend the possible mobilization of the flap.4 In oblique injuries, there is often a need to further shorten the remaining distal phalanx and nail bed to fashion a well-rounded tip and to allow suture of the flap distally to the nail bed. To minimize further shortening of the thumb, we describe the novel use of a composite Moberg flap that includes

Anas Naasan, F.R.C.S.(Plast.) Department of Plastic Surgery Ninewells Hospital Dundee, United Kingdom Correspondence to Dr. Kandamany Department of Plastic Surgery Ninewells Hospital Dundee DD1 9SY, Scotland, United Kingdom [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Jones JM, Schenck RR, Chesney RB. Digital replantation and amputation: Comparison of function. J Hand Surg Am. 1982;7:183–189. 2. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg Am. 1964;46:817–825.


Swine sign: a valuable audible sign in liposuction.

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