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Pre-existing venous disease and the gastrocnemius muscle flap
Short reports and correspondence
Figure 1--The patient is positioned in the 70~ sitting-up position. Both arms are abducted to 90~ and secured to the arm-rests with tubi-grip, seen prior to final draping. Marking of the breasts is carried out as a sterile procedure. We carry out the marking of the breast and perform breastreduction surgery with the anaesthetised patient in the sitting position to avoid these problems (Fig. 1). This facilitates the planning of the operation, the surgery and the final assessment of the result of surgery before completion of the procedure. After intubation, the patient is positioned in the 'sitting' position (70 ~ flexion at the hip joint). The arms are abducted at 90 ~ and immobilised on the arm-rests with tubi-grip. The head is immobilised on a head ring in an upright position. After skin preparation and draping, the operative markings are made as a sterile procedure. This adds approximately 7 min to the operation time. The operation is performed under normotensive anaesthesia. We have used this position for bilateral reduction mammaplasty for the last 16 years, both in the National Health Service and the private sector. We have had no complications related to the sitting position. We recommend this position for both bilateral and unilateral reduction mammaplasty, and believe that the aesthetic outcome is improved by keeping the anatomical landmarks of the breasts in relatively normal undisplaced positions during the operation. We have found the sitting position especially useful for correcting asymmetry of the breasts.
559 the flap are rare. In 85% of cases the muscle bellies have a type 1 blood supply (single pedicle to each belly), while the remainder have a type 2 supply (double pedicle to the belly). Isolated high-grade stenosis of the sural artery has been described as the cause of flap failure on one occasion. 6 We have recently used this flap to cover a primary knee replacement at the time of insertion. The patient was 74 years old, with a history of varicose veins and deep venous thrombosis affecting the leg in question. Previous knee surgery had left a medial scar that could not be included in the arthroplasty incision. There was concern that the skin bridge between the scars would necrose, exposing the prosthesis. For this reason it was decided to excise the intervening skin and immediately reconstruct the defect with a gastrocnemius muscle flap. After total knee arthroplasty, the medial belly of the gastrocnemius muscle was exposed in the standard manner through a posterior midline incision. The muscle was found to be contracted and fibrotic, making it difficult to transpose, and it only just reached the midline anteriorly below the patella (Fig. 1). The flap was covered with a skin graft and fortunately healed without incident. A review of the literature on the use of the gastrocnemius muscle did not reveal any difficulty in raising a useful healthy flap unless there was an anomalous vascular pedicle. We advise caution in the use of this muscle in patients with pre-existing venous disease, and surgeons should be prepared to use an alternative or additional flap if necessary. 7 Yours faithfully, D. Hedley FRCS, Senior House Officer Department of Orthopaedics, Arrowe Park Hospital, Upton, Merseyside L49 5PE, UK.
Yours faithfully, Peter O ' l t a r e FRCS, Consultant Plastic Surgeon Shailesh Vadodaria FRCS(Plast), Senior Specialist Registrar 24 Gisbourne Road, Sheffield, S11 7HB, UK. doi: 10.1054/bjps.2001.3621
Pre-existing venous disease and the gastrocnemius muscle flap Sir, The gastrocnemius muscle flap is well recognised for coverage of the anterior aspect of the knee following the exposure of a knee prosthesis and associated infection. 1,2 Indeed, many surgeons now routinely use this flap when carrying out revision arthroplasty because of the high incidence of wound breakdown and exposure. 3'4 The gastrocnemius muscle flap is very robust, with the medial and/or lateral bellies being raised on the medial or lateral sural vessels, and can easily cover the anterior of the knee and lower thigh. It can also be raised as a free flap. 5 Difficulties in raising
Figure 1--Medial gastrocnemius muscle flap inset medially below the patella.
560 D. A. Munnoch FRCSEd, Specialist Registrar in Plastic Surgery K. Hancock FRCS, FRCS(PIast), Consultant Plastic Surgeon Department of Plastic Surgery, Whiston Hospital, Prescot, Merseyside L35 5DR, UK.
References 1. Gerwin M, Rothaus KO, Windsor RE, Brause BD, Insall JN. Gastrocnemius muscle flap coverage of exposed or infected knee prostheses. Clin Orthop 1993; 286: 64-70. 2. Greenberg B, LaRossa D, Lotke PA, Murphy JB, Noone RB. Salvage of jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap. Plast Reconstr Surg 1989; 83: 85-9. 3. Browne EZ Jr, Stulberg BN, Sood R. The use of muscle flaps for salvage of failed total knee arthroplasty. Br J Hast Surg 1994; 47: 42-5. 4. McPherson EJ, Patzakis MJ, Gross JE, Holtom PD, Song M, Dorr LD. Infected total knee arthroplasty: two-stage reimplantation with a gastrocnemius rotational flap. Clin Orthop 1997; 341: 73-81. 5. Potparl6 Z, Colen LB, ~udur D, Carwell GR, Carraway JH. The gastrocnemius muscle as a free-flap donor site. Plast Reconstr Surg 1995; 95: 1245-52. 6. Mendez-Fernandez MA. Failure of a gastrocnemius muscle flap due to an isolated high-grade stenosis of the sural artery. Ann Plast Surg 1998; 40: 186-8. 7. Laing JHE, Hancock K, Harrison DH. The exposed total knee replacement prosthesis: a new classification and treatment algorithm. Br J Plast Surg 1992; 45: 66-9.
British Journal of Plastic Surgery (Fig. 1). The overlying skin element is formed by porcine skin that is conformable to the bag of saline and semi-physiological (Fig. 2). Thereafter, any skin-graft harvesting technique can be practised. Pig skin is used because it is an excellent human-skin substitute that is readily available, cheap and can be stored in the freezer. Split skin can be harvested by any technique, including the use of a manual dermatome such as the Watson knife or a compressed-air powered dermatome such as the Zimmer dermatome, which allows for good control of the oscillating blade (Fig. 3). It is very difficult to harvest a split-skin graft from a dead pig due to the laxity of the skin, and hence the apparatus is constructed in such a way as to allow a graft to be taken without the need for an assistant. However, an assistant, as in the reallife situation, can use wooden boards to flatten the graft bed. The surgeon in training or assessment can practise with variable blade settings, pressures and skin-blade angles until he or she is competent at taking 'grafts' of the required size and thickness. On completion, the thickness, size and accuracy of the graft can be assessed. Once harvested, grafts can be either used as they are or meshed, with or without expansion. In addition, a fullthickness recipient site can be manufactured. This allows the
doi: 10.1054/bjps.2001.3602
Surgical simulation in plastic surgery Sir, We present a device that is currently being used to simulate skin-graft harvesting. We envisage that the device will be useful as both a teaching and a patient-education aid. With the advent of junior doctors' working hours and the inevitable reduction in experience gained during operating-theatre time, surgeons in training are under pressure to learn and practise new techniques in the surgical workshop. There is a need to reduce the patient morbidity associated with the learning curve of any new operative procedure. With the accelerating pace of technical innovation in surgery, the skills required to perform a number of different operative procedures can now be learned and practised on artificial simulators.1 When sufficient skill, competence and confidence have been gained, trainees are allowed to practise the craft of surgery on their own For many years, dental students have been taught, and examined on, basic and advanced operative techniques on 'phantom' heads containing real teeth before being allowed to operate on human volunteers. The correct harvesting of a split-skin graft requires a level of technical skill and confidence that can only be acquired through practice. With respect to split-skin harvesting, the morbidity associated with an incorrect technique is high, resulting in harvesting from another donor site. As a result, we have developed a simulator on which to practise the art of split-skin graft harvesting. Initial reproductions of skin-graft harvesting techniques rely on synthetic materials; however, no consideration is given to the physiological properties of skin that are encountered in human grafting. Using simplified models based on concepts in the recent literature 2 we have developed an advanced simulator. The simulator comprises a wooden mechanical base with two side arms that secure and stretch the skin substitute, using spikes, over a synthetic limb segment. The limb segment is formed by a 500 ml bag of crystalloid to which is added a further 150-250 ml of water to create the required turgot and shape
Figure 1--The simulator is constructed from a wooden mechanical base with two side arms that secure and stretch the skin substitute over a synthetic limb segment formed from a 500ml bag of crystalloid to which is added a further 150-250ml of water to create the required turgor and shape.
Figure 2--The overlying skin element is formed from porcine skin, which is conformable to the bag of saline and semi-physiological.
Figure 1--The patient is positioned in the 70~ sitting-up position. Both arms are abducted to 90~ and secured to the arm-rests with tubi-grip, seen prior to final draping. Marking of the breasts is carried out as a sterile procedure. We carry out the marking of the breast and perform breastreduction surgery with the anaesthetised patient in the sitting position to avoid these problems (Fig. 1). This facilitates the planning of the operation, the surgery and the final assessment of the result of surgery before completion of the procedure. After intubation, the patient is positioned in the 'sitting' position (70 ~ flexion at the hip joint). The arms are abducted at 90 ~ and immobilised on the arm-rests with tubi-grip. The head is immobilised on a head ring in an upright position. After skin preparation and draping, the operative markings are made as a sterile procedure. This adds approximately 7 min to the operation time. The operation is performed under normotensive anaesthesia. We have used this position for bilateral reduction mammaplasty for the last 16 years, both in the National Health Service and the private sector. We have had no complications related to the sitting position. We recommend this position for both bilateral and unilateral reduction mammaplasty, and believe that the aesthetic outcome is improved by keeping the anatomical landmarks of the breasts in relatively normal undisplaced positions during the operation. We have found the sitting position especially useful for correcting asymmetry of the breasts.
559 the flap are rare. In 85% of cases the muscle bellies have a type 1 blood supply (single pedicle to each belly), while the remainder have a type 2 supply (double pedicle to the belly). Isolated high-grade stenosis of the sural artery has been described as the cause of flap failure on one occasion. 6 We have recently used this flap to cover a primary knee replacement at the time of insertion. The patient was 74 years old, with a history of varicose veins and deep venous thrombosis affecting the leg in question. Previous knee surgery had left a medial scar that could not be included in the arthroplasty incision. There was concern that the skin bridge between the scars would necrose, exposing the prosthesis. For this reason it was decided to excise the intervening skin and immediately reconstruct the defect with a gastrocnemius muscle flap. After total knee arthroplasty, the medial belly of the gastrocnemius muscle was exposed in the standard manner through a posterior midline incision. The muscle was found to be contracted and fibrotic, making it difficult to transpose, and it only just reached the midline anteriorly below the patella (Fig. 1). The flap was covered with a skin graft and fortunately healed without incident. A review of the literature on the use of the gastrocnemius muscle did not reveal any difficulty in raising a useful healthy flap unless there was an anomalous vascular pedicle. We advise caution in the use of this muscle in patients with pre-existing venous disease, and surgeons should be prepared to use an alternative or additional flap if necessary. 7 Yours faithfully, D. Hedley FRCS, Senior House Officer Department of Orthopaedics, Arrowe Park Hospital, Upton, Merseyside L49 5PE, UK.
Yours faithfully, Peter O ' l t a r e FRCS, Consultant Plastic Surgeon Shailesh Vadodaria FRCS(Plast), Senior Specialist Registrar 24 Gisbourne Road, Sheffield, S11 7HB, UK. doi: 10.1054/bjps.2001.3621
Pre-existing venous disease and the gastrocnemius muscle flap Sir, The gastrocnemius muscle flap is well recognised for coverage of the anterior aspect of the knee following the exposure of a knee prosthesis and associated infection. 1,2 Indeed, many surgeons now routinely use this flap when carrying out revision arthroplasty because of the high incidence of wound breakdown and exposure. 3'4 The gastrocnemius muscle flap is very robust, with the medial and/or lateral bellies being raised on the medial or lateral sural vessels, and can easily cover the anterior of the knee and lower thigh. It can also be raised as a free flap. 5 Difficulties in raising
Figure 1--Medial gastrocnemius muscle flap inset medially below the patella.
560 D. A. Munnoch FRCSEd, Specialist Registrar in Plastic Surgery K. Hancock FRCS, FRCS(PIast), Consultant Plastic Surgeon Department of Plastic Surgery, Whiston Hospital, Prescot, Merseyside L35 5DR, UK.
References 1. Gerwin M, Rothaus KO, Windsor RE, Brause BD, Insall JN. Gastrocnemius muscle flap coverage of exposed or infected knee prostheses. Clin Orthop 1993; 286: 64-70. 2. Greenberg B, LaRossa D, Lotke PA, Murphy JB, Noone RB. Salvage of jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap. Plast Reconstr Surg 1989; 83: 85-9. 3. Browne EZ Jr, Stulberg BN, Sood R. The use of muscle flaps for salvage of failed total knee arthroplasty. Br J Hast Surg 1994; 47: 42-5. 4. McPherson EJ, Patzakis MJ, Gross JE, Holtom PD, Song M, Dorr LD. Infected total knee arthroplasty: two-stage reimplantation with a gastrocnemius rotational flap. Clin Orthop 1997; 341: 73-81. 5. Potparl6 Z, Colen LB, ~udur D, Carwell GR, Carraway JH. The gastrocnemius muscle as a free-flap donor site. Plast Reconstr Surg 1995; 95: 1245-52. 6. Mendez-Fernandez MA. Failure of a gastrocnemius muscle flap due to an isolated high-grade stenosis of the sural artery. Ann Plast Surg 1998; 40: 186-8. 7. Laing JHE, Hancock K, Harrison DH. The exposed total knee replacement prosthesis: a new classification and treatment algorithm. Br J Plast Surg 1992; 45: 66-9.
British Journal of Plastic Surgery (Fig. 1). The overlying skin element is formed by porcine skin that is conformable to the bag of saline and semi-physiological (Fig. 2). Thereafter, any skin-graft harvesting technique can be practised. Pig skin is used because it is an excellent human-skin substitute that is readily available, cheap and can be stored in the freezer. Split skin can be harvested by any technique, including the use of a manual dermatome such as the Watson knife or a compressed-air powered dermatome such as the Zimmer dermatome, which allows for good control of the oscillating blade (Fig. 3). It is very difficult to harvest a split-skin graft from a dead pig due to the laxity of the skin, and hence the apparatus is constructed in such a way as to allow a graft to be taken without the need for an assistant. However, an assistant, as in the reallife situation, can use wooden boards to flatten the graft bed. The surgeon in training or assessment can practise with variable blade settings, pressures and skin-blade angles until he or she is competent at taking 'grafts' of the required size and thickness. On completion, the thickness, size and accuracy of the graft can be assessed. Once harvested, grafts can be either used as they are or meshed, with or without expansion. In addition, a fullthickness recipient site can be manufactured. This allows the
doi: 10.1054/bjps.2001.3602
Surgical simulation in plastic surgery Sir, We present a device that is currently being used to simulate skin-graft harvesting. We envisage that the device will be useful as both a teaching and a patient-education aid. With the advent of junior doctors' working hours and the inevitable reduction in experience gained during operating-theatre time, surgeons in training are under pressure to learn and practise new techniques in the surgical workshop. There is a need to reduce the patient morbidity associated with the learning curve of any new operative procedure. With the accelerating pace of technical innovation in surgery, the skills required to perform a number of different operative procedures can now be learned and practised on artificial simulators.1 When sufficient skill, competence and confidence have been gained, trainees are allowed to practise the craft of surgery on their own For many years, dental students have been taught, and examined on, basic and advanced operative techniques on 'phantom' heads containing real teeth before being allowed to operate on human volunteers. The correct harvesting of a split-skin graft requires a level of technical skill and confidence that can only be acquired through practice. With respect to split-skin harvesting, the morbidity associated with an incorrect technique is high, resulting in harvesting from another donor site. As a result, we have developed a simulator on which to practise the art of split-skin graft harvesting. Initial reproductions of skin-graft harvesting techniques rely on synthetic materials; however, no consideration is given to the physiological properties of skin that are encountered in human grafting. Using simplified models based on concepts in the recent literature 2 we have developed an advanced simulator. The simulator comprises a wooden mechanical base with two side arms that secure and stretch the skin substitute, using spikes, over a synthetic limb segment. The limb segment is formed by a 500 ml bag of crystalloid to which is added a further 150-250 ml of water to create the required turgot and shape
Figure 1--The simulator is constructed from a wooden mechanical base with two side arms that secure and stretch the skin substitute over a synthetic limb segment formed from a 500ml bag of crystalloid to which is added a further 150-250ml of water to create the required turgor and shape.
Figure 2--The overlying skin element is formed from porcine skin, which is conformable to the bag of saline and semi-physiological.