- Email: [email protected]
PRIMARY REPAIR OF SKIN DEFECTS WITH LOCAL FLAPS
854
Although, we are unwilling to challenge the histological identity of various types of kernicterus, there must remain considerable doubt about extending this identity. The sequelae in certain children who have survived the neurological damage associated with icterus gravis are well established ; dromes most
these children present definite synand recently described by Gerrard.7
fully Despite much attention to the development of surviving premature infants there is no evidence which would suggest that their nervous systems have been subjected to any such specific damage. Intrinsic pigmentation of the primary dentition is a further feature of icterus gravis which has not so far been described in any other group 8 of children. It appears, therefore, that whatever the measure of between the various types of kernicterus some identity mechanism other than anoxia, anaemia, or blood-group incompatibility explains its onset, and this is probably associated in some way with pigment metabolism. R. M. FORRESTER Park Hospital, D. C. A. BEVIS. Davyhulme, near Manchester. RARE COMPLICATION OF CHICKENPOX interested to see your annotation of I have just had a case of chickenpox in a married woman of 32, in whom a troublesome cough began the day after the rash first appeared. Two days later she sent for me because paroxysms of coughing were making her short of breath. She looked very ill, was too weak to sit up, and had bloodstained sputum. The only signs I detected in the lungs were rapid respiration and scanty, generalised rhonchi. Her condition was unchanged for two days, and thereafter she made a gradual recovery. P. R. BOUCHER.
SIR,—I
April
was
11.
PRIMARY REPAIR OF SKIN DEFECTS WITH LOCAL FLAPS
SIR,—It is
to be hoped that surgeons will not be carried away by Mr. McLaughlin’s enthusiastic advocacy of local flaps for the primary repair of skin defects (April 11). Such flaps occasionally necrose, leaving a defect as large as, if not larger than, the original ; and the
incidence of necrosis varies inversely with the experience of the operator. Apart from primary trauma, it must be very unusual for any surgeon to be confronted unexpectedly with a large defect in urgent need of immediate repair, since such defects are created by the radical removal of surface lesions, the extent and depth of which can commonly be assessed or at least suspected on clinical examination before operation. In other words, the need for a local flap and the design of such a flap can be decided in advance, and it is here that the plastic surgeon with experience of these methods can be of the greatest assistance. In traumatic surgery, and particularly in hand injuries, the need for immediate cover with a vascular skin-flap frequently arises, and the technique of such operations is fairly widely known. All the illustrations of Mr. McLaughlin’s paper, however, and most of his remarks, seem to be concerned with defects created by the excision of either malignant or septic lesions, and it is very doubtful if primary repair by local flaps of these defects is justifiable apart from two small groups of cases. The first group is those defects whose base is unsuitable for free skin grafting because of exposure of extensive areas of denuded bone, tendon, or ligament, exposure of the dura or the pleura, or an opening into one of the body cavities. The second group is those malignant lesions which have recurred after irradiation, and in which it is desired to give further irradiation after excision. The use of a local flap of non-irradiated skin will permit this.
7. Gerrard, J. Brain, 1952, 75, 526. 8. Miller, J. Brit. dent. J. 1951, 91, 121.
But these instances can almost always be foreseen and for in advance, with the aid of a plastic surgeon if necessary ; and in most other cases the use -of a free skin graft is much more satisfactory, and in malignant Some doubt must always cases frequently obligatory. exist as to the completeness of the local excision of a malignant skin lesion no matter how radical the operation, and surely it is wiser to cover such a defect with a thin free graft, and so allow early recognition of any recurrence, than to mask the area with a thick local flap, the use of which opens up widely neighbouring tissue planes. We feel that Mr. McLaughlin dismisses too lightly-the use of free skin grafts. They are simple to cut and apply. They take readily on freshly cut tissues (with the excep. tions mentioned above). Their cosmetic appearance is not always good, but in certain situations they are preferable in this respect to local flaps as a permanent repair. The use of free full-thickness post-auricular skin grafts around the eyelids and nose, or full-thickness or thick split grafts for certain defects of hand and fingers, are two examples. In other instances they should be regarded as a simple, quick method of achieving immediate temporary cover. They then avoid the use of a hastily planned local flap at the end of an extensive operation; they allow a definitive secondary repair to be planned and carried out at leisure and under ideal conditions; they allow skin to be prepared and brought from a distance when necessary ; and they allow the delay of the secondary repair until the risk of local recurrence of malignant disease is minimal. Two of the illustrations invite further comment. The repair shown in fig. 3, excellent as it is, is only made possible by the lax neck skin of the aged, and might well be disastrous if attempted in a young adult. The proce. dure shown in fig. 7 is practically impossible as a primary repair, since the inturned flaps must hinge almost on the margin of the excision and would be unlikely to survive. Even when carried out as a secondary repair it is frequently better to delay " such flaps before rotating them into position.
planned
"
Plastic Surgery Unit,
Ballochmyle Hospital, Mauchline, Ayrshire.
THOMAS GIBSON J. SCOTT TOUGH.
THE PROBLEM OF PEPTIC ULCERATION "
SIR,—Sir Heneage Ogilvie (March 21), at the risk of giving offence," criticised the work of the late Hedley Visick. This criticism is obviously sincere, and I hope will understand if I reply in the same spirit of these criticisms and that he will forgive me if I endeavour to correct a misconception. Visick’s policy of high gastrectomy was only under. taken after much deliberation and discussion, and was more likely the result of undue optimism than a " policy of despair." The primary reason was that early in the series we encountered 5 recurrent ulcers (3 following Polya and 2 following Billroth-i resections) ; these were submitted to further and more radical resection, the Billroths being converted into Polyas. As all 5 patients remained well without further recurrence, it seemed reasonable gradually to increase the initial extent of the resection. In my to indicate this point by classifying 201 analysis I tried " as patients developing measured radical gastrectomy." There is little doubt that a high resection does give a practical, if not an absolute, immunity from recurrence, but I do agree that the removal of too much stomach is unnecessary and is one, but only one, of the factors that lead to postprandial symptoms. The difficulty is to defipe what is meant by " too much," for there appears to be an optimum degree, and it was this ideal which Visick was seeking ; he hoped that by measuring the extent of the stomach remnant, and later assessing the results, it would be possible to estimate it. It is true that towards the end of the series Visick was abandoning the Sir
to
Heneage
some
Although, we are unwilling to challenge the histological identity of various types of kernicterus, there must remain considerable doubt about extending this identity. The sequelae in certain children who have survived the neurological damage associated with icterus gravis are well established ; dromes most
these children present definite synand recently described by Gerrard.7
fully Despite much attention to the development of surviving premature infants there is no evidence which would suggest that their nervous systems have been subjected to any such specific damage. Intrinsic pigmentation of the primary dentition is a further feature of icterus gravis which has not so far been described in any other group 8 of children. It appears, therefore, that whatever the measure of between the various types of kernicterus some identity mechanism other than anoxia, anaemia, or blood-group incompatibility explains its onset, and this is probably associated in some way with pigment metabolism. R. M. FORRESTER Park Hospital, D. C. A. BEVIS. Davyhulme, near Manchester. RARE COMPLICATION OF CHICKENPOX interested to see your annotation of I have just had a case of chickenpox in a married woman of 32, in whom a troublesome cough began the day after the rash first appeared. Two days later she sent for me because paroxysms of coughing were making her short of breath. She looked very ill, was too weak to sit up, and had bloodstained sputum. The only signs I detected in the lungs were rapid respiration and scanty, generalised rhonchi. Her condition was unchanged for two days, and thereafter she made a gradual recovery. P. R. BOUCHER.
SIR,—I
April
was
11.
PRIMARY REPAIR OF SKIN DEFECTS WITH LOCAL FLAPS
SIR,—It is
to be hoped that surgeons will not be carried away by Mr. McLaughlin’s enthusiastic advocacy of local flaps for the primary repair of skin defects (April 11). Such flaps occasionally necrose, leaving a defect as large as, if not larger than, the original ; and the
incidence of necrosis varies inversely with the experience of the operator. Apart from primary trauma, it must be very unusual for any surgeon to be confronted unexpectedly with a large defect in urgent need of immediate repair, since such defects are created by the radical removal of surface lesions, the extent and depth of which can commonly be assessed or at least suspected on clinical examination before operation. In other words, the need for a local flap and the design of such a flap can be decided in advance, and it is here that the plastic surgeon with experience of these methods can be of the greatest assistance. In traumatic surgery, and particularly in hand injuries, the need for immediate cover with a vascular skin-flap frequently arises, and the technique of such operations is fairly widely known. All the illustrations of Mr. McLaughlin’s paper, however, and most of his remarks, seem to be concerned with defects created by the excision of either malignant or septic lesions, and it is very doubtful if primary repair by local flaps of these defects is justifiable apart from two small groups of cases. The first group is those defects whose base is unsuitable for free skin grafting because of exposure of extensive areas of denuded bone, tendon, or ligament, exposure of the dura or the pleura, or an opening into one of the body cavities. The second group is those malignant lesions which have recurred after irradiation, and in which it is desired to give further irradiation after excision. The use of a local flap of non-irradiated skin will permit this.
7. Gerrard, J. Brain, 1952, 75, 526. 8. Miller, J. Brit. dent. J. 1951, 91, 121.
But these instances can almost always be foreseen and for in advance, with the aid of a plastic surgeon if necessary ; and in most other cases the use -of a free skin graft is much more satisfactory, and in malignant Some doubt must always cases frequently obligatory. exist as to the completeness of the local excision of a malignant skin lesion no matter how radical the operation, and surely it is wiser to cover such a defect with a thin free graft, and so allow early recognition of any recurrence, than to mask the area with a thick local flap, the use of which opens up widely neighbouring tissue planes. We feel that Mr. McLaughlin dismisses too lightly-the use of free skin grafts. They are simple to cut and apply. They take readily on freshly cut tissues (with the excep. tions mentioned above). Their cosmetic appearance is not always good, but in certain situations they are preferable in this respect to local flaps as a permanent repair. The use of free full-thickness post-auricular skin grafts around the eyelids and nose, or full-thickness or thick split grafts for certain defects of hand and fingers, are two examples. In other instances they should be regarded as a simple, quick method of achieving immediate temporary cover. They then avoid the use of a hastily planned local flap at the end of an extensive operation; they allow a definitive secondary repair to be planned and carried out at leisure and under ideal conditions; they allow skin to be prepared and brought from a distance when necessary ; and they allow the delay of the secondary repair until the risk of local recurrence of malignant disease is minimal. Two of the illustrations invite further comment. The repair shown in fig. 3, excellent as it is, is only made possible by the lax neck skin of the aged, and might well be disastrous if attempted in a young adult. The proce. dure shown in fig. 7 is practically impossible as a primary repair, since the inturned flaps must hinge almost on the margin of the excision and would be unlikely to survive. Even when carried out as a secondary repair it is frequently better to delay " such flaps before rotating them into position.
planned
"
Plastic Surgery Unit,
Ballochmyle Hospital, Mauchline, Ayrshire.
THOMAS GIBSON J. SCOTT TOUGH.
THE PROBLEM OF PEPTIC ULCERATION "
SIR,—Sir Heneage Ogilvie (March 21), at the risk of giving offence," criticised the work of the late Hedley Visick. This criticism is obviously sincere, and I hope will understand if I reply in the same spirit of these criticisms and that he will forgive me if I endeavour to correct a misconception. Visick’s policy of high gastrectomy was only under. taken after much deliberation and discussion, and was more likely the result of undue optimism than a " policy of despair." The primary reason was that early in the series we encountered 5 recurrent ulcers (3 following Polya and 2 following Billroth-i resections) ; these were submitted to further and more radical resection, the Billroths being converted into Polyas. As all 5 patients remained well without further recurrence, it seemed reasonable gradually to increase the initial extent of the resection. In my to indicate this point by classifying 201 analysis I tried " as patients developing measured radical gastrectomy." There is little doubt that a high resection does give a practical, if not an absolute, immunity from recurrence, but I do agree that the removal of too much stomach is unnecessary and is one, but only one, of the factors that lead to postprandial symptoms. The difficulty is to defipe what is meant by " too much," for there appears to be an optimum degree, and it was this ideal which Visick was seeking ; he hoped that by measuring the extent of the stomach remnant, and later assessing the results, it would be possible to estimate it. It is true that towards the end of the series Visick was abandoning the Sir
to
Heneage
some