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Earlobe vs. ear lobule
Short reports and correspondence
Four limbs were initially amputated at a level distal to the limit of arterial flow/bone viability that was suggested by imaging and all of these were revised to a higher level. Three limbs were amputated at or very close to the limit of viability and in this subgroup two stumps were revised. The remaining four limbs were amputated proximal to the limit of suggested viability and two stumps had wound breakdown but no revisions were performed. In the case of the patient who had a bone scan, this was a 3-year-old girl who had quadrilateral amputations in the third week of her illness. Bone scan showed viability to the upper tibiae, to upper left forearm and to mid right forearm. Initial amputation levels were bilateral TKA and bilateral distal forearms. Neither of the lower limb stumps required revision although one needed some further debridement. Both of the distal forearm amputations, which were each fashioned beyond the level of viability as shown by the bone scan, went on to be revised proximally. This demonstrates that the bone scan is an important adjunct to the planning of amputation in this condition. As a result of these findings we suggest that all children with meningococcal septicaemia who require amputation of major limb segments are investigated with bone scans and/or arterial Doppler studies. Surgeons should select a level of amputation that is proximal to the imaged limit of viability. We acknowledge that the decision over the timing and extent of amputation in this age group is never easy. It should be made in a multidisciplinary setting with appropriate involvement and counselling of the child’s parents.
References 1. Treharne LJ, Banwell P, Cadier M. Mandatory bone scans for the assessment of extremity loss in meningococcal septicaemia? Br J Plast Surg 2003;56:55—6. 2. Herrera R, Hobar C, Ginsberg CM. Surgical intervention for the complications of meningococcal induced purpura fulminans. Pediatr Infect Dis J 1994;13(8):734—7. 3. Wheeler JS, Anderson BJ, De Chalain TM. Surgical interventions in children with meningococcal purpura fulminans—a review of 117 procedures in 21 children. J Pediatr Surg 2003; 38(4):597—603. 4. Silbart S, Oppenheim W. Purpura fulminans. Medical, surgical, and rehabilitative considerations. Clin Orthop 1985;(193): 206—13.
Oliver J.H. Harley, Omar A. Ahmed, Roy L.H. Ng Department of Plastic Surgery, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK doi:10.1016/j.bjps.2003.11.016
175
Earlobe vs. ear lobule I read the correspondence from Mr Griffiths1 in response to the article by Singh and Singh2 with great interest. While one is taught in Medical School that ‘lobule’ is the correct nomenclature, not ‘earlobe’—there seems to be an amazing amount of confusion regarding this. As Mr Griffiths has pointed out—the major anatomy textbooks prefer lobule over earlobe. However, earlobe, not earlobule is the term accepted by all major dictionaries (Oxford, Webster etc.). Webster’s dictionary3 instructs that lobule [Cf. F. lobule, dim. of lobe] is a small lobe or a subdivision of a lobe. It also says that ‘Lobule of the ear’ (Anat.) is the same as ‘Lobe of the ear’. Coming to the medical literature, the popular textbooks ‘Plastic Surgery’ by McCarthy4 and ‘Grabb and Smith’s Plastic Surgery’5 both use only the word earlobe and not lobule. A search of OVID Medling (http://www.sun.bma.org.uk/ovidweb_T/ ovidweb.cgi) (1996 to present) shows 440 entries for earlobe, only one for ‘earlobule’ and 23 for ‘ear lobule’. The only relatively recent article on anatomical nomenclature of facial parts6 uses the word lobe first and provides lobule as an alternative name. Looking into the websites of the leading Plastic Surgery bodies—the American Society of Plastic Surgeons (http://www.plsticsurgery.org/ news_room/Terms-and-Definitions.cfm) uses the term earlobe only. So does the British Association of Aesthetic Plastic Surgeons in a couple of their information leaflets (http://www.baaps.org.uk/ pdf/Prominentears.pdf and http://www.baaps. org.uk/pdf/facelifts.pdf). The British Association of Plastic Surgeons (www.baps.co.uk) fares better with mention of both lobule and earlobe in the glossaries. To conclude one gets the distinct impression that though lobule may be the correct anatomical term for this particular body part, earlobe seems to be the more commonly used term, both in lay and medical literature. So use of the term earlobe only may avoid any further confusion.
References 1. Griffiths RW. Earlobe reconstruction using a Limberg flap in six ears. Br J Plast Surg 2003;56:620. 2. Singh A, Singh G. Earlobe reconstruction using a Limberg flap in six cases. Br J Plast Surg 2003;56:33—6. 3. Merriam Webster Collegiate Dictionary. 11th ed. HarperCollins; 2003.
176
Short reports and correspondence
4. McCarthy JG, editor. Plastic surgery. London: Saunders; 1990. p. 2105. see also pp. 2141. 5. Smith JW, Aston SJ, editors. Grabb and Smith’s plastic surgery, 4th ed. Boston, NY: Little Brown; 1990. p. 484. 6. Dunn KW, Harrison RK. Naming of parts: a presentation of facial surface anatomical terms. Br J Plast Surg 1997;50(8): 584—9.
Anindya Lahiri Registrar in Plastic Surgery, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK doi:10.1016/j.bjps.2003.12.002
How soft are Soft Touchw breast implants? Increased leakage and easier folding of breast implants with a supple, thin wall and a soft, semiliquid filler gel resulted in the production of thickerwalled silicone implants with a firmer, high cohesive filler material, since the early 1990s.1 The anatomic contour was re-introduced and the surface was produced in a textured fashion to prevent capsular contraction.2 – 5 The Style 410w breast implant (McGhan, Arklow, Ireland) was marketed on this basis since 1993.6,7 Recently, a softer, less cohesive gel filler has been introduced under the name of Style 410 Soft Touch w (McGhan, Arklow, Ireland) for it’s allegedly more natural feel to the breast. There is no difference in anatomic shape, volume, and thickness of shell or texturing of the surface between these types of implants. The difference in softness to touch should be significant to justify using the new Soft Touch implant rather than the original Style 410 implant. Because we had difficulty in noticing this difference, we set out this study. Twelve plastic surgeons, 10 plastic surgery residents, and 11 lay volunteers were recruited in various Amsterdam hospitals. They were 21 men and 12 women with ages ranging between 25 and 63 years (mean, 39 years). Thirty subjects were righthanded (91%), and three were left-handed (9%). The lay volunteers were randomly chosen from hospital personnel and had never palpated a breast implant before.
The subjects were blindfolded and seated at a table to assess a new original Style 410 (280 MM) and a new Style 410 Soft Touch (280 MM) 10 times. For the first five assessments the implants were put on the table in random order, one in front of the right hand and one in front of the left (test 1). The posterior surface of the implant was placed on the surface of the table and its caudal side pointed towards the subject. Subjects were asked to locate the softer implant without removing the implants from the table. Subsequently, each implant was put in a palm of the subjects’ hands in random order and they were allowed to grasp and squeeze the implants for 15 seconds to determine which was the softer implant (test 2). The one sample t-test was used with a test value of 0.50 to compare results with outcomes that would be expected by chance. Analysis of variance (ANOVA) was used to determine variation of the results between the three subject groups. A paired sample t-test was used to determine differences between results of tests 1 and 2. A possible influence of training during repeated tests was excluded by comparing the results of the first and fifth assessment within both tests. Over all, the three groups were able to feel the difference between the two implants ðP , 0:01Þ: Men and women scored equally, as did left-handed and right-handed subjects. Professionals singled out the correct implant in 7.9 out of the 10 assessments during both tests (Table 1). The lay volunteers recognised the softer implant significantly less frequent ðP ¼ 0:02Þ: Professionals were more successful in assessing the implants when placed on the table (test 1) than when they were held in the hands (test 2) ðP ¼ 0:04Þ: There was no significant difference between results of tests 1 and 2 for the volunteers. No difference was seen in success rate between the first and fifth assessment of tests 1 or 2, among all subject groups.
Comments As long as the ideal breast implant that has the consistency of breast tissue, is not visible or
Table 1 Fractions of correct assessments (and 95% confidence interval) during tests 1, 2, and for the combined tests (over all) in the groups of plastic surgeons, of plastic surgery residents, and of lay volunteers, as well as for all subjects
Test 1 Test 2 Over all
Plastic surgeons ðn ¼ 12Þ
Residents ðn ¼ 10Þ
Volunteers ðn ¼ 11Þ
All subjects ðn ¼ 33Þ
0.83 (0.73–0.94) 0.75 (0.64–0.86) 0.79 (0.72–0.86)
0.88 (0.76–1.0) 0.70 (0.51–0.89) 0.79 (0.66–0.92)
0.56 (0.42– 0.71) 0.71 (0.56– 0.86) 0.64 (0.54– 0.73)
0.76 (0.68 –0.84) 0.72 (0.64 –0.80) 0.74 (0.68 –0.80)
Four limbs were initially amputated at a level distal to the limit of arterial flow/bone viability that was suggested by imaging and all of these were revised to a higher level. Three limbs were amputated at or very close to the limit of viability and in this subgroup two stumps were revised. The remaining four limbs were amputated proximal to the limit of suggested viability and two stumps had wound breakdown but no revisions were performed. In the case of the patient who had a bone scan, this was a 3-year-old girl who had quadrilateral amputations in the third week of her illness. Bone scan showed viability to the upper tibiae, to upper left forearm and to mid right forearm. Initial amputation levels were bilateral TKA and bilateral distal forearms. Neither of the lower limb stumps required revision although one needed some further debridement. Both of the distal forearm amputations, which were each fashioned beyond the level of viability as shown by the bone scan, went on to be revised proximally. This demonstrates that the bone scan is an important adjunct to the planning of amputation in this condition. As a result of these findings we suggest that all children with meningococcal septicaemia who require amputation of major limb segments are investigated with bone scans and/or arterial Doppler studies. Surgeons should select a level of amputation that is proximal to the imaged limit of viability. We acknowledge that the decision over the timing and extent of amputation in this age group is never easy. It should be made in a multidisciplinary setting with appropriate involvement and counselling of the child’s parents.
References 1. Treharne LJ, Banwell P, Cadier M. Mandatory bone scans for the assessment of extremity loss in meningococcal septicaemia? Br J Plast Surg 2003;56:55—6. 2. Herrera R, Hobar C, Ginsberg CM. Surgical intervention for the complications of meningococcal induced purpura fulminans. Pediatr Infect Dis J 1994;13(8):734—7. 3. Wheeler JS, Anderson BJ, De Chalain TM. Surgical interventions in children with meningococcal purpura fulminans—a review of 117 procedures in 21 children. J Pediatr Surg 2003; 38(4):597—603. 4. Silbart S, Oppenheim W. Purpura fulminans. Medical, surgical, and rehabilitative considerations. Clin Orthop 1985;(193): 206—13.
Oliver J.H. Harley, Omar A. Ahmed, Roy L.H. Ng Department of Plastic Surgery, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK doi:10.1016/j.bjps.2003.11.016
175
Earlobe vs. ear lobule I read the correspondence from Mr Griffiths1 in response to the article by Singh and Singh2 with great interest. While one is taught in Medical School that ‘lobule’ is the correct nomenclature, not ‘earlobe’—there seems to be an amazing amount of confusion regarding this. As Mr Griffiths has pointed out—the major anatomy textbooks prefer lobule over earlobe. However, earlobe, not earlobule is the term accepted by all major dictionaries (Oxford, Webster etc.). Webster’s dictionary3 instructs that lobule [Cf. F. lobule, dim. of lobe] is a small lobe or a subdivision of a lobe. It also says that ‘Lobule of the ear’ (Anat.) is the same as ‘Lobe of the ear’. Coming to the medical literature, the popular textbooks ‘Plastic Surgery’ by McCarthy4 and ‘Grabb and Smith’s Plastic Surgery’5 both use only the word earlobe and not lobule. A search of OVID Medling (http://www.sun.bma.org.uk/ovidweb_T/ ovidweb.cgi) (1996 to present) shows 440 entries for earlobe, only one for ‘earlobule’ and 23 for ‘ear lobule’. The only relatively recent article on anatomical nomenclature of facial parts6 uses the word lobe first and provides lobule as an alternative name. Looking into the websites of the leading Plastic Surgery bodies—the American Society of Plastic Surgeons (http://www.plsticsurgery.org/ news_room/Terms-and-Definitions.cfm) uses the term earlobe only. So does the British Association of Aesthetic Plastic Surgeons in a couple of their information leaflets (http://www.baaps.org.uk/ pdf/Prominentears.pdf and http://www.baaps. org.uk/pdf/facelifts.pdf). The British Association of Plastic Surgeons (www.baps.co.uk) fares better with mention of both lobule and earlobe in the glossaries. To conclude one gets the distinct impression that though lobule may be the correct anatomical term for this particular body part, earlobe seems to be the more commonly used term, both in lay and medical literature. So use of the term earlobe only may avoid any further confusion.
References 1. Griffiths RW. Earlobe reconstruction using a Limberg flap in six ears. Br J Plast Surg 2003;56:620. 2. Singh A, Singh G. Earlobe reconstruction using a Limberg flap in six cases. Br J Plast Surg 2003;56:33—6. 3. Merriam Webster Collegiate Dictionary. 11th ed. HarperCollins; 2003.
176
Short reports and correspondence
4. McCarthy JG, editor. Plastic surgery. London: Saunders; 1990. p. 2105. see also pp. 2141. 5. Smith JW, Aston SJ, editors. Grabb and Smith’s plastic surgery, 4th ed. Boston, NY: Little Brown; 1990. p. 484. 6. Dunn KW, Harrison RK. Naming of parts: a presentation of facial surface anatomical terms. Br J Plast Surg 1997;50(8): 584—9.
Anindya Lahiri Registrar in Plastic Surgery, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK doi:10.1016/j.bjps.2003.12.002
How soft are Soft Touchw breast implants? Increased leakage and easier folding of breast implants with a supple, thin wall and a soft, semiliquid filler gel resulted in the production of thickerwalled silicone implants with a firmer, high cohesive filler material, since the early 1990s.1 The anatomic contour was re-introduced and the surface was produced in a textured fashion to prevent capsular contraction.2 – 5 The Style 410w breast implant (McGhan, Arklow, Ireland) was marketed on this basis since 1993.6,7 Recently, a softer, less cohesive gel filler has been introduced under the name of Style 410 Soft Touch w (McGhan, Arklow, Ireland) for it’s allegedly more natural feel to the breast. There is no difference in anatomic shape, volume, and thickness of shell or texturing of the surface between these types of implants. The difference in softness to touch should be significant to justify using the new Soft Touch implant rather than the original Style 410 implant. Because we had difficulty in noticing this difference, we set out this study. Twelve plastic surgeons, 10 plastic surgery residents, and 11 lay volunteers were recruited in various Amsterdam hospitals. They were 21 men and 12 women with ages ranging between 25 and 63 years (mean, 39 years). Thirty subjects were righthanded (91%), and three were left-handed (9%). The lay volunteers were randomly chosen from hospital personnel and had never palpated a breast implant before.
The subjects were blindfolded and seated at a table to assess a new original Style 410 (280 MM) and a new Style 410 Soft Touch (280 MM) 10 times. For the first five assessments the implants were put on the table in random order, one in front of the right hand and one in front of the left (test 1). The posterior surface of the implant was placed on the surface of the table and its caudal side pointed towards the subject. Subjects were asked to locate the softer implant without removing the implants from the table. Subsequently, each implant was put in a palm of the subjects’ hands in random order and they were allowed to grasp and squeeze the implants for 15 seconds to determine which was the softer implant (test 2). The one sample t-test was used with a test value of 0.50 to compare results with outcomes that would be expected by chance. Analysis of variance (ANOVA) was used to determine variation of the results between the three subject groups. A paired sample t-test was used to determine differences between results of tests 1 and 2. A possible influence of training during repeated tests was excluded by comparing the results of the first and fifth assessment within both tests. Over all, the three groups were able to feel the difference between the two implants ðP , 0:01Þ: Men and women scored equally, as did left-handed and right-handed subjects. Professionals singled out the correct implant in 7.9 out of the 10 assessments during both tests (Table 1). The lay volunteers recognised the softer implant significantly less frequent ðP ¼ 0:02Þ: Professionals were more successful in assessing the implants when placed on the table (test 1) than when they were held in the hands (test 2) ðP ¼ 0:04Þ: There was no significant difference between results of tests 1 and 2 for the volunteers. No difference was seen in success rate between the first and fifth assessment of tests 1 or 2, among all subject groups.
Comments As long as the ideal breast implant that has the consistency of breast tissue, is not visible or
Table 1 Fractions of correct assessments (and 95% confidence interval) during tests 1, 2, and for the combined tests (over all) in the groups of plastic surgeons, of plastic surgery residents, and of lay volunteers, as well as for all subjects
Test 1 Test 2 Over all
Plastic surgeons ðn ¼ 12Þ
Residents ðn ¼ 10Þ
Volunteers ðn ¼ 11Þ
All subjects ðn ¼ 33Þ
0.83 (0.73–0.94) 0.75 (0.64–0.86) 0.79 (0.72–0.86)
0.88 (0.76–1.0) 0.70 (0.51–0.89) 0.79 (0.66–0.92)
0.56 (0.42– 0.71) 0.71 (0.56– 0.86) 0.64 (0.54– 0.73)
0.76 (0.68 –0.84) 0.72 (0.64 –0.80) 0.74 (0.68 –0.80)