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Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria: • Text—maximum of 500 words (not including references) • References—maximum of five • Authors—no more than five • Figures/Tables—no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/ prs/. We strongly encourage authors to submit figures in color. We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

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A Modified Template for Microtia Reconstruction Tested by Surgical Simulation batatas The Cosmetic Surgery Stigma:on AnIpomoea American Sir: Cultural Phenomenon?

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icrotia reconstruction is a challenge for plastic surgeons because its variable clinical presenlthough over 15.1 of million cosmetic procedures 1 Although tation and difficult surgical reconstruction. (compared with 5.7 million reconstructive proceseveral were reconstructive have been dures) performedmethods in the United Statesproposed, in 2013,1 reconstruction autologous costal cartilage, as elabthere is, withoutwith question, a stigma in American culture orated and modifiedsurgery by Tanzer, Nagata, attached to cosmetic and aBrent, hiddenand condescenremains the best optionundergoing with which to obtain favorable sion toward patients these procedures. results with fewer complications than other reconstrucSteps should be taken to address and resolve this issue. tive Perhaps options.2 the first step is to admit its existence. The isthree-dimensional of the There some resistance topography to accept this viewexternal in acaear accurately shape of the internal cartidemic circles, reflects and onethe possible factor is that plastic 3 Reproducing anatomical andmay struclaginous skeleton. surgeons are reluctant to admit that their work be controversial and who for choose tural details of thestigmatized. external earIndividuals is a challenge any to undergo these often themselves plastic surgeon and procedures requires a high levelfind of surgical skill and training to fulfill the patient’s expectation. Surgical Sir:

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condescended to development or shamed, and even skills, accused of havsimulation allows of these reducing ing psychological problems, in turn influences mistakes, shortening surgical which time, and improving re4 or deny that they have gone under the themintovivo. hide We performed a surgical simulation exsults knife. Manystudy, celebrities, considered cultural icons of perimental evaluating traditional and modified natural beauty, are “outed” later their careers in a auricular templates as guides forincarving ear framedemeaning and salacious manner by the media as works on Ipomoea batatas, comparing and analyzing theif surgery is a shameful secret of their past. Beauty is not obtained results. skin deep, and cosmetic surgery is not superficial in The traditional templates were based on sheets of terms of itssketched impact on patients’ lives: it the often addresses paper and lines representing main strucpsychosocial issues that deeper more complex tures of the external earare (i.e., helix,and antihelix, tragus, than pure aesthetics. Evidence has shown thatand patients antitragus, triangular fossa, scaphoid fossa, conwho undergo theseproposed procedures enjoy benefits such as cha) (Fig. 1). The modified templates were improved sex lives, self-confidence, and self-image.2,3 based on paper sheets, with lines representing the main The reasons for the discomfort with plastic surgery structures and markings detailing the depths of each of in American culture—one that prides itself in more these structures as follows: whole painted, striped, and liberal views—remain unclear. Maybe this is a cultural unpainted (meaning deep, often not deep, and elevated, rephenomenon. The media describes Iran as the spectively). The striped lines, at the same time, reprerhinoplasty capital of the world, perhaps because of the sented depth when drawn closer together (Fig. 1). Persianmore cultural acceptance and endorsement of the Ipomoea batatas, also known as sweet potato, was pursuit of a higher aesthetic ideal. Brazil is the country used because of its largest similarity in consistency in which the second number of cosmeticand sur5 4 flexibility to human rib cartilage. Each sweet perpogery procedures are performed ; there, the public ception is that plastic surgery one’s self-image tato model was referred toimproves as an individual case. 5 and quality of life. Five common carving tools with different curves the stigma hasEight to do and Perhaps angles were used in to American sculpt theculture models. with disrupting antiquated, classicist ideals that beauty novel surgeons were tested; half of them used the is something with which one is born. The compeltraditional template andborn the with otherit?” half used the ling slogan “Maybe she’s (Maybelline, modified template. The exercise was repeated New York, N.Y.) comes to mind. If beauty is bought or twice. resulting were eval-it assistedThe with surgery, auricular does thatsculptures somehow cheapen and devalue uated basedits onluster? aesthetic results, ranked according As advocates to forthe our patients, intervening steps to resemblance real ear model, being classhouldas bepoor, taken to address this problem. sified fair, or good results. The media are in part responsible for perpetuating this stigma. Rather Aesthetically different auricular frameworks than stigmatizing plastic surgery, media messages can were obtained using the two different types of foster acceptance and more realistic views about inditemplates. definition three-dimensional viduals who Better make this choice. Ifof patients and the celebstructures (i.e., helix, antihelix, tragus, rities serving as culture’s tastemakers and antitragus, role models scaphoid fossa, triangular fossa, and concha) and are more confident and transparent about their decisions, we may experience paradigm shift in the field. better aesthetic results awere obtained using the From an academic modified templatestandpoint, (n  16).more education needs to be provided to explain the potential psychosocial benefits of plastic surgery in patients’ lives. Academics from both surgery and psychology backgrounds can collaborate to change harmful public perceptions. Until we can recognize the stigma plaguing our field and pursue means of reversing the detrimental perceptions about plastic surgery, the empowerment inherent in the choice to enhance self-image is muddled with the shame that can haunt our patients. DOI: 10.1097/PRS.0000000000000604

Saba Motakef, M.D. Department of Plastic Surgery Loma Linda University Loma Linda, Calif.

Sahar Motakef, M.A. Graduate School of Education and Psychology Pepperdine University Malibu, Calif. Fig. 1. Traditional and modified auricular templates.

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Volume 134, Number 5 • Viewpoints Michael T. Chung, M.D. Department of Surgery Division of Plastic, Maxillofacial, and Oral Surgery Duke University Durham, N.C.

Michael J. Ingargiola, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Mount Sinai Hospital New York, N.Y.

Jose Rodriguez-Feliz, M.D. Department of Surgery Division of Plastic Surgery Albany Medical Center Albany, N.Y. Correspondence to Dr. Motakef Department of Plastic Surgery Loma Linda University 11175 Campus Street, CP 21126 Loma Linda, Calif. 92354 [email protected]

DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. American Society of Plastic Surgeons. 2013 plastic surgery statistics report. Available at: http://www.plasticsurgery.org/ Documents/news-resources/statistics/2013-statistics/plasticsurgery-statistics-full-report-2013.pdf. Accessed May 20, 2014. 2. Ozgür F, Tuncali D, Güler Gürsu K. Life satisfaction, selfesteem, and body image: A psychosocial evaluation of aesthetic and reconstructive surgery candidates. Aesthetic Plast Surg. 1998;22:412–419. 3. Bolton MA, Pruzinsky T, Cash TF, Persing JA. Measuring outcomes in plastic surgery: Body image and quality of life in abdominoplasty patients. Plast Reconstr Surg. 2003;112:619–625; discussion 626. 4. International Society of Aesthetic Plastic Surgeons. ISAPS international survey on aesthetic/cosmetic procedures performed in 2011. Available at: http://www.isaps.org/Media/ Default/global-statistics/ISAPS-Results-Procedures-2011. pdf. Accessed May 20, 2014. 5. Edmonds A. A ‘necessary vanity’. The New York Times August 13, 2011. Available at: http://opinionator.blogs.nytimes. com/2011/08/13/ a-necessary-vanity/?_php=true&_type= blogs&_r=0. Accessed May 20, 2014.

An Ultrasound-Based Approach to Preoperative Confirmation of Reverse Radial Forearm Flap Perfusion Sir:

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he reverse radial forearm flap serves as a workhorse for reconstruction of dorsal hand defects with denuded tendon exposure following trauma, burns, and tumor excision. Successful flap perfusion following proximal division of the radial artery relies

on reversal of arterial flow through the superficial and deep palmar arch branches of the ulnar artery.1,2 Preoperative assessment of radioulnar collateralization must be performed to ascertain adequate digital perfusion following radial artery division. In most cases, an Allen test can aid in determining whether sacrificing the radial or ulnar artery will result in compromised digital blood flow.3 However, some situations, such as severe hand burns, undermine the utility of an Allen test, which relies on visualizing skin color changes and manual compression over potentially sensitive areas.4 In this communication, we present a case using a novel Doppler ultrasound method of assessing the adequacy of an ulnar-based flap and digital perfusion with direct visualization of radial artery flow reversal. A 43-year-old man with a history of posttraumatic stress disorder and multiple substance abuse sustained third-degree burns to his left lateral arm, dorsal forearm, and dorsal hand in a motor vehicle collision. On postburn day 7, the patient underwent tangential excision and allografting of all of his left upper extremity burns. Whereas his left arm and dorsal forearm burns showed subsequent improvement in their wound beds, the dorsal hand deteriorated, revealing exposed and desiccated extensor tendon over the radial dorsal hand, index, and long finger proximal interphalangeal joints. Soft-tissue coverage with a reversed radial forearm flap was planned. Because of extensive hand and wrist burns precluding Allen testing, alternatives were considered. Computed tomographic and traditional angiography were undesirable because of deteriorating renal function. To assess digital and flap perfusion preoperatively, we combined the use of two Doppler-based examinations. First, the patient underwent a Doppler ultrasound-based examination of the radial artery near the level of the proximal wrist crease. We obtained ultrasound waveforms and flow velocities before and after manual occlusion proximal to this site, simulating arterial division. Preocclusion waveforms showed arterial, proximal-to-distal directional signals, with a peak velocity of 83 cm/second; whereas postocclusion waveforms showed arterial, distal-to-proximal flow, with a peak velocity of −15 cm/second and color change indicating reversal of flow (Figs. 1 and 2). We supplemented this test with a traditional Doppler Allen test by verifying the presence of triphasic signals in all five digits during occlusion of the radial artery. The patient subsequently underwent a reverse radial forearm flap. He required a 3-day course of leeching postoperatively, but the flap remained viable thereafter. In this case, we demonstrate a convenient bedside method for directly visualizing and quantifying the reversal of radial artery flow in anticipation of performing a reverse radial forearm flap for soft-tissue coverage of dorsal hand defects. This is a simple and useful method for verifying flap perfusion and digital perfusion when supplemented with a Doppler Allen test. This combination of Doppler-based modalities represents a previously unreported method of verifying

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The cosmetic surgery stigma: an american cultural phenomenon?

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