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Preoperative surgical skin marking in plastic surgery
556
British Journal of Plastic Surgery
Cadmium, also used in photoelectric cells, has been shown to be a cause of photosensitivity in red tattoos, 5-7 even in the absence of other metals. This seems to be the case in this patient, who exhibited a photosensitive reaction to his tattoo, confined to the red (cadmium containing) areas. Sarcoidosis has been shown to present in tattoos, 8 but our patient showed no clinical features of the condition. When presented with a red-dye reaction in a recent tattoo, mercury can no longer be presumed to be the cause because its exclusion from dye manufacture has not resulted in the cessation of sensitivity reactions. In tattoos performed recently, using mercury-free dye, cadmium should be suspected if photosensitivity is limited to red areas only. Yours faithfully, I-Iamid Yazdian-Tehrani MBBS, Senior House Officer in Plastic Surgery M o h a m m e d M. Shihu FRCSEd, FRCS(Plast), Consultant in Plastic Surgery Nigel C. C a r v e r MS, FRCS, FRCS(Plast), Consultant in Plastic Surgery Department of Plastic Surgery, Royal London Whitechapel, London E1 1BB, UK.
Hospital,
ascertain local practice among plastic surgeons. Viomedex| and Porex | surgical skin-marking permanent-ink felt-tipped pens and the Sommerlad pen in association with Bonney's Blue ink (BP1980 brilliant green 0.5% w/v, crystal violet 0.5% w/v and alcohol absolute 45% v/v) were reported as by far the most commonly used. A small study using six such pens was carded out on the forearm skin of a volunteer to determine their relative 'permanence' and their ability to withstand surgical skin preparation. In keeping with recent trends advocating the use of alcoholbased over aqueous-based paints, s two commonly used skin paints, Betadine | (povidone iodine United States Pharmocopeia 10% w/v) and Hydrex | (pink chlorhexidine gluconate 0.5% w/v in 70% v/v industrial methylated spirits) were used to clean forearm skin markings made with these six pens (Fig. 1). To standardise, a single operator cleaned each marking for a period of 60 s. The end results are shown in Figure 2 and the associated tabulation of subjective scoring of durability (range: 0 =disappeared, through to 5 = no fading) is shown in Table 1. The results confirm the relative indelibility and success of the Viomedex | pen in withstanding both alcohol-based skin preparations. The Sommerlad pen with Bonney's blue ink showed excellent resilience to povidone iodine but was poor with chlorhexidine gluconate. No skin marking approached a maximal score in withstanding the use of both these commonly
References 1. Bj6rnberg A. Allergic reactions to chrome in green tattoo markings. Acta Derm Venereol (Stockh) 1959; 39: 23-9. 2. Bj6rnberg A. Allergic reactions to cobalt in light blue tattoo markings. Acta Derm Venereol (Stockh) 1961; 41: 259-63. 3. Schwartz RA, Mathias CG, Miller CH, Rajas-Corona R, Lambert WC. Granulomatous reaction to purple tattoo pigment. Contact Dermatitis 1987; 16: 198-202. 4. BjSrnberg A. Reactions to light in yellow tattoos from cadmium sulfide. Arch Dermatol 1963; 88: 267-71. 5. McGrouther DA, Downie PA, Thompson WD. Reactions to red tattoos. Br J Plast Surg 1977; 30: 84--5. 6. Goldstein N. Mercury--cadmium sensitivity in tattoos: a photoallergic reaction in red pigment. Ann Intern Med 1967; 67: 984-9. 7. Sowden JM, Byrne JPH, Smith AG, et al. Red tattoo reactions: X-ray microanalysis and patch-test studies. Br J Dermatol 1991; 124: 576--80. 8. Weidman AI, Andrade R, Franks AG. Sarcoidosis. Report of a case of sarcoid lesions in a tattoo and subsequent discovery of pulmonary sarcoidosis. Arch Dermatol 1966; 94: 320--5. doi:10.1054/bjps.2001.3634
Figure 1--Pre-preparation skin markings on volunteer's forearms.
Preoperative surgical skin marking in plastic surgery Sir, In plastic and reconstructive surgery the importance of fine accurate indelible preoperative skin markings of key reference points and lines is essential if surgery is to be precise. Often the visible success of the operation is determined by this. Skin markings made preoperatively need to be robust to withstand the surgical skin preparation with antiseptic prepping solutions. Innovative methods of surgical tattooing and skin scratching 1'2 have the potential to cause hypertrophic scarfing and keloid formarion, as well as being rather cumbersome and often requiring the patient to be anaesthetised prior to marking. The use of cotton felttipped pens and the ability of their inks to withstand the figours of surgical skin preparation have been investigated by others, 3'4 and the results reveal a wide variation in the permanence of the inks. We investigated a small sample of skin-marking pens used commonly in plastic surgery departments in southeast England. Theatre sisters were contacted in a number of hospitals to
Figure 2--Results following preparation with chlorhexidine gluconate (right forearm) and povidone iodine (left forearm).
Short reports and correspondence
557
Table 1 Pens used and 'durability score' in withstanding surgical skin preparation Pen number
Pen name
Chlorhexidine gluconate preparation (score 0-5)
Povidone iodine preparation (score 0-5)
1 2 3 4 5 6
Devon| skin marker Viomedex | vxl00 Porex | squeeze-mark Sharpie | skin marker Securline | 1000 Sommerlad/Bonney's
1 3 1 2 1 1
2 3 3 2 2 4
used skin paints, and the tendency was for all inks to be less resilient to chlorhexidine gluconate paint. These are important considerations that the individual surgeon should take into account in his or her daily practice when choosing a preoperative surgical skin-marking tool. Yours faithfully,
Taran Tafla MRCS, Senior House Officer Department of Otolaryngology and Head and Neck Surgery, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
Hamid Yazdian-Tehrani MBBS, Senior House Officer M. Shibu F R C S E d , FRCS(Plast), Consultant Plastic Surgeon Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Eva Luckes House, Whitechapel, London E1 1BB, UK.
References 1. Kjar JG, Jackson IT. A simple instrument for surgical tattooing and skin marking. Plast Reconstr Surg 1988; 81 : 106-8. 2. Joseph HL. Preoperative skin marking. J Dermatol Surg Oncol 1988; 14: 120. 3. Granick MS, Heckler FR, West Jones E. Surgical skin-marking techniques. Plast Reconstr Surg 1987; 79: 573-80. 4. Lafferty K, Glass RG. Making your mark in surgery. Br J Surg 1986; 73: 609. 5. Graham GP, Dent CM, Fairclough JA. Preparation of skin for surgery. J R Coil Surg Edinb 1991; 36: 264-6.
Figure 1--The 'backup' flap tubed.
Whilst harvesting the flap, the superficial inferior epigastric vessels were noted to be of sufficient calibre and thus were selected for anastomosis. There was sufficient tissue in zones 1 and 2 for the reconstruction. Following a midline incision, the abdominal ellipse was divided into two equal halves and the flaps raised, based on the superficial inferior epigastric arteries. This has the advantage over the more conventional TRAM flap of much lower donor-site morbidity, and maintains the integrity of the abdominal musculature. 1-3 The SIEA flap was transferred to the chest wall and successfully anastomosed to the internal mammary vessels. Instead of discarding the remaining tissue (zones 3 and 4), it was kept in situ as a 'backup' for use if the flap failed, and 'tubed' using a continuous nylon suture (Fig. 1). The donor site was closed, leaving a small gap for the pedicle of the 'backup' flap, which was stabilised with large gauze dressings taped in place to prevent traction on the vessels. Both 'flaps' were healthy and well perfused 48 h later. The 'backup' flap was not required and its pedicle was ligated and the tissue removed on the ward. No anaesthetic was required for removal of the tissue, and the patient did not describe any physical or psychological discomfort with the 'backup' flap in situ or on ligation of the pedicle. Minimal additional operative time was spent on raising the spare flap, which did not contribute to patient morbidity. If zones 1 and 2 are sufficient for reconstruction and remain well perfused when raised as a SIEA flap then we suggest that, in the event of flap failure, this banked flap may prove invaluable. Yours faithfully,
doi:10.1054/bjps.2001.3609
The contralateral superficial inferior epigastric artery flap as a backup in breast reconstruction Sir, We describe a method of banking spare tissue in a patient undergoing breast reconstruction with free abdominal-tissue transfer, based on ~;~e superficial inferior epigastric artery (SIEA). A 31-year-old female underwent delayed breast reconstruction following a left total mastectomy for an infiltrating ductal carcinoma. The contralateral breast was of moderate size with grade 2 ptosis. The preoperative plan was to use a deep inferior epigastric perforator (DIEP) flap for reconstruction, anastomosed to the internal mammary vessels.
Alastair E Brown FRCS, L.A.T. Plastic Surgery H, Lewis MD, FRCS, Specialist Registrar in Plastic Surgery S. Sinclair MD, FRCS, Consultant Plastic Surgeon Northern Ireland Plastic and Maxillofacial Service, The Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast BT16 0RH, UK.
References 1. Arne~ ZM, Khan U, Pogorelec D, Planin~ek E Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg 1999; 52: 351-4. 2. Arne~ ZM, Khan U, Pogorelec D, Planin~ek E Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg 1999; 52: 276-9. 3. Stern HS, Nahai E The versatile superficial inferior epigastric artery free flap. Br J Plast Surg 1992; 45: 270-4.
British Journal of Plastic Surgery
Cadmium, also used in photoelectric cells, has been shown to be a cause of photosensitivity in red tattoos, 5-7 even in the absence of other metals. This seems to be the case in this patient, who exhibited a photosensitive reaction to his tattoo, confined to the red (cadmium containing) areas. Sarcoidosis has been shown to present in tattoos, 8 but our patient showed no clinical features of the condition. When presented with a red-dye reaction in a recent tattoo, mercury can no longer be presumed to be the cause because its exclusion from dye manufacture has not resulted in the cessation of sensitivity reactions. In tattoos performed recently, using mercury-free dye, cadmium should be suspected if photosensitivity is limited to red areas only. Yours faithfully, I-Iamid Yazdian-Tehrani MBBS, Senior House Officer in Plastic Surgery M o h a m m e d M. Shihu FRCSEd, FRCS(Plast), Consultant in Plastic Surgery Nigel C. C a r v e r MS, FRCS, FRCS(Plast), Consultant in Plastic Surgery Department of Plastic Surgery, Royal London Whitechapel, London E1 1BB, UK.
Hospital,
ascertain local practice among plastic surgeons. Viomedex| and Porex | surgical skin-marking permanent-ink felt-tipped pens and the Sommerlad pen in association with Bonney's Blue ink (BP1980 brilliant green 0.5% w/v, crystal violet 0.5% w/v and alcohol absolute 45% v/v) were reported as by far the most commonly used. A small study using six such pens was carded out on the forearm skin of a volunteer to determine their relative 'permanence' and their ability to withstand surgical skin preparation. In keeping with recent trends advocating the use of alcoholbased over aqueous-based paints, s two commonly used skin paints, Betadine | (povidone iodine United States Pharmocopeia 10% w/v) and Hydrex | (pink chlorhexidine gluconate 0.5% w/v in 70% v/v industrial methylated spirits) were used to clean forearm skin markings made with these six pens (Fig. 1). To standardise, a single operator cleaned each marking for a period of 60 s. The end results are shown in Figure 2 and the associated tabulation of subjective scoring of durability (range: 0 =disappeared, through to 5 = no fading) is shown in Table 1. The results confirm the relative indelibility and success of the Viomedex | pen in withstanding both alcohol-based skin preparations. The Sommerlad pen with Bonney's blue ink showed excellent resilience to povidone iodine but was poor with chlorhexidine gluconate. No skin marking approached a maximal score in withstanding the use of both these commonly
References 1. Bj6rnberg A. Allergic reactions to chrome in green tattoo markings. Acta Derm Venereol (Stockh) 1959; 39: 23-9. 2. Bj6rnberg A. Allergic reactions to cobalt in light blue tattoo markings. Acta Derm Venereol (Stockh) 1961; 41: 259-63. 3. Schwartz RA, Mathias CG, Miller CH, Rajas-Corona R, Lambert WC. Granulomatous reaction to purple tattoo pigment. Contact Dermatitis 1987; 16: 198-202. 4. BjSrnberg A. Reactions to light in yellow tattoos from cadmium sulfide. Arch Dermatol 1963; 88: 267-71. 5. McGrouther DA, Downie PA, Thompson WD. Reactions to red tattoos. Br J Plast Surg 1977; 30: 84--5. 6. Goldstein N. Mercury--cadmium sensitivity in tattoos: a photoallergic reaction in red pigment. Ann Intern Med 1967; 67: 984-9. 7. Sowden JM, Byrne JPH, Smith AG, et al. Red tattoo reactions: X-ray microanalysis and patch-test studies. Br J Dermatol 1991; 124: 576--80. 8. Weidman AI, Andrade R, Franks AG. Sarcoidosis. Report of a case of sarcoid lesions in a tattoo and subsequent discovery of pulmonary sarcoidosis. Arch Dermatol 1966; 94: 320--5. doi:10.1054/bjps.2001.3634
Figure 1--Pre-preparation skin markings on volunteer's forearms.
Preoperative surgical skin marking in plastic surgery Sir, In plastic and reconstructive surgery the importance of fine accurate indelible preoperative skin markings of key reference points and lines is essential if surgery is to be precise. Often the visible success of the operation is determined by this. Skin markings made preoperatively need to be robust to withstand the surgical skin preparation with antiseptic prepping solutions. Innovative methods of surgical tattooing and skin scratching 1'2 have the potential to cause hypertrophic scarfing and keloid formarion, as well as being rather cumbersome and often requiring the patient to be anaesthetised prior to marking. The use of cotton felttipped pens and the ability of their inks to withstand the figours of surgical skin preparation have been investigated by others, 3'4 and the results reveal a wide variation in the permanence of the inks. We investigated a small sample of skin-marking pens used commonly in plastic surgery departments in southeast England. Theatre sisters were contacted in a number of hospitals to
Figure 2--Results following preparation with chlorhexidine gluconate (right forearm) and povidone iodine (left forearm).
Short reports and correspondence
557
Table 1 Pens used and 'durability score' in withstanding surgical skin preparation Pen number
Pen name
Chlorhexidine gluconate preparation (score 0-5)
Povidone iodine preparation (score 0-5)
1 2 3 4 5 6
Devon| skin marker Viomedex | vxl00 Porex | squeeze-mark Sharpie | skin marker Securline | 1000 Sommerlad/Bonney's
1 3 1 2 1 1
2 3 3 2 2 4
used skin paints, and the tendency was for all inks to be less resilient to chlorhexidine gluconate paint. These are important considerations that the individual surgeon should take into account in his or her daily practice when choosing a preoperative surgical skin-marking tool. Yours faithfully,
Taran Tafla MRCS, Senior House Officer Department of Otolaryngology and Head and Neck Surgery, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
Hamid Yazdian-Tehrani MBBS, Senior House Officer M. Shibu F R C S E d , FRCS(Plast), Consultant Plastic Surgeon Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Eva Luckes House, Whitechapel, London E1 1BB, UK.
References 1. Kjar JG, Jackson IT. A simple instrument for surgical tattooing and skin marking. Plast Reconstr Surg 1988; 81 : 106-8. 2. Joseph HL. Preoperative skin marking. J Dermatol Surg Oncol 1988; 14: 120. 3. Granick MS, Heckler FR, West Jones E. Surgical skin-marking techniques. Plast Reconstr Surg 1987; 79: 573-80. 4. Lafferty K, Glass RG. Making your mark in surgery. Br J Surg 1986; 73: 609. 5. Graham GP, Dent CM, Fairclough JA. Preparation of skin for surgery. J R Coil Surg Edinb 1991; 36: 264-6.
Figure 1--The 'backup' flap tubed.
Whilst harvesting the flap, the superficial inferior epigastric vessels were noted to be of sufficient calibre and thus were selected for anastomosis. There was sufficient tissue in zones 1 and 2 for the reconstruction. Following a midline incision, the abdominal ellipse was divided into two equal halves and the flaps raised, based on the superficial inferior epigastric arteries. This has the advantage over the more conventional TRAM flap of much lower donor-site morbidity, and maintains the integrity of the abdominal musculature. 1-3 The SIEA flap was transferred to the chest wall and successfully anastomosed to the internal mammary vessels. Instead of discarding the remaining tissue (zones 3 and 4), it was kept in situ as a 'backup' for use if the flap failed, and 'tubed' using a continuous nylon suture (Fig. 1). The donor site was closed, leaving a small gap for the pedicle of the 'backup' flap, which was stabilised with large gauze dressings taped in place to prevent traction on the vessels. Both 'flaps' were healthy and well perfused 48 h later. The 'backup' flap was not required and its pedicle was ligated and the tissue removed on the ward. No anaesthetic was required for removal of the tissue, and the patient did not describe any physical or psychological discomfort with the 'backup' flap in situ or on ligation of the pedicle. Minimal additional operative time was spent on raising the spare flap, which did not contribute to patient morbidity. If zones 1 and 2 are sufficient for reconstruction and remain well perfused when raised as a SIEA flap then we suggest that, in the event of flap failure, this banked flap may prove invaluable. Yours faithfully,
doi:10.1054/bjps.2001.3609
The contralateral superficial inferior epigastric artery flap as a backup in breast reconstruction Sir, We describe a method of banking spare tissue in a patient undergoing breast reconstruction with free abdominal-tissue transfer, based on ~;~e superficial inferior epigastric artery (SIEA). A 31-year-old female underwent delayed breast reconstruction following a left total mastectomy for an infiltrating ductal carcinoma. The contralateral breast was of moderate size with grade 2 ptosis. The preoperative plan was to use a deep inferior epigastric perforator (DIEP) flap for reconstruction, anastomosed to the internal mammary vessels.
Alastair E Brown FRCS, L.A.T. Plastic Surgery H, Lewis MD, FRCS, Specialist Registrar in Plastic Surgery S. Sinclair MD, FRCS, Consultant Plastic Surgeon Northern Ireland Plastic and Maxillofacial Service, The Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast BT16 0RH, UK.
References 1. Arne~ ZM, Khan U, Pogorelec D, Planin~ek E Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg 1999; 52: 351-4. 2. Arne~ ZM, Khan U, Pogorelec D, Planin~ek E Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg 1999; 52: 276-9. 3. Stern HS, Nahai E The versatile superficial inferior epigastric artery free flap. Br J Plast Surg 1992; 45: 270-4.