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A modified needleholder for microsurgery—reply
British Journal ofPlastic Surgery (1991). 44.471472 0 1991 The Trustees of British Association of Plastic Surgeons
Letters to the Editor
Local anaesthetics
Removal of unwanted
in dental cartridges
Sir, The problem of unwanted tattoos is on the increase. Due to constraints of finances and heavy work load most units have found it necessary to halt all new referrals. Unfortunately the patients’ regrets are never considered. Fifty six patients who have been on the waiting list for over ten years for removal of tattoos of their hands and forearm were considered for this study. These were all amateur tattoos, inflicted at the age of thirteen to sixteen. All patients were treated under local anaesthesia as outpatients. All patients regretted their tattoos. Fifty one patients (91%) admitted smoking before the age of sixteen. Twelve patients (21%) tried to remove their own tattoos using oven pads and required hospital treatment. Sixteen patients (28.5%) were refused jobs in checkouts of department stores. Twenty two patients (39%) felt that they were discriminated against in hospitals as they were questioned about past history of hepatitis. Twenty patients (35.7%) had been refused entry to night clubs at least once in the past. Six patients were under care of psychiatrists for depression; this included two patients who had a history of drug overdose. Forty patients said their partners had tattoos. All our patients regretted their misfortune and admitted that they had been tattooed due to their immature mental state at the time, and all patients were happy to accept a scar immaterial of the quality. Although various methods for removal of tattoos have been described, removal of amateur and professional tattoos can be a time-consuming and costly undertaking. More should be done to educate the young population in order to prevent these regrets in later life.
Sir, Many plastic surgeons use the dental cartridge syringe system for injecting local anaesthetics. Most, however, have preferred a weaker concentration than the 2% lignocaine with 1 in 80 000 adrenaline which is the standard dental preparation. 0.5% lignocaine with 1 in 200 000 adrenaline has been used for many years, but production of cartridges containing this concentration ceased recently, and most units’ supplies ran out during 1990. In the past few years several individuals have gathered information about the demand amongst plastic surgeons for this product, in the hope that the resulting information would stimulate its reinstatement. Most recently we carried out a survey in mid 1990. Simple questionnaires were sent to 135 consultant Plastic Surgeons in the UK and Ireland; replies were received from 116, an 86% return. Of these, 70% said that they currently used local anaesthetics in dental cartridges. 84 (72%) said that they would be interested in obtaining furthersuppliesof cartridges containing 0.5% lignocaine with 1 in 200 000 adrenaline; 72 gave estimates of the numbers of cartridges they might need annually-these totalled over 92 000.57 (49%) said that they had tried the alternative prefilled glass syringes containing this concentration, but only four said that they found these satisfactory. The position currently is that lignocaine with “dilute” adrenaline is not available in dental cartridges. Although the demand demonstrated by this survey is considerable, it is not enough to persuade any manufacturer to produce this item within Britain. It could, however, almost certainly be obtained in batches from manufacturers in Europe or Scandinavia. This would require permission from the Ministry of Health for “special” importation. This is not an uncommon procedure, but the MoH would need to be convinced of the demand by direct representations from senior surgeons or their representatives. In the meantime, dental cartridges are available containing plain 2% lignocaine, and 2% lignocaine with 1 in 80 000 adrenaline. 0.5% lignocaine with 1 in 200 000 adrenaline is available in 20 ml multidose vials, and in prefilled 5 ml glass and plastic syringes. Although these latter were felt to be unsatisfactory by many of our respondents, they are supplied with a slim flexible needle very similar to that used in the dental cartridge system. Worries were expressed by some respondents about the risk of the glass plunger of this type of syringe breaking and injuring the operator; in response to this the manufacturer is producing a batch with the end covered by a protective plastic cap-which will have the additional advantage of permitting aspiration prior to injection-which has always been a disadvantage of the dental cartridge system. Yours faithfully, Peter Riley FRCS Dept. of Plastic Surgery, Whiston Hospital, Prescot, Merseyside.
tattoos
Yours faithfully, C. Balakrishnan, FRCS, FRCSI, Locum Consultant. R. Papini, FRCS, Rotating Registrar, Dept. of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP.
A modified needleholder microsurgery-reply
for
Sir, This is in reply to the points raised by Dr. Vickers in response to my paper ‘A modified needle holder for microsurgery’. Since papers presented at conferences are not accessible through indexed literature searches, I was unaware of a similar design having been described by Vickers in 1978. However, Vickers (1988) seems to find no advantage in the paraxial design because ‘lateral displacement of the axis of the jaws will produce a circular motion of the needle
Anthony H N Roberts FRCS Dept. of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury. 471
472
British Journal of Plastic Surgery
which may or may not be coincident with its own curvature’ (italics mine). This is true only as long as one is not specific about the magnitude of the offset of the jaws. My point is that when the offset is made equal to the radius of curvature of the needle, it tracks perfectly along its own curvature. This makes it possible to achieve penetration as well as protrusion by a single continuous circular movement, rather than by the biphasic manoeuvre as described by Vickers in relation to the type II instrument. The preference for the ‘propeller-like’ movement of the needle over the smooth curvilinear movement effected by the new design seems inconsistent with the ergonomic point of view. Yours faithfully, Philip Korula, Department of Plastic Surgery, Christian Medical College Hospital, Vellore, India
cutaneous flaps rather than cutaneous flaps. Compared to Morrison, the distance between the pedicle and the flap did not appear to raise any problems. Obry’s model consisted of a group comprising an arteriovenous fistula. Obry, like Morrison, found a significant rate of partial necrosis of the flap (20 to SO%), as well as total necrosis. This model appears to be less reliable. Finally, Morrison considers a survival rate of 50% to be successful. We think that this percentage is probably too low. We were very much impressed by Morrison’s work, especially the histological results, and were disappointed that our work was not mentioned, which we hope is due to the relative lack of awareness of French publications. Yours faithfully, V. Martinot-Duquennoy, M.D., Department of Paediatric Surgery, Hopital Claude Huriez, Centre Hospitalier Regional, 59037 Lille Cedex, France.
Reference Vickers, D. W. (1988). Ergonomic ments. A Decade of Experience. Brunelli, Ed. Masson, p. 12.
Design of Microsurgery InstruIn Textbook ofMicrosurgery. G.
References Martinet-Duquennoy, V., Leps, P., Sdmofs, M., Pa6znotre,P. and Pellerin, P. (1986). Lambeau cutane a ptdicule art&%-veineuz induit: etude experimentale. The induced arteriovenous neovascularisation of skin flaps: an experimental study. Ann&s de
ChirurgiePlastique, 31,291. Obry, C., Lalo, J. and Martinot-Duquennoy, study of axial vascularized
Prefabrication of thin transferable axialpattern skin flaps Sir, We read with much interest the article “Prefabrication of thin transferable axial-pattern skin flaps : an experimental study in rabbits” by W. A. Morrison et al. (British Journal of Plastic Surgery, 43,445). We have performed a similar study in 1986, and Obry et al. have also reported in addition an arterio-venous loop in 1990. We would like to make certain comments with regard to our results and the above publication. Our initial experimental model (1986) was performed on 20 rats, by implanting a femoral pedicle beneath the abdominal skin. The protocol was thus similar to Morrison’s group I. The raised flaps were larger, i.e. 6 x 7 cm. In order to establish that the survival of the flap was indeed due to a neovascularisation, we have laid, in two cases, the flap onto a plastic interface in order to prevent revascularisation from the deep surface. The flaps were raised between 8 to 10 weeks. Our survival rate of the flaps were slightly better than Morrison for the same comparable group I, with the same delay (8 to 12 weeks). In 3 cases there was 100% survival; in 16 cases 70 to 80% survival, and in 2 early and complete necrosis (occurring on the second post-operative day). Methylene blue perfusion allowed a simple means of visualising the vascular tree, thus confirming the neovascularisation. We have observed the presence of a vessel-bearing fascia joining the flap onto the skin. The flap resembles fascio-
V. (1990). Experimental pedicle flap induced in the rat. An&es
de Chirurgie,44,311.
Prefabrication of thin transferable axialpattern skin flaps-reply Sir, We apologise to Dr. Martinot-Duquennoy for not acknowledging the studies of his group on the prefabrication of skin flaps by subcutaneous implantation of a vascular pedicle. Our search of the literature failed to identify his papers. We are very glad to have independent confirmation of our work and especially of the finding that an interval of 8-10 weeks is required between transplantation of the pedicle and successful elevation of the flap. This slow pace of neovascularisation is the major obstacle to clinical application of the technique and we are investigating whether local application of angiogenic factors can accelerate neovascularisation of the flap. Yours faithfully, Wayne A. Morrison, MBBS, FRACS,
Deputy Director and Senior Research Fellow, Microsurgery Research Centre, St. Vincent’s Hospital 41 Victoria Parade Fitzroy 3065 Australia
Letters to the Editor
Local anaesthetics
Removal of unwanted
in dental cartridges
Sir, The problem of unwanted tattoos is on the increase. Due to constraints of finances and heavy work load most units have found it necessary to halt all new referrals. Unfortunately the patients’ regrets are never considered. Fifty six patients who have been on the waiting list for over ten years for removal of tattoos of their hands and forearm were considered for this study. These were all amateur tattoos, inflicted at the age of thirteen to sixteen. All patients were treated under local anaesthesia as outpatients. All patients regretted their tattoos. Fifty one patients (91%) admitted smoking before the age of sixteen. Twelve patients (21%) tried to remove their own tattoos using oven pads and required hospital treatment. Sixteen patients (28.5%) were refused jobs in checkouts of department stores. Twenty two patients (39%) felt that they were discriminated against in hospitals as they were questioned about past history of hepatitis. Twenty patients (35.7%) had been refused entry to night clubs at least once in the past. Six patients were under care of psychiatrists for depression; this included two patients who had a history of drug overdose. Forty patients said their partners had tattoos. All our patients regretted their misfortune and admitted that they had been tattooed due to their immature mental state at the time, and all patients were happy to accept a scar immaterial of the quality. Although various methods for removal of tattoos have been described, removal of amateur and professional tattoos can be a time-consuming and costly undertaking. More should be done to educate the young population in order to prevent these regrets in later life.
Sir, Many plastic surgeons use the dental cartridge syringe system for injecting local anaesthetics. Most, however, have preferred a weaker concentration than the 2% lignocaine with 1 in 80 000 adrenaline which is the standard dental preparation. 0.5% lignocaine with 1 in 200 000 adrenaline has been used for many years, but production of cartridges containing this concentration ceased recently, and most units’ supplies ran out during 1990. In the past few years several individuals have gathered information about the demand amongst plastic surgeons for this product, in the hope that the resulting information would stimulate its reinstatement. Most recently we carried out a survey in mid 1990. Simple questionnaires were sent to 135 consultant Plastic Surgeons in the UK and Ireland; replies were received from 116, an 86% return. Of these, 70% said that they currently used local anaesthetics in dental cartridges. 84 (72%) said that they would be interested in obtaining furthersuppliesof cartridges containing 0.5% lignocaine with 1 in 200 000 adrenaline; 72 gave estimates of the numbers of cartridges they might need annually-these totalled over 92 000.57 (49%) said that they had tried the alternative prefilled glass syringes containing this concentration, but only four said that they found these satisfactory. The position currently is that lignocaine with “dilute” adrenaline is not available in dental cartridges. Although the demand demonstrated by this survey is considerable, it is not enough to persuade any manufacturer to produce this item within Britain. It could, however, almost certainly be obtained in batches from manufacturers in Europe or Scandinavia. This would require permission from the Ministry of Health for “special” importation. This is not an uncommon procedure, but the MoH would need to be convinced of the demand by direct representations from senior surgeons or their representatives. In the meantime, dental cartridges are available containing plain 2% lignocaine, and 2% lignocaine with 1 in 80 000 adrenaline. 0.5% lignocaine with 1 in 200 000 adrenaline is available in 20 ml multidose vials, and in prefilled 5 ml glass and plastic syringes. Although these latter were felt to be unsatisfactory by many of our respondents, they are supplied with a slim flexible needle very similar to that used in the dental cartridge system. Worries were expressed by some respondents about the risk of the glass plunger of this type of syringe breaking and injuring the operator; in response to this the manufacturer is producing a batch with the end covered by a protective plastic cap-which will have the additional advantage of permitting aspiration prior to injection-which has always been a disadvantage of the dental cartridge system. Yours faithfully, Peter Riley FRCS Dept. of Plastic Surgery, Whiston Hospital, Prescot, Merseyside.
tattoos
Yours faithfully, C. Balakrishnan, FRCS, FRCSI, Locum Consultant. R. Papini, FRCS, Rotating Registrar, Dept. of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP.
A modified needleholder microsurgery-reply
for
Sir, This is in reply to the points raised by Dr. Vickers in response to my paper ‘A modified needle holder for microsurgery’. Since papers presented at conferences are not accessible through indexed literature searches, I was unaware of a similar design having been described by Vickers in 1978. However, Vickers (1988) seems to find no advantage in the paraxial design because ‘lateral displacement of the axis of the jaws will produce a circular motion of the needle
Anthony H N Roberts FRCS Dept. of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury. 471
472
British Journal of Plastic Surgery
which may or may not be coincident with its own curvature’ (italics mine). This is true only as long as one is not specific about the magnitude of the offset of the jaws. My point is that when the offset is made equal to the radius of curvature of the needle, it tracks perfectly along its own curvature. This makes it possible to achieve penetration as well as protrusion by a single continuous circular movement, rather than by the biphasic manoeuvre as described by Vickers in relation to the type II instrument. The preference for the ‘propeller-like’ movement of the needle over the smooth curvilinear movement effected by the new design seems inconsistent with the ergonomic point of view. Yours faithfully, Philip Korula, Department of Plastic Surgery, Christian Medical College Hospital, Vellore, India
cutaneous flaps rather than cutaneous flaps. Compared to Morrison, the distance between the pedicle and the flap did not appear to raise any problems. Obry’s model consisted of a group comprising an arteriovenous fistula. Obry, like Morrison, found a significant rate of partial necrosis of the flap (20 to SO%), as well as total necrosis. This model appears to be less reliable. Finally, Morrison considers a survival rate of 50% to be successful. We think that this percentage is probably too low. We were very much impressed by Morrison’s work, especially the histological results, and were disappointed that our work was not mentioned, which we hope is due to the relative lack of awareness of French publications. Yours faithfully, V. Martinot-Duquennoy, M.D., Department of Paediatric Surgery, Hopital Claude Huriez, Centre Hospitalier Regional, 59037 Lille Cedex, France.
Reference Vickers, D. W. (1988). Ergonomic ments. A Decade of Experience. Brunelli, Ed. Masson, p. 12.
Design of Microsurgery InstruIn Textbook ofMicrosurgery. G.
References Martinet-Duquennoy, V., Leps, P., Sdmofs, M., Pa6znotre,P. and Pellerin, P. (1986). Lambeau cutane a ptdicule art&%-veineuz induit: etude experimentale. The induced arteriovenous neovascularisation of skin flaps: an experimental study. Ann&s de
ChirurgiePlastique, 31,291. Obry, C., Lalo, J. and Martinot-Duquennoy, study of axial vascularized
Prefabrication of thin transferable axialpattern skin flaps Sir, We read with much interest the article “Prefabrication of thin transferable axial-pattern skin flaps : an experimental study in rabbits” by W. A. Morrison et al. (British Journal of Plastic Surgery, 43,445). We have performed a similar study in 1986, and Obry et al. have also reported in addition an arterio-venous loop in 1990. We would like to make certain comments with regard to our results and the above publication. Our initial experimental model (1986) was performed on 20 rats, by implanting a femoral pedicle beneath the abdominal skin. The protocol was thus similar to Morrison’s group I. The raised flaps were larger, i.e. 6 x 7 cm. In order to establish that the survival of the flap was indeed due to a neovascularisation, we have laid, in two cases, the flap onto a plastic interface in order to prevent revascularisation from the deep surface. The flaps were raised between 8 to 10 weeks. Our survival rate of the flaps were slightly better than Morrison for the same comparable group I, with the same delay (8 to 12 weeks). In 3 cases there was 100% survival; in 16 cases 70 to 80% survival, and in 2 early and complete necrosis (occurring on the second post-operative day). Methylene blue perfusion allowed a simple means of visualising the vascular tree, thus confirming the neovascularisation. We have observed the presence of a vessel-bearing fascia joining the flap onto the skin. The flap resembles fascio-
V. (1990). Experimental pedicle flap induced in the rat. An&es
de Chirurgie,44,311.
Prefabrication of thin transferable axialpattern skin flaps-reply Sir, We apologise to Dr. Martinot-Duquennoy for not acknowledging the studies of his group on the prefabrication of skin flaps by subcutaneous implantation of a vascular pedicle. Our search of the literature failed to identify his papers. We are very glad to have independent confirmation of our work and especially of the finding that an interval of 8-10 weeks is required between transplantation of the pedicle and successful elevation of the flap. This slow pace of neovascularisation is the major obstacle to clinical application of the technique and we are investigating whether local application of angiogenic factors can accelerate neovascularisation of the flap. Yours faithfully, Wayne A. Morrison, MBBS, FRACS,
Deputy Director and Senior Research Fellow, Microsurgery Research Centre, St. Vincent’s Hospital 41 Victoria Parade Fitzroy 3065 Australia