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Subscapular vascular axis for raising flaps
Short Reports and Correspondence
485
a step-wise decrease in survival with increasing primary tumour thickness. Figure 2 shows the actual slopes of the 5- and 10-year survival curves with progressively thicker tumours, as arrived at by using Cox regression. We found an eight degree slope (8'7o), indicating that for each millimetre increase in primary tumour thickness, we can expect an 8% decrease in both 5- and 10-year survival. Taking some examples to illustrate the application of this formula; the probability of 5-year survival for patients with 4 mm cutaneous melanoma was found to be 0.54, that is 54% of these patients can expect to survive to 5 years (see Fig. 2). The probability of a patient with an 8 mm thick melanoma surviving to 5 years is 0.54 x 0.92 x 0.92 x 0.92 x 0.92 which equals 0.39. The variable 0.92 reflects an 8% (100% 8%=92% or 0.92) decrease in 5-year survival for each millimetre increase in tumour thickness. As 8 mm is 4 mm greater than 4 mm then the 5-year survival for an 8 mm thick tumour may be arrived at by multiplying 0.54 by four lots of 0.92. This formula can be used for all thicknesses of tumour. A 5-year survival of patients with a 12 mm tumour is 0.28, 16mm tumour is 0.2, 2 0 m m tumour is 0.14. This same formula is applicable to 10-year survival. The statistical analyses were performed by the hospital's medical statistician using SPSS statistical software? This finding reveals a mathematical relationship between increasing Breslow thickness and patient mortality. Patients with tumours greater than or equal to 4 mm are generally considered as one prognostic group.: This study has shown that this is not really the case. Earlier authors have identified the ongoing prognostic importance of Breslow thickness, but it has not hitherto been quantified?~ We have been prompted by these findings to ask whether this highly significant prognostic variable may not be worth considering when looking at TCM patient outcomes with adjuvant therapies, e.g. high dose interferon? That is, does increasing thickness also adversely affect treatment outcome? One would think not, as it is systemic therapy aimed at eliminating distant disease. However, such data would be interesting to see and should be easy to retrieve retrospectively. It may also provide useful future selection criteria for what is currently a marginally effective though very toxic treatment.
Survival Times ~"~ ~ , ,
.6
- - -10 years 95%C[-U
\~',,
\, "
= \
.5 -I
-~
10 years 95%C[-L
" , ",
5 years 95%CI-U \,,
.4
lOyears
9
\ ",
c~ 5 years
\
,
\ ',
5 years 95%CI-L
"~,...
.3
\\',
9
o~
\
. \,.
\ k
9 \\
"\
"~'~'c.-. 0.0 0
10
20 Melanoma
30 Thickness
40
50
(mm)
Figure 2 - Probabilities of melanoma patients surviving to 5 and 10 years (with 95% CI's) for a range of primary tumour thicknesses from 4.0 to 35 ram.
Yours faithfully,
Peter Sylaidis FRCS, FRCSI Registrar in Plastic Surgery
Clive Reid FRCS Consultant in Plastic Surgery Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Frenchay, Bristol, UK. Correspondence to Peter Sylaidis, Department of Plastic Surgery, West Norwich Hospital, Norwich NR2 3TU, UK.
References 1. Statisticalpackage for the social scientist. SPSS for Windows release 6.1 1994.SPSS Inc, 444 North Michegan Ave,Chicago, IL 60611. 2. Henson DE, Ries L, Shambaugh EM. Survival results depend on the staging system. Semin Surg Oncol 1992; 8:57 61. 3. Coit D, Sauven E Brennan M. Prognosis of thick cutaneous melanoma of the trunk and extremity. Arch Snrg 1990; 125: 322 6. 4. Buttner R Garbe C, Bertz J, et al. Primary cutaneous melanoma. Optimized cutoff points of tumor thickness and importance of Clark's level for prognostic classification. Cancer 1995; 75:2499 506. 5. Kirkwood JM, Stawderman MH, Ernstoff MS, Smith TJ, Borden EC, Blum RH. Interferon alphs-213adjuvant therapy of high risk resected cutaneous melanoma: the Eastern Co-operative Oncology Group trial EST 1684. J Clin Oncol 1996; 14:7 17.
Subscapular vascular axis for raising flaps Sir, We read with interest the paper by Wu et al describing the use of subscapular vascular axis for raising flaps designed for limb reconstruction.' The authors, all orthopaedic surgeons, are to be complimented for their work on the use of a combination of free flaps for reconstructing large defects. We would like to highlight the fact that the subscapular vascular system is not limited to the latissimus dorsi muscle flap, serratus anterior muscle flap, scapular flap, parascapular flap, ascending scapular flap and the lateral scapular flap as described by these authors. Besides these six flaps, the subscapular axis has the additional potential for other flaps based on the cutaneous branch of the thoracodorsal artery. 24 Although the amount of tissue harvested may be limited, this vessel cannot be ignored as an alternative source of a free flap which can be used either alone or in combination with the latissimus dorsi or serratus anterior muscle flaps for reconstructing difficult defects as has been described in the paper. We have described pedicled subaxillary and the lateral thoracic flaps which are also based on the cutaneous branch of the thoracodorsal artery? ~These flaps have been designed and developed for resurfacing defects on the dorsum of the hand, thumb, fingers and webspaces. They supply thin, pliable and non-hairy skin with a good colour match for resurfacing hand defects. Such transfers are obviously much quicker and, with appropriate aftercare, more reliable also. With the current state of affairs where free flaps rule the
486 roost, the conventional, time honoured and reliable staged transfers should not be written off. Yours faithfully, R. Agarwat MS, MCh, MNAMS Registrar R. Chandra MS, FRCS Professor and Head Post Graduate Department of Plastic and Reconstructive Surgery, King George's Medical College, Lucknow, India.
British Journal of Plastic Surgery A number of studies have concluded the eventual return of some touch, temperature.4 and even pain sensibility4 in the skin following breast reconstruction, but whether this is sufficient to provide any form of protective sensory feedback is unknown. Despite. the findings of 'Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis', these patients are still at risk of accidental burn injury due to sensory loss, and should be warned of this potential complication. Yours faithfully,
References
J.A. Davison MSe, FRCSEd Research Fellow
1. Wu wc, Chang YP, So YC, Ip WY, Lam CK, Lain JJ. The combined use of flaps based on the subscapular vascular system for limb reconstruction. Br J Plast Surg 1997; 50: 73-80. 2. YangZN, Shih H-R, Chao L, Shih TS. Free Transplantation of sub-axillary lateral thoracodorsal flap in burn surgery. Burns 1983; 10: 1649. 3. Cabanie H, Garbe J-F, Guimberteau J-C. Anatomical basis of the thoracodorsal axillary flap with respect to its transfer by means of microvascular surgery. Anatomica Clinic 1980; 2: 65-73. 4. Coninck A de, Vanderlinden E, Boeckx W. The thoracodorsal skin flap: A possible donor site in distant transfer of island flaps by microvascular anastomosis. Chirurgia Plastica 1976; 3: 283-91. 5. Chandra R, Kumar R Abdi SHM. The subaxillary pedicled flap. Br J Plast Surg 1988;41: 16%73. 6. Bhattacharya S, Bhagia SR Bhatnagar SK, Chandra R. The lateral thoracic region flap. Br J Plast Surg 1990;43:162-8. 7. Bhattacharya S, Pandey SD, Chandra R, Bhatnagar SK. Lateral chest wall fasciocutaneous flaps in the management of burn contractures on the dorsum of the hand. Eur J Plast Surg 1988; 11: 8-11. 8. Bhattacharya S, Bhagia SP, Bhatnagar SK, Abdi SHM, Chandra R. The anatomical basis of the lateral thoracic flap. Eur J Plast Surg 1990; 13: 238-40.
D.M. Mercer FRCS Consultant Plastic Surgeon
Accidental burn following subcutaneous mastectomy and reconstruction with a prosthesis Sir, The paper 'Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis', 1which assessed touch sensation using yon Frey's monofilaments, concludes that 'touch is substantially retained in the skin of the reconstructed breast'. We report a patient who underwent subcutaneous mastectomy and reconstruction with an implant, using inframammary incision and a subcutaneously located prosthesis (Group D in the above study). Six months after surgery she presented with a full thickness burn to the lower outer quadrant of the breast (i.e. below and lateral to the scar). This had been caused by contact with a hot water bottle, although the patient was unaware of the injury until the following morning. She was taken to theatre where the burn was excised. The defect, which extended down onto the surface of the implant, was covered with a local transposition flap. Postoperatively the wound healed with no underlying problem but she was left with a scar. The accidental burns to reconstructed breasts which have been reported in the literature,~.3have followed myocutaneous flap reconstruction. It is clearly important to warn patients of this potential complication. Injury has ranged from 2 months to 5 years following surgery, and treatment of the burns has ranged from dressings through to revision free flap surgery.
Department of Plastic and Reconstructive Surgery, St. Thomas' Hospital, London, UK. Correspondence to Mr J. A. Davison, Breast Fellow, Department of Plastic Surgery, Bradford Royal Infirmary, Duckworth Lane, Bradford BO9 6R J, UK.
References 1. Benediktsson KP, Perbeck L, Geigant E, Solders G. Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis. Br J Plast Surg 1997; 50:443 9. 2. Lejour M. Burn of a reconstructed breast. Plast Reconstr Surg 1996; 97: 1306-7. 3. MaxwellGP, Tornambe R. Second- and Third-degree burns as a complication in breast reconstruction. Ann Plast Surg 1989; 22: 386-90. 4. Liew S, Hunt J, Pennington D. Sensory recovery followingfree TRAM flap breast reconstruction. Br J Plast Surg 1996; 49: 210 13. 5. SlezakS, McGibbon B, Dellon AL. The Sensational Transverse Rectus Abdominis Musculocutaneous (TRAM) Flap: Return of Sensibilityafter TRAM Breast Reconstruction. Ann Plast Surg 1992; 28: 210-17. 6. Lehmann C, Gumener R, Montandon D. Sensibility and Cutaneous Reinnervation after Breast Reconstruction with Musculocutaneous Flaps. Ann Plast Surg 1991; 26: 325-7.
Cutting diathermy for removal of implants Sir, We report the use of cutting diathermy for capsulotomy and removal of silicone implants. The silicone shell does not conduct electricity and diathermy can safely be used in close contact with the implant with no risk of rupture. Surgical diathermy involves the passage of high frequency alternating current through body tissues; where the current is locally concentrated, heat is produced. Its uses and hazards in clinical practice are widely described. Cutting diathermy involves a continuous output, causing an arc to be struck between the active electrode and the tissue. Temperatures up to 1000~ are produced resulting in vaporization of cell water and tissue disruption with a variable degree of coagulation of bleeding vessels. The shell of tissue expanders, saline-filled and silicone gelfilled implants is fabricated from high viscosity silicone rubber elastomer produced by the cross-linking of poly-
485
a step-wise decrease in survival with increasing primary tumour thickness. Figure 2 shows the actual slopes of the 5- and 10-year survival curves with progressively thicker tumours, as arrived at by using Cox regression. We found an eight degree slope (8'7o), indicating that for each millimetre increase in primary tumour thickness, we can expect an 8% decrease in both 5- and 10-year survival. Taking some examples to illustrate the application of this formula; the probability of 5-year survival for patients with 4 mm cutaneous melanoma was found to be 0.54, that is 54% of these patients can expect to survive to 5 years (see Fig. 2). The probability of a patient with an 8 mm thick melanoma surviving to 5 years is 0.54 x 0.92 x 0.92 x 0.92 x 0.92 which equals 0.39. The variable 0.92 reflects an 8% (100% 8%=92% or 0.92) decrease in 5-year survival for each millimetre increase in tumour thickness. As 8 mm is 4 mm greater than 4 mm then the 5-year survival for an 8 mm thick tumour may be arrived at by multiplying 0.54 by four lots of 0.92. This formula can be used for all thicknesses of tumour. A 5-year survival of patients with a 12 mm tumour is 0.28, 16mm tumour is 0.2, 2 0 m m tumour is 0.14. This same formula is applicable to 10-year survival. The statistical analyses were performed by the hospital's medical statistician using SPSS statistical software? This finding reveals a mathematical relationship between increasing Breslow thickness and patient mortality. Patients with tumours greater than or equal to 4 mm are generally considered as one prognostic group.: This study has shown that this is not really the case. Earlier authors have identified the ongoing prognostic importance of Breslow thickness, but it has not hitherto been quantified?~ We have been prompted by these findings to ask whether this highly significant prognostic variable may not be worth considering when looking at TCM patient outcomes with adjuvant therapies, e.g. high dose interferon? That is, does increasing thickness also adversely affect treatment outcome? One would think not, as it is systemic therapy aimed at eliminating distant disease. However, such data would be interesting to see and should be easy to retrieve retrospectively. It may also provide useful future selection criteria for what is currently a marginally effective though very toxic treatment.
Survival Times ~"~ ~ , ,
.6
- - -10 years 95%C[-U
\~',,
\, "
= \
.5 -I
-~
10 years 95%C[-L
" , ",
5 years 95%CI-U \,,
.4
lOyears
9
\ ",
c~ 5 years
\
,
\ ',
5 years 95%CI-L
"~,...
.3
\\',
9
o~
\
. \,.
\ k
9 \\
"\
"~'~'c.-. 0.0 0
10
20 Melanoma
30 Thickness
40
50
(mm)
Figure 2 - Probabilities of melanoma patients surviving to 5 and 10 years (with 95% CI's) for a range of primary tumour thicknesses from 4.0 to 35 ram.
Yours faithfully,
Peter Sylaidis FRCS, FRCSI Registrar in Plastic Surgery
Clive Reid FRCS Consultant in Plastic Surgery Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Frenchay, Bristol, UK. Correspondence to Peter Sylaidis, Department of Plastic Surgery, West Norwich Hospital, Norwich NR2 3TU, UK.
References 1. Statisticalpackage for the social scientist. SPSS for Windows release 6.1 1994.SPSS Inc, 444 North Michegan Ave,Chicago, IL 60611. 2. Henson DE, Ries L, Shambaugh EM. Survival results depend on the staging system. Semin Surg Oncol 1992; 8:57 61. 3. Coit D, Sauven E Brennan M. Prognosis of thick cutaneous melanoma of the trunk and extremity. Arch Snrg 1990; 125: 322 6. 4. Buttner R Garbe C, Bertz J, et al. Primary cutaneous melanoma. Optimized cutoff points of tumor thickness and importance of Clark's level for prognostic classification. Cancer 1995; 75:2499 506. 5. Kirkwood JM, Stawderman MH, Ernstoff MS, Smith TJ, Borden EC, Blum RH. Interferon alphs-213adjuvant therapy of high risk resected cutaneous melanoma: the Eastern Co-operative Oncology Group trial EST 1684. J Clin Oncol 1996; 14:7 17.
Subscapular vascular axis for raising flaps Sir, We read with interest the paper by Wu et al describing the use of subscapular vascular axis for raising flaps designed for limb reconstruction.' The authors, all orthopaedic surgeons, are to be complimented for their work on the use of a combination of free flaps for reconstructing large defects. We would like to highlight the fact that the subscapular vascular system is not limited to the latissimus dorsi muscle flap, serratus anterior muscle flap, scapular flap, parascapular flap, ascending scapular flap and the lateral scapular flap as described by these authors. Besides these six flaps, the subscapular axis has the additional potential for other flaps based on the cutaneous branch of the thoracodorsal artery. 24 Although the amount of tissue harvested may be limited, this vessel cannot be ignored as an alternative source of a free flap which can be used either alone or in combination with the latissimus dorsi or serratus anterior muscle flaps for reconstructing difficult defects as has been described in the paper. We have described pedicled subaxillary and the lateral thoracic flaps which are also based on the cutaneous branch of the thoracodorsal artery? ~These flaps have been designed and developed for resurfacing defects on the dorsum of the hand, thumb, fingers and webspaces. They supply thin, pliable and non-hairy skin with a good colour match for resurfacing hand defects. Such transfers are obviously much quicker and, with appropriate aftercare, more reliable also. With the current state of affairs where free flaps rule the
486 roost, the conventional, time honoured and reliable staged transfers should not be written off. Yours faithfully, R. Agarwat MS, MCh, MNAMS Registrar R. Chandra MS, FRCS Professor and Head Post Graduate Department of Plastic and Reconstructive Surgery, King George's Medical College, Lucknow, India.
British Journal of Plastic Surgery A number of studies have concluded the eventual return of some touch, temperature.4 and even pain sensibility4 in the skin following breast reconstruction, but whether this is sufficient to provide any form of protective sensory feedback is unknown. Despite. the findings of 'Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis', these patients are still at risk of accidental burn injury due to sensory loss, and should be warned of this potential complication. Yours faithfully,
References
J.A. Davison MSe, FRCSEd Research Fellow
1. Wu wc, Chang YP, So YC, Ip WY, Lam CK, Lain JJ. The combined use of flaps based on the subscapular vascular system for limb reconstruction. Br J Plast Surg 1997; 50: 73-80. 2. YangZN, Shih H-R, Chao L, Shih TS. Free Transplantation of sub-axillary lateral thoracodorsal flap in burn surgery. Burns 1983; 10: 1649. 3. Cabanie H, Garbe J-F, Guimberteau J-C. Anatomical basis of the thoracodorsal axillary flap with respect to its transfer by means of microvascular surgery. Anatomica Clinic 1980; 2: 65-73. 4. Coninck A de, Vanderlinden E, Boeckx W. The thoracodorsal skin flap: A possible donor site in distant transfer of island flaps by microvascular anastomosis. Chirurgia Plastica 1976; 3: 283-91. 5. Chandra R, Kumar R Abdi SHM. The subaxillary pedicled flap. Br J Plast Surg 1988;41: 16%73. 6. Bhattacharya S, Bhagia SR Bhatnagar SK, Chandra R. The lateral thoracic region flap. Br J Plast Surg 1990;43:162-8. 7. Bhattacharya S, Pandey SD, Chandra R, Bhatnagar SK. Lateral chest wall fasciocutaneous flaps in the management of burn contractures on the dorsum of the hand. Eur J Plast Surg 1988; 11: 8-11. 8. Bhattacharya S, Bhagia SP, Bhatnagar SK, Abdi SHM, Chandra R. The anatomical basis of the lateral thoracic flap. Eur J Plast Surg 1990; 13: 238-40.
D.M. Mercer FRCS Consultant Plastic Surgeon
Accidental burn following subcutaneous mastectomy and reconstruction with a prosthesis Sir, The paper 'Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis', 1which assessed touch sensation using yon Frey's monofilaments, concludes that 'touch is substantially retained in the skin of the reconstructed breast'. We report a patient who underwent subcutaneous mastectomy and reconstruction with an implant, using inframammary incision and a subcutaneously located prosthesis (Group D in the above study). Six months after surgery she presented with a full thickness burn to the lower outer quadrant of the breast (i.e. below and lateral to the scar). This had been caused by contact with a hot water bottle, although the patient was unaware of the injury until the following morning. She was taken to theatre where the burn was excised. The defect, which extended down onto the surface of the implant, was covered with a local transposition flap. Postoperatively the wound healed with no underlying problem but she was left with a scar. The accidental burns to reconstructed breasts which have been reported in the literature,~.3have followed myocutaneous flap reconstruction. It is clearly important to warn patients of this potential complication. Injury has ranged from 2 months to 5 years following surgery, and treatment of the burns has ranged from dressings through to revision free flap surgery.
Department of Plastic and Reconstructive Surgery, St. Thomas' Hospital, London, UK. Correspondence to Mr J. A. Davison, Breast Fellow, Department of Plastic Surgery, Bradford Royal Infirmary, Duckworth Lane, Bradford BO9 6R J, UK.
References 1. Benediktsson KP, Perbeck L, Geigant E, Solders G. Touch sensibility in the breast after subcutaneous mastectomy and immediate reconstruction with a prosthesis. Br J Plast Surg 1997; 50:443 9. 2. Lejour M. Burn of a reconstructed breast. Plast Reconstr Surg 1996; 97: 1306-7. 3. MaxwellGP, Tornambe R. Second- and Third-degree burns as a complication in breast reconstruction. Ann Plast Surg 1989; 22: 386-90. 4. Liew S, Hunt J, Pennington D. Sensory recovery followingfree TRAM flap breast reconstruction. Br J Plast Surg 1996; 49: 210 13. 5. SlezakS, McGibbon B, Dellon AL. The Sensational Transverse Rectus Abdominis Musculocutaneous (TRAM) Flap: Return of Sensibilityafter TRAM Breast Reconstruction. Ann Plast Surg 1992; 28: 210-17. 6. Lehmann C, Gumener R, Montandon D. Sensibility and Cutaneous Reinnervation after Breast Reconstruction with Musculocutaneous Flaps. Ann Plast Surg 1991; 26: 325-7.
Cutting diathermy for removal of implants Sir, We report the use of cutting diathermy for capsulotomy and removal of silicone implants. The silicone shell does not conduct electricity and diathermy can safely be used in close contact with the implant with no risk of rupture. Surgical diathermy involves the passage of high frequency alternating current through body tissues; where the current is locally concentrated, heat is produced. Its uses and hazards in clinical practice are widely described. Cutting diathermy involves a continuous output, causing an arc to be struck between the active electrode and the tissue. Temperatures up to 1000~ are produced resulting in vaporization of cell water and tissue disruption with a variable degree of coagulation of bleeding vessels. The shell of tissue expanders, saline-filled and silicone gelfilled implants is fabricated from high viscosity silicone rubber elastomer produced by the cross-linking of poly-