Lasagne: a simple model to assess the practical skills of split-skin graft harvesting and meshing

Short reports and correspondence the next few days, he had gathered the necessary equipment to conduct the surgery on himself. There were three main areas of scarfing that he was concemed about: first and most important was a group of horizontal scars on his left mid-forearm measuring 10 cm x 3 cm; second was a 5 cm scar on his left bicep area; and third was a 6 cm scar on his left pectoral area. All these scars were well healed, pale and fiat. A week prior to performing the surgery, he had made 1 cm incisions in other pre-existing scars to practice his suturing. He had bought some topical lidocaine gel for mouth ulcers at a local pharmacy, and then proceeded to cut ellipses around the scars with a sterile razor blade. He then smeared the gel into the wounds, which provided sufficient anaesthesia for him to continue the surgery. He then sutured himself using a household needle and cotton. He presented to his local Accident and Emergency department 7 days later with three infected wounds. All the sutures were removed, leaving superficially infected wounds. He was treated appropriately, and we saw him on day 10, when there was some resolving cellulitis around the upper arm and chest wounds, although he was systemically well. He had very good insight into his mental condition, and stated that he was not psychotic when he performed the surgery, and that it had been a carefully planned procedure over a number of days. Examination of his wounds revealed that he had cut perfect ellipses around all his scars and perfectly de-epithelialised the skin on one before suturing the wound. The other two scars were completely excised down to fat and sutured. The puncture marks of the sutures were correctly and neatly placed along the lengths of all three wounds. We elected to treat his wounds conservatively with regular dressings and to review him regularly. He was seen by a psychiattic team during his visit to our unit and was deemed not to be psychotic; he was discharged home to the care of his local psychiatric team. His wounds have since healed, although they are much wider than his original scars. We will not be offering him any surgical treatment in the foreseeable future, despite his requests, as he is now under close regular review by his psychiatric team. He would not allow photographs of his wounds to be taken. As more people gain access to detailed footage of surgery, the basics will become common knowledge to a significant number of people. Problems may arise when this information is misused. In a psychiatric patient with a history of self-harm we have seen that these broadcasts can have a significant influence on behaviour. Instead of the 'cry for help' or 'coping mechanism' traditionally associated with self-harm, these patients can, in their view, now have a new and more beneficial 'reason' for inflicting harm on themselves.

703 doi:10.1054/bjps.2002.3947

Lasagne: a simple model to assess the practical skills of split-skin graft harvesting and meshing Sir, In view of the increasing pressure for the practical assessment of the surgical skills of trainees, we have developed a simple model to allow split-skin graft harvesting technique to be taught and tested without patient morbidity. The method uses pieces of standard egg lasagne, easily and cheaply purchased from supermarkets. The lasagne sheets are part-cooked until softening commences, by soaking them in boiling water for approximately 10 min, ensuring that the sheets are kept separate. They are then cooled in cold water, and kept submerged until needed. The lasagne sheet is then draped over a litre bag of IV fluid to simulate the donor area.

Figure 1--The lasagne is draped over a bag of IV fluid to simulate the donor area.

Yours faithfully, ~i84

C. R. Barton, Senior House Officer W. A. Diekson BSe, MB, ChB, FRCS(Glasg), Consultant Plastic Surgeon Welsh Regional Centre for Burns and Plastic Surgery, Morriston Hospital, Morriston, Swansea SA6 6NL, UK.

Figure 2---A sheet of 'split skin' can be obtained from the lasagne with a good technique.

704

British Journal of Plastic Surgery Yours faithfully, Tania C. S. Cubison FRCS, Specialist Registrar in Plastic Surgery Tom Clare FRCS, Hand Fellow Department of Plastic Surgery, The Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, UK.

doi:10.1054fojps.2002.3957

Versatility of the semi-rigid ruler in plastic surgery Figure 3--The deeper layers of the lasagne are left intact.

Sir, Shaping and measuring are important aspects of plastic surgical operations; however, it may sometimes be difficult to perform these actions on flexible soft tissues, and plastic surgeons have tried various methods to make things easierJ '2 We have discovered a practical tool that can help to overcome the problems we face in measuring curved distances or planning curved incisions. It consists of a semi-rigid wire covered with plastic. A millimetric scale is printed on the plastic. It can easily be sterilised and the scale does not fade. This device has been used in a number of our operations, and we have found it to be especiaily useful in the following ways. 1. During abdominoplasty, after dissection has been completed, planning an exact copy of the lower incision on the upper

Figure 4--The 'split skin' can be passed through a mesher and expanded.

An assistant supports the ends of the fluid bag with towels, while immobilising and slightly stretching the lasagne skin, and the surgeon directs this in the same manner as during standard skin harvest. The surface of the lasagne sheet is lubricated with oil or water, and the skin knife used with standard to thick settings (Fig. 1). A sheet of 'split skin' can be obtained (Fig. 2), leaving the deeper layers intact (Fig. 3), although this requires a good technique and careful positioning of the assistant. The 'split skin' can then be passed through a mesher and expanded to demonstrate an understanding of this equipment (Fig. 4). This model has been used by various members of the surgical team, and has been found to demonstrate their current skill level. Plastic surgery trainees were able to harvest skin more easily than were nursing staff, and our anaesthetist quickly mastered the technique after a short practice period. The SHOs have been very keen to use this model: it is extremely stressful learning to handle a graft knife on patients because of anxieties about permanent donor-site scarring. Although other training models have been used, they have certain limitations: the use of pig skin has both health and safety issues and cost implications, and foam-rubber substitutes do not cut or mesh well. We recommend the use of lasagne as a simple, cheap and realistic alternative.

Figure 1--The semi-rigid ruler is shaped to match exactly the lower abdominal flap.

Figure 2--Measurement of curved surfaces.