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.
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.
