Correspondence and communications 1753

maxillo-mandibular fixation and titanium plate fixationbetween the posterior maxilla and coronoid process beforemandibulectomy, the reproducibility of the remainingmandibular bone after mandibulectomy was not necessarilycomplete. Recently, using a 3-dimensional adjustable fixa-tion device, the precise reproduction of the remainingmandibular bone was achieved without maxillo-mandibularfixation. Moreover, we were able to perform man-dibulectomy according to the planned line of resection withthe surgical guide, and more accurate shaping of the har-vested fibula, in accordance with the configuration of thevirtual graft in the prefabricated SLMM. Thus, it waspossible to perform mandibular reconstruction more accu-rately, shorten the operation time, and achieve favourableaesthetic results. As disadvantages of the SLMM, productionof the stereolithographic model takes time, and it isexpensive. In addition, the patient’s exposure timeincreases on making this model, and the form of the SLMMmay be inappropriate due to artifacts in CT scans.3 There-fore, it is difficult to use the SLMM in all cases. As a newmodel-making process, a model fabricated using a 3Dprinter has been reported in orthognathic surgery.5

Recently, we also attempted making a plaster of parismodel with this technology for reconstruction surgery. Thismodel is cheaper in comparison with the conventionalstereolithographic model, and the production time is short.This method may be generally accepted for model-basedsurgery in the near future.

In conclusion, this procedure using a prefabricatedstereolithographic mandibular model was able to effec-tively facilitate mandibular reconstruction surgery, and isuseful to increase the accuracy and shorten theoperation time, achieving satisfactory aesthetic results.Our technique is simple and effective. We believe itwill be helpful for surgeons performing mandibularreconstruction.

Conflict of interest

N/A.

Funding

N/A.

References

1. Hidalgo DA. Fibula free flap: a new method of mandiblereconstruction. Plast Reconstr Surg 1989;84:71e9.

2. Brown GA, Milner B, Firoozbakhsh K. Application of computer-generated stereolithography and interpositioning template inacetabular fractures: a report of eight cases. J Orthop Trauma2002;16:347e52.

3. Cunningham LL Jr, Madsen MJ, Peterson G. Stereolithographicmodeling technology applied to tumor resection. J Oral Max-illofac Surg 2005;63:873e8.

4. Yeung RW, Samman N, Cheung LK, et al. Stereomodel-assistedfibula flap harvest and mandibular reconstruction. J Oral Max-illofac Surg 2007;65:1128e34.

5. Mavili ME, Canter HI, Saglam-Aydinatay B, et al. Use of three-dimensional medical modeling methods for precise planning oforthognathic surgery. J Craniofac Surg 2007;18:740e7.

Yasutsugu YamanakaDepartment of Oral and Maxillofacial Surgery,

Nara Medical University, 840 Shijo-cho, Kashihara,Nara 634-8522, Japan

Department of Oral and Maxillofacial Surgery,Kouseikai Takai Hospital, 461-2 Kuranosho-cho, Tenri,

Nara 632-0006, Japan

Hiroshi YajimaDepartment of Orthopaedic Surgery, Nara Medical

University, 840 Shijo-cho, Kashihara,Nara 634-8522, Japan

Tadaaki KiritaDepartment of Oral and Maxillofacial Surgery,

Nara Medical University, 840 Shijo-cho, Kashihara,Nara 634-8522, Japan

E-mail address: tkirita@naramed-u.ac.jp

Hiroyuki ShimomuraShigehiro Tamaki

Department of Oral and Maxillofacial Surgery,Kouseikai Takai Hospital, 461-2 Kuranosho-cho, Tenri,

Nara 632-0006, Japan

Kumiko AokiNobuhiro Yamakawa

Yuichiro ImaiDepartment of Oral and Maxillofacial Surgery,

Nara Medical University, 840 Shijo-cho, Kashihara,Nara 634-8522, Japan

ª 2010 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2010.03.001

Laser ablation of abnormal skinpigmentation post syndactylyrelease

Syndactyly is a relatively common problem in the handaffecting one in every 2000 to 2500 live births.1 Tradition-ally, syndactyly release produces a shortage of skinfrequently requiring a full-thickness skin graft, harvestedfrom the groin. Long-term follow-up has reported prob-lematic hair growth and pigmentation in these grafts.2

Graft less syndactyly repair3,4 is now used for majority ofpatients and those patients who need full-thickness skingraft a meticulous care is taken to harvest it from lateralpart of groin thereby avoiding potential hair growth atpuberty.

In children the groin skin is initially hairless and ofa similar pigmentation. As puberty approaches, hair growthincreases in this area and pigment deepens. Hydroquinonecreams have been used but with poor results in children.Lasers are widely used for depigmentation and hairremoval5,6 but its use for post syndactyly release pigmen-tation has not been described.

Figure 1 Pre-laser and post-laser treatment of graft pigmentation at three-year follow-up.

Figure 2 Pre-laser and post-laser treatment of graft pigmentation in another patient.

1754 Correspondence and communications

Wehaveused laser therapy to reducepigmentation in full-thickness skin grafts taken from the groin for syndactylyrelease in 8 patients. All patients were of Fitzpatrick SkinType 2&3.Q-switchedNd:YAGLaser(532 nm)with fluence of2.4 J/cm2 was used for depigmentation. A long-pulsedNd:YAG (1064 nm) was used for hair removal.

There was a good response to depigmentation at only 4weeks. On average four treatments achieved depigmenta-tion. Good results were obtained when fluence of 2.4 J/cm2

was used. No recurrence of pigmentation was seen at3 years of follow-up [Figures 1 and 2]. Laser hair treatmentoffered a significant hair-free interval (average of12 months).

Laser depigmentation appears a promising treatmentfor this difficult problem but needs longer follow-up toestablish chances of re-pigmentation. Nd:YAG (532 nm) is

relatively painless when it is used to treat hyperpigmen-tation. The long-pulsed Nd:YAG laser used for additionalhair removal is painful.

Conflict of interest

None.

Funding sources

None.

References

1. Eaton JE, Lister GD. Syndactyly. Hand Clin 1990;6:555e75.

Correspondence and communications 1755

2. Deunk J, Nicolai JP, Hamburg SM. Long-term results of syndac-tyly correction: full-thickness versus split-thickness skin grafts.J Hand Surg (Br) 2003 Apr;28:125e30.

3. Ekerot L. Syndactyly correction without skin grafting. J HandSurg (Br) 1996;21:330e7.

4. Niranjan NS, Azad SM, Fleming AN, et al. Long-term results ofprimary syndactyly correction by the trilobed flap technique. BrJ Plast Surg 2005 Jan;58:14e21.

5. Liew SH. Laser hair removal: guidelines for management. Am JClin Dermatol 2002;3:107e15.

6. Nanni CA, Alster TS. Laser-assisted hair removal: side effects ofQ-switched Nd:YAG, long-pulsed ruby, and alexandrite lasers.J Am Acad Dermatol 1999 Aug;41:165e71.

A. MishraK. NelsonS. McNallyC. Gorst

P. McArthurAldey Hey Children Hospital,

Liverpool L12 2AP, UKE-mail address: anuj.mishra73@gmail.com

ª 2010 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2010.03.014

Tricophytic or pre-trichophyticclosure?

Dear Editor

I read with interest the hypothesis expounded by Ahmadregarding the technique of trichophytic closure.1 However,there are some definitions that need to be considered inusing these terms. These are Trichal incisions and pretrichalincisions. The trichal incision has previously been used ina forehead lift. An incision is made along the hairline andthe scar may be visible along the edge of the hairline; thefollicles are not transected. A pretrichal incision involves anincision within the hairline with a bevelled approachtransecting the follicles as described by Mazola.2

This technique has been used for several years in anattempt to disguise the scar in several different operationswhere there is potential for hair growth within the scar. Inparticular following an abdominoplasty the scar in thesuprapubic region and the pubic triangle (escutcheon) maybe elevated. Therefore the scar is placed lower in order totransect the pubic hairline. The area including the hairbearing area is incised in keeping with the pretrichaltechnique.

Traditional views on ‘shelving’ wound closure warn thatwound closure should be performed with sharply definedand well-aligned wound edges to heal with the minimumamount of scar.3 However, having used this closure tech-nique in abdominoplasties over a period of over 10-years noissues related to the shelving closure or hair in-growth inthe scar has been observed.

In some cases it is not necessary to take into account theTriangular pubic hair outline and then the scar is placed isas inconspicuous position as possible.

Conflict of interest

None.

References

1. Ahmad M. Does the trichophytic technique have any role infacial wound closure? A hypothesis. Plast Reconstr Surg 2009;62:662. doi:10.1016/j.bjps.2008.11.077.

2. Mazola M. Single-scar harvesting technique. In: Haber RS,Stough DB, editors. Hair transplantation. Philadelphia: ElsevierSaunders; 2006. p. 83e6.

3. Lorenz P, Longaker MT. Wound healing: repair biology andwound and scar treatment. In: Mathes SJ, editor. Plasticsurgery. 2nd ed. Philadelphia: Elsevier Saunders; 2006. p. 221.

M. Dalvi HumzahWest Midlands Hospital, Colman Hill,

West Midlands B63 2AH,UKE-mail address: dhumzah@hotmail.com

ª 2010 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2010.02.035