Mrish Jouma~ofPlas?ic Surgery ( 1992), 45,179180 0 1992 The Trustees of British Association of Plastic Surgeons
Letters to the Editor Donor area healing under the alginate and the hydrocolloid dressings was compared at the time of the first dressing change and at the time of the tirst observation of complete healing. The former comparison could not have been affected by the use of tulle gras whereas the latter comparison may have been affected in 14 out of the 28 alginate treated patients. Your correspondents are right to point out that there was a tendency to remove the hydrocolloids earlier than the alginates but they should have noted that the mean time between operation and the first dressing change was not significantly different for the two dressing materials. The paper makes no claim to measure actual healing times. Throughout the investigation the “time from operation to the first observation of complete healing” was recorded and this terminology was used consistently throughout the paper. In particular I have stated that “many of the donor areas may have been healed before they were first inspected”. Actual healing times could only have been measured if the donor areas had been kept under continuous inspection. Yours faithfully, J. M. Porter MS FRCS, Plastic Surgery and Bums Unit, Ward 39, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
Split skin graft donor areas Sir, We were interested to read the paper by J. M. Porter (British Journal of Plastic Surgery, 44, 333) reporting on the performances of hydrocolloid and alginate dressing materials in the healing of split skin graft donor areas. We would like to make some comments. It appears from the description of the methods that if the donor areas in the alginate group were unhealed at first inspection, further dressings were continued with paraffin gauze whereas in the hydrocolloid group the same dressing was used until the donor area had re-epithelialised. This means the author has compared hydrocolloids with a combination of alginate and paraffin gauze, and as it has been shown that donor sites heal consistently better under calcium alginate compared with tulle gras (Attwood, 1989) it is evident that the study cannot conclude that “the time from operation to complete healing was 10 days for the donor areas dressed with the hydrocolloid and 15.5 days for the donor areas dressed with alginate”. Furthermore, the paper states that the hydrocolloid dressings were removed early (5-13 days) due to excessive leakage whereas the alginate dressings were removed later (7-19 days) because they were dry and adherent. As healing may have occurred under the Kaltostat, as suggested by the absence of gel, it is wrong to conclude that healing has not occurred unless the dressing has been soaked off, which is the recommended technique for removing an adherent alginate dressing. Yours faithfully, Paul Vanstraelen FRCS (G) Registrar in Plastic Surgery, R. Papini FRCS (Ed) SHO in Plastic Surgery, St. Lawrence Hospital, Chepstow, Gwent NP6 SYX.
Lower eyelid repair Sir, I would like to comment on the recently published “Lower eyelid repair utilising triangular skin flaps with subcutaneous pedicles” by Destro et al. (British Journal of Plastic Surgery, 44,363).
Revisiting a good and useful technique is desirable but “old users” should be recognised and at least mentioned in the references, since we have described the same technique for a total lower eyelid reconstruction (Peled et al., 1980; Peled and Wexler, 1990). The cases here illustrated are of reconstruction of partial defects of the lower eyelid but this technique applies to total reconstruction as well. The authors state that a possible complication is ectropion following surgery. This can be avoided or minimised by the suspension of the flap to the orbital rim. Yours faithfully, Professor Isaac J. Peled, M.D. Department of Plastic Surgery, Rambam Medical Center, Haifa, Israel
References Athood, A. I. (1989). Calcium alginate dressing accelerates split skin graft donor site healing. British Jouma~ofPkzstic Surgery, 42, 313.
Porter, J. M. (1991). A comparative investigation of re-epithelialisation of split skin graft donor areas after application of hydrocolloid and alginate dressings. British Journal of Plastic Surgery, 44,333.
Split skin graft donor areas-reply Sir, Mr Vanstraelen and Mr Papini are correct to point out that the alginate dressed donor areas, which were unhealed at the time of the first dressing, were subsequently dressed with tulle gras. This fact was clearly stated in the Materials and Methods section and in the discussion it was conceded that the use of tulle gras may have prolonged the healing times in the alginate treated patients.
References Peled, I., Kaplan,I-I.and Wexler, M. R. (1980). Lower eyelid reconstruction by V-Y advancement cheek flaps. Annals ofPlastic
Surgery, 5,321.
179
180 Peled, I. J. and Weller, M. R. (1990). Cheek V-Y advancement skin flap to the lower eyelid. In Strauch, Vasconez and Hall-Findlay (Eds.). Grabb’s Encyclopedia of Flaps. Vol. 1. Boston, Toronto, London, Little, Brown & Co., p. 81.
Lower eyelid repair-reply Sir, In relation to the letter of Professor Peled, we would make it clear that we have been introduced to the technique of triangular skin flaps with subcutaneous pedicles, by publications which date from 1975 (see references in our paper), and also that we have been using this technique since 1976. Our early experience (4.5 cases located on the face) was presented as a paper at the VII International Congress of Plastic Surgery, in 1979, and published in the Transactions. We therefore consider ourselves “old users” of this technique, as we have been publishing on the matter since 1979. We apologise to Professor Peled for failing to refer to his paper, but we were unaware of its existence. Yours faithfully, Marco W. B. De&o, MD, Rua Joaquim Tavares no. 50, Taubate-Cep 12.050, S&oPaulo, Brazil
British Journal of Plastic Surgery The flap vessels are quite spasm prone. We avoid dissection under pneumatic tourniquet which prolongs the operating time. The spasm reacts well to topical papaverine and hot sponges. The posterior interosseous flap can fail (2/16 = 12.5% cases in our series). This again requires a salvage procedure, preferably a free flap transfer. Finally, in many cases a free flap reconstruction (such as the lateral arm flap from the same or the contralateral side) offers the following advantages: technically less demanding harvesting, simultaneous working of two operating teams, hence shorter operating time, fewer complications and a failure rate less than 5%. Yours faithfully, Zoran M. ArneZ,MD, PLD, Associate Professor and Head, University Department of Plastic Surgery and Bums, University Medical Center, Zaloika 7, 61000 Ljubljana, Yugoslavia Reference Costa, H., Comba, S., Martins,
A., Rodrigues, J., Reis, J. and Amarante, J. (1991). Further experience with the posterior interosseous flap. British Joumalof Plastic Surgery, 44,449.
Local anaesthetics in dental cartridgesreply Posterior interosseous flap Sir, The versatility and many advantages of the posterior interosseous flap were extensively discussed in the excellent paper by Costa et al. (British Journal of Plastic Surgery, 44, 449).
Surgeons less experienced with harvesting of this flap, however, might find useful some additional information about potential dangers and disadvantages of this procedure. The principal danger when harvesting the posterior interosseous flap lies in potential damage to motor branches of the radial (posterior interosseous) nerve : the motor branch to extensor carpi ulnarius proximally (1 case in our series of 16), and the motor branch extensor digiti quinti distally (2 cases in our series). Either results in respective muscle palsy. Arterial perfusion of this flap is usually excellent, but problems may arise with venous drainage. With larger flaps when the donor site cannot be closed directly and requires skin grafting (“extended” posterior interosseous flap) the venous outflow via the two venae comitantes is often insufficient (3 cases in our series). Since then, in large flaps, a superficial vein has been included in the flap and clamped. The venous return through the superficial system has always been more substantial and addition of an end-to-end venous microvascular anastomosis has proved to be the only way of salvaging the flap from venous engorgement. In such cases a microscope and microsurgical skills have to be available.
Sir, For skin infiltration the dental cartridge system has two great advantages over a disposable plastic syringe and needle; the long flexible needle facilitates a wide area of soft tissue infiltration via a single skin puncture, and the fine needle bore significantly reduces the volume of fluid injected with “standard” plunger pressure. I agree with Riley and Roberts (Britkh Journal of Plastic Surgery, 44, 471) that the discontinuation of cartridges containing 0.5% lignocainell-in-200 adrenaline is an occasional nuisance, although in our unit we use 2% lignocaine/ l-in-80 000 adrenaline exclusively around the head and neck and have not seen any complications. Even end organs such as the pinna may be safely anaesthetised with this concentration so long as an excess of solution is not injected. Where a more dilute concentration is preferred, I suggest the use of a Steriseal 1275A retrobulbar needle.This is a flexible 2 inch 26 gauge needle which closely approximates a dental needle. When used with a disposable plastic syringe it offers a significantly cheaper alternative to the prefilled glass syringe system. Yours faithfully, John Townend, STERISEAL, Consultant-Maxillofacial Surgery, Thomhill Road, St. Richards Hospital, Redditch, Spitalfield Lane, Worcs B98 9NL. Chichester, West Sussex PO19 4SE.
Letters to the Editor Donor area healing under the alginate and the hydrocolloid dressings was compared at the time of the first dressing change and at the time of the tirst observation of complete healing. The former comparison could not have been affected by the use of tulle gras whereas the latter comparison may have been affected in 14 out of the 28 alginate treated patients. Your correspondents are right to point out that there was a tendency to remove the hydrocolloids earlier than the alginates but they should have noted that the mean time between operation and the first dressing change was not significantly different for the two dressing materials. The paper makes no claim to measure actual healing times. Throughout the investigation the “time from operation to the first observation of complete healing” was recorded and this terminology was used consistently throughout the paper. In particular I have stated that “many of the donor areas may have been healed before they were first inspected”. Actual healing times could only have been measured if the donor areas had been kept under continuous inspection. Yours faithfully, J. M. Porter MS FRCS, Plastic Surgery and Bums Unit, Ward 39, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
Split skin graft donor areas Sir, We were interested to read the paper by J. M. Porter (British Journal of Plastic Surgery, 44, 333) reporting on the performances of hydrocolloid and alginate dressing materials in the healing of split skin graft donor areas. We would like to make some comments. It appears from the description of the methods that if the donor areas in the alginate group were unhealed at first inspection, further dressings were continued with paraffin gauze whereas in the hydrocolloid group the same dressing was used until the donor area had re-epithelialised. This means the author has compared hydrocolloids with a combination of alginate and paraffin gauze, and as it has been shown that donor sites heal consistently better under calcium alginate compared with tulle gras (Attwood, 1989) it is evident that the study cannot conclude that “the time from operation to complete healing was 10 days for the donor areas dressed with the hydrocolloid and 15.5 days for the donor areas dressed with alginate”. Furthermore, the paper states that the hydrocolloid dressings were removed early (5-13 days) due to excessive leakage whereas the alginate dressings were removed later (7-19 days) because they were dry and adherent. As healing may have occurred under the Kaltostat, as suggested by the absence of gel, it is wrong to conclude that healing has not occurred unless the dressing has been soaked off, which is the recommended technique for removing an adherent alginate dressing. Yours faithfully, Paul Vanstraelen FRCS (G) Registrar in Plastic Surgery, R. Papini FRCS (Ed) SHO in Plastic Surgery, St. Lawrence Hospital, Chepstow, Gwent NP6 SYX.
Lower eyelid repair Sir, I would like to comment on the recently published “Lower eyelid repair utilising triangular skin flaps with subcutaneous pedicles” by Destro et al. (British Journal of Plastic Surgery, 44,363).
Revisiting a good and useful technique is desirable but “old users” should be recognised and at least mentioned in the references, since we have described the same technique for a total lower eyelid reconstruction (Peled et al., 1980; Peled and Wexler, 1990). The cases here illustrated are of reconstruction of partial defects of the lower eyelid but this technique applies to total reconstruction as well. The authors state that a possible complication is ectropion following surgery. This can be avoided or minimised by the suspension of the flap to the orbital rim. Yours faithfully, Professor Isaac J. Peled, M.D. Department of Plastic Surgery, Rambam Medical Center, Haifa, Israel
References Athood, A. I. (1989). Calcium alginate dressing accelerates split skin graft donor site healing. British Jouma~ofPkzstic Surgery, 42, 313.
Porter, J. M. (1991). A comparative investigation of re-epithelialisation of split skin graft donor areas after application of hydrocolloid and alginate dressings. British Journal of Plastic Surgery, 44,333.
Split skin graft donor areas-reply Sir, Mr Vanstraelen and Mr Papini are correct to point out that the alginate dressed donor areas, which were unhealed at the time of the first dressing, were subsequently dressed with tulle gras. This fact was clearly stated in the Materials and Methods section and in the discussion it was conceded that the use of tulle gras may have prolonged the healing times in the alginate treated patients.
References Peled, I., Kaplan,I-I.and Wexler, M. R. (1980). Lower eyelid reconstruction by V-Y advancement cheek flaps. Annals ofPlastic
Surgery, 5,321.
179
180 Peled, I. J. and Weller, M. R. (1990). Cheek V-Y advancement skin flap to the lower eyelid. In Strauch, Vasconez and Hall-Findlay (Eds.). Grabb’s Encyclopedia of Flaps. Vol. 1. Boston, Toronto, London, Little, Brown & Co., p. 81.
Lower eyelid repair-reply Sir, In relation to the letter of Professor Peled, we would make it clear that we have been introduced to the technique of triangular skin flaps with subcutaneous pedicles, by publications which date from 1975 (see references in our paper), and also that we have been using this technique since 1976. Our early experience (4.5 cases located on the face) was presented as a paper at the VII International Congress of Plastic Surgery, in 1979, and published in the Transactions. We therefore consider ourselves “old users” of this technique, as we have been publishing on the matter since 1979. We apologise to Professor Peled for failing to refer to his paper, but we were unaware of its existence. Yours faithfully, Marco W. B. De&o, MD, Rua Joaquim Tavares no. 50, Taubate-Cep 12.050, S&oPaulo, Brazil
British Journal of Plastic Surgery The flap vessels are quite spasm prone. We avoid dissection under pneumatic tourniquet which prolongs the operating time. The spasm reacts well to topical papaverine and hot sponges. The posterior interosseous flap can fail (2/16 = 12.5% cases in our series). This again requires a salvage procedure, preferably a free flap transfer. Finally, in many cases a free flap reconstruction (such as the lateral arm flap from the same or the contralateral side) offers the following advantages: technically less demanding harvesting, simultaneous working of two operating teams, hence shorter operating time, fewer complications and a failure rate less than 5%. Yours faithfully, Zoran M. ArneZ,MD, PLD, Associate Professor and Head, University Department of Plastic Surgery and Bums, University Medical Center, Zaloika 7, 61000 Ljubljana, Yugoslavia Reference Costa, H., Comba, S., Martins,
A., Rodrigues, J., Reis, J. and Amarante, J. (1991). Further experience with the posterior interosseous flap. British Joumalof Plastic Surgery, 44,449.
Local anaesthetics in dental cartridgesreply Posterior interosseous flap Sir, The versatility and many advantages of the posterior interosseous flap were extensively discussed in the excellent paper by Costa et al. (British Journal of Plastic Surgery, 44, 449).
Surgeons less experienced with harvesting of this flap, however, might find useful some additional information about potential dangers and disadvantages of this procedure. The principal danger when harvesting the posterior interosseous flap lies in potential damage to motor branches of the radial (posterior interosseous) nerve : the motor branch to extensor carpi ulnarius proximally (1 case in our series of 16), and the motor branch extensor digiti quinti distally (2 cases in our series). Either results in respective muscle palsy. Arterial perfusion of this flap is usually excellent, but problems may arise with venous drainage. With larger flaps when the donor site cannot be closed directly and requires skin grafting (“extended” posterior interosseous flap) the venous outflow via the two venae comitantes is often insufficient (3 cases in our series). Since then, in large flaps, a superficial vein has been included in the flap and clamped. The venous return through the superficial system has always been more substantial and addition of an end-to-end venous microvascular anastomosis has proved to be the only way of salvaging the flap from venous engorgement. In such cases a microscope and microsurgical skills have to be available.
Sir, For skin infiltration the dental cartridge system has two great advantages over a disposable plastic syringe and needle; the long flexible needle facilitates a wide area of soft tissue infiltration via a single skin puncture, and the fine needle bore significantly reduces the volume of fluid injected with “standard” plunger pressure. I agree with Riley and Roberts (Britkh Journal of Plastic Surgery, 44, 471) that the discontinuation of cartridges containing 0.5% lignocainell-in-200 adrenaline is an occasional nuisance, although in our unit we use 2% lignocaine/ l-in-80 000 adrenaline exclusively around the head and neck and have not seen any complications. Even end organs such as the pinna may be safely anaesthetised with this concentration so long as an excess of solution is not injected. Where a more dilute concentration is preferred, I suggest the use of a Steriseal 1275A retrobulbar needle.This is a flexible 2 inch 26 gauge needle which closely approximates a dental needle. When used with a disposable plastic syringe it offers a significantly cheaper alternative to the prefilled glass syringe system. Yours faithfully, John Townend, STERISEAL, Consultant-Maxillofacial Surgery, Thomhill Road, St. Richards Hospital, Redditch, Spitalfield Lane, Worcs B98 9NL. Chichester, West Sussex PO19 4SE.
