- Email: [email protected]
Re: ‘Reconstruction of orbital floor and maxilla with divided vascularised calvarial bone flap in one session’
Short reports and correspondence The use of drains as a haemostatic device A 34-year-old gentleman with type I neurofibromatosis presented with massive plexiform neurofibromata involving his lower back and buttocks (Fig. 1). The mass had been present for 15 years and had steadily increased in size. He was unable to find suitable clothing and complained that it was becoming increasingly uncomfortable to sit down. The patient was counselled for a de-bulking of the tumour and was warned of the substantial risk of bleeding. The association between excessive bleeding and excision of neurofibromata has been reported in the literature.1,2 Two 14 French gauge drains were used as haemostatic devices for each buttock. A drain was passed using the trocar through the deep aspect of each side of the plexiform mass in a similar fashion to a continuous running suture. A haemostat was used to maintain tension on each end of the drain (Fig. 2). A total of 8.5 kg of tissue was
115 excised. The drain was released one pass at a time maintaining tension on the drain while the wound was closed in layers. It was felt that haemodynamic instability and even more blood loss would have been encountered had the drains not been used to aid haemostasis. This novel technique for the use of drains as a haemostatic device has not been previously reported. We believe that this simple and effective technique reduced our operative blood loss and contributed to the successful postoperative recovery of the patient.
References 1. Littlewood AH, Stilwell JH. The vascular features of plexiform neurofibroma with some observations on the importance of pre-operative angiography and the value of pre-operative intra-arterial embolisation. Br J Plast Surg 1983;36:501e6. 2. Lin YC, Chen HC. Rare complications of massive haemorrhage in neurofibromatosis with arteriovenous malformation. Ann Plast Surg 2000;44:221e4.
B. Youssef A. Dancey F.C. Peart Regional Department of Burns and Plastic Surgery, University Hospital Birmingham, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK E-mail address: [email protected] ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.08.008
Figure 1 Massive plexiform neurofibromata involving the buttocks and lower back.
Re: ‘Reconstruction of orbital floor and maxilla with divided vascularised calvarial bone flap in one session’ We have reviewed the clinical study, conducted by Bilge et al., regarding the use of vascularised calvarial bone grafts in the reconstruction of orbital floor and maxilla.1 In this paper, the authors emphasise the necessity of elevating the temporoparietal hairy skin in the supragaleal-subfollicular plane to preserve the superficial temporal vascular territory in the temporal region. The vascular supply of the cranium has been studied by Cutting et al.2 They demonstrated three sources of blood supply to the anterior calvarium; (1) the middle meningeal artery and its branches, (2) branches of the anterior and posterior deep temporal arteries, and (3) a vascular plexus fed by the supraorbital supratrochlear, superficial temporal and occipital arteries. Although the middle meningeal artery and its branches are the most important vascular supply of all of these three sources, they are not suitable as a pedicle for vascularised bone transfer. The second source of blood supply consists of the branches of the anterior and
Figure 2 The drains passed through the tissue, in a similar fashion to a continuous running suture, using the trocar as a needle. The tension is being maintained by the haemostats.
DOI of original article:10.1016/j.bjps.2005.12.048.
116
Short reports and correspondence
posterior deep temporal arteries. These arteries also supply the temporalis muscle. Finally, there is a vascular plexus fed by the supraorbital, supratrochlear, superficial temporal and occipital arteries, which lies superficial to the galea but which has perforators that pass through the galea and periosteum to supply the underlying bone.3 Antonyshyn et al. in a rabbit model demonstrated that vascularised skull grafts survived when they were based only on temporalis muscle and periosteum.4 Besides these experimental studies the temporalis muscle flap, by itself, has been used for intraoral reconstruction.5 The temporalis muscle osteofacial flap has been used extensively for zygomatic arch and malar reconstruction especially in Treacher Collins syndrome and hemifacial microsomia,3 in temporomandibular joint disc reconstruction6 and in mandibular reconstruction.7 From these publications and our clinical experience we know that the anterior and posterior deep temporal arteries are sufficient for successful transfer of vascularised calvarial bone flaps. It is enough to preserve the attachment of temporal muscle to the calvarial bone and to transfer the bone along the axis of that muscle to achieve a successful surgical outcome. Any attempt to dissect in the supragalealsubfollicular plane in order to preserve the superficial temporal vascular territory in the temporal region not only elongates the operating time but also increases the risk of losing temporoparietal hair due to possible damage to the hair follicules during that dissection.
References
Subcutaneous infusion anaesthesia for sentinel lymph node biopsy in melanoma: method and complications* In 1992 Morton et al.1 published the technique of preoperative lymphoscintigraphy and sentinel lymph node (SLN) biopsy for mapping of regional basins draining primary melanomas. Technetium 99 m-labelled radioisotope and a hand-held gamma probe in combination with a blue dye are used to achieve a success rate in detecting the SLN of up to 97%.2 The percentage of positive SLN ranges from 15 to 33% of patients.3,4 Tumescent local anaesthesia was first described by Klein5 in 1987 for liposuction. Breuninger et al.6 described a variation of this procedure and called it slow infusion tumescent anaesthesia or subcutaneous infusion anaesthesia (SIA).7 In SIA a volume controlled infusion pump is used for achieving a slow and steady penetration of the solution into the adipose tissue. Advantages of a slow infusion rate include the lack of pain and/or the sensation of compression during infiltration, and a slower rise of anaesthetic plasma levels resulting in less toxicity and the possibility of using higher amounts of local anaesthetic, better skin surface anaesthesia and a more sustained postoperative effect.8,9 A complication rate of 4.6% associated with SLN biopsy has been reported in a large multi-institutional series,10 whereas the rates given in several smaller series ranged from 5.9 to 33.0%.11e13
Patients and methods
1. Bilen BT, Kılınc H, Arslan A, et al. Reconstruction of orbital floor and maxilla with divided vascularised calvarial bone flap in one session. J Plast Reconstr Aesthet Surg 2006;59:1305e11. 2. Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps. Plast Reconstr Surg 1984;74:603e10. 3. Bite U, Jackson IT, Wahner HW, et al. Vascularized skull bone grafts in craniofacial surgery. Ann Plast Surg 1987;19:3e15. 4. Antonyshyn O, Colcleugh RG, Hurst LN, et al. The temporalis myo-osseous flap: an experimental study. Plast Reconstr Surg 1986;77:406e15. 5. Wong TY, Chung CH, Huang JS, et al. The inverted temporalis muscle flap for intraoral reconstruction: its rationale and the results of its application. J Oral Maxillofac Surg 2004;62:667e75. 6. Rossi DC, Kappel DA. Temporalis muscle osteofascial flap reconstruction of a temporomandibular joint disk in an Ehlers-Danlos patient. Plast Reconstr Surg 2006;117:40ee3e. 7. Jackson IT, Helden G, Marx R. Skull bone grafts in maxillofacial and craniofacial surgery. J Oral Maxillofac Surg 1986;44:949e55.
Halil Ibrahim Canter Ian T. Jackson Providence Hospital, Craniofacial Institute, Southfiled, Michigan, USA E-mail address: [email protected] ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.08.010
The study group consisted of 181 patients with primary melanomas of the trunk and extremities with tumour thicknesses 1 mm (for exceptions see results). Informed consent was given by all patients. Documentation included the following parameters: age, tumour location, tumour thickness and Clark level, number of SLN basins, number of excised nodes, complications. For lymphoscintigraphy 18e48 MBq TC-99 m microcolloid was injected intradermally around the scar 1 day before surgery. Diazepam 5e10 mg on the evening before and 1 h before surgery, or midazolam 7.5 mg only before surgery were given as sedation. During administration of SIA heart rate, arterial oxygen saturation and blood pressure were monitored. Location of SLN was checked with a hand-held gamma probe (C-Trak) and then SIA was infiltrated. Routinely we use a 0.2% solution containing 450 ml of Ringer solution, 50 ml of lidocaine hydrochloride 2%, and 0.5 ml epinephrine (recommended maximum doses of 0.2% solution: 300e400 ml, of 0.1% solution: 600e1000 ml, dependent on body weight). For overweight patients with more than one SLN basin we prefer to use 0.2% solution initially and then switch to 0.1% solution to reduce the total amount of lidocaine hydrochloride applied. Maximum dosages of lidocaine of 35 mg/kg are described in the literature for tumescent
*
Results of this study were presented at the 5th Biennial International Sentinel Node Society Meeting in Rome, November 1e4, 2006 as a poster presentation.
115 excised. The drain was released one pass at a time maintaining tension on the drain while the wound was closed in layers. It was felt that haemodynamic instability and even more blood loss would have been encountered had the drains not been used to aid haemostasis. This novel technique for the use of drains as a haemostatic device has not been previously reported. We believe that this simple and effective technique reduced our operative blood loss and contributed to the successful postoperative recovery of the patient.
References 1. Littlewood AH, Stilwell JH. The vascular features of plexiform neurofibroma with some observations on the importance of pre-operative angiography and the value of pre-operative intra-arterial embolisation. Br J Plast Surg 1983;36:501e6. 2. Lin YC, Chen HC. Rare complications of massive haemorrhage in neurofibromatosis with arteriovenous malformation. Ann Plast Surg 2000;44:221e4.
B. Youssef A. Dancey F.C. Peart Regional Department of Burns and Plastic Surgery, University Hospital Birmingham, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD, UK E-mail address: [email protected] ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.08.008
Figure 1 Massive plexiform neurofibromata involving the buttocks and lower back.
Re: ‘Reconstruction of orbital floor and maxilla with divided vascularised calvarial bone flap in one session’ We have reviewed the clinical study, conducted by Bilge et al., regarding the use of vascularised calvarial bone grafts in the reconstruction of orbital floor and maxilla.1 In this paper, the authors emphasise the necessity of elevating the temporoparietal hairy skin in the supragaleal-subfollicular plane to preserve the superficial temporal vascular territory in the temporal region. The vascular supply of the cranium has been studied by Cutting et al.2 They demonstrated three sources of blood supply to the anterior calvarium; (1) the middle meningeal artery and its branches, (2) branches of the anterior and posterior deep temporal arteries, and (3) a vascular plexus fed by the supraorbital supratrochlear, superficial temporal and occipital arteries. Although the middle meningeal artery and its branches are the most important vascular supply of all of these three sources, they are not suitable as a pedicle for vascularised bone transfer. The second source of blood supply consists of the branches of the anterior and
Figure 2 The drains passed through the tissue, in a similar fashion to a continuous running suture, using the trocar as a needle. The tension is being maintained by the haemostats.
DOI of original article:10.1016/j.bjps.2005.12.048.
116
Short reports and correspondence
posterior deep temporal arteries. These arteries also supply the temporalis muscle. Finally, there is a vascular plexus fed by the supraorbital, supratrochlear, superficial temporal and occipital arteries, which lies superficial to the galea but which has perforators that pass through the galea and periosteum to supply the underlying bone.3 Antonyshyn et al. in a rabbit model demonstrated that vascularised skull grafts survived when they were based only on temporalis muscle and periosteum.4 Besides these experimental studies the temporalis muscle flap, by itself, has been used for intraoral reconstruction.5 The temporalis muscle osteofacial flap has been used extensively for zygomatic arch and malar reconstruction especially in Treacher Collins syndrome and hemifacial microsomia,3 in temporomandibular joint disc reconstruction6 and in mandibular reconstruction.7 From these publications and our clinical experience we know that the anterior and posterior deep temporal arteries are sufficient for successful transfer of vascularised calvarial bone flaps. It is enough to preserve the attachment of temporal muscle to the calvarial bone and to transfer the bone along the axis of that muscle to achieve a successful surgical outcome. Any attempt to dissect in the supragalealsubfollicular plane in order to preserve the superficial temporal vascular territory in the temporal region not only elongates the operating time but also increases the risk of losing temporoparietal hair due to possible damage to the hair follicules during that dissection.
References
Subcutaneous infusion anaesthesia for sentinel lymph node biopsy in melanoma: method and complications* In 1992 Morton et al.1 published the technique of preoperative lymphoscintigraphy and sentinel lymph node (SLN) biopsy for mapping of regional basins draining primary melanomas. Technetium 99 m-labelled radioisotope and a hand-held gamma probe in combination with a blue dye are used to achieve a success rate in detecting the SLN of up to 97%.2 The percentage of positive SLN ranges from 15 to 33% of patients.3,4 Tumescent local anaesthesia was first described by Klein5 in 1987 for liposuction. Breuninger et al.6 described a variation of this procedure and called it slow infusion tumescent anaesthesia or subcutaneous infusion anaesthesia (SIA).7 In SIA a volume controlled infusion pump is used for achieving a slow and steady penetration of the solution into the adipose tissue. Advantages of a slow infusion rate include the lack of pain and/or the sensation of compression during infiltration, and a slower rise of anaesthetic plasma levels resulting in less toxicity and the possibility of using higher amounts of local anaesthetic, better skin surface anaesthesia and a more sustained postoperative effect.8,9 A complication rate of 4.6% associated with SLN biopsy has been reported in a large multi-institutional series,10 whereas the rates given in several smaller series ranged from 5.9 to 33.0%.11e13
Patients and methods
1. Bilen BT, Kılınc H, Arslan A, et al. Reconstruction of orbital floor and maxilla with divided vascularised calvarial bone flap in one session. J Plast Reconstr Aesthet Surg 2006;59:1305e11. 2. Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps. Plast Reconstr Surg 1984;74:603e10. 3. Bite U, Jackson IT, Wahner HW, et al. Vascularized skull bone grafts in craniofacial surgery. Ann Plast Surg 1987;19:3e15. 4. Antonyshyn O, Colcleugh RG, Hurst LN, et al. The temporalis myo-osseous flap: an experimental study. Plast Reconstr Surg 1986;77:406e15. 5. Wong TY, Chung CH, Huang JS, et al. The inverted temporalis muscle flap for intraoral reconstruction: its rationale and the results of its application. J Oral Maxillofac Surg 2004;62:667e75. 6. Rossi DC, Kappel DA. Temporalis muscle osteofascial flap reconstruction of a temporomandibular joint disk in an Ehlers-Danlos patient. Plast Reconstr Surg 2006;117:40ee3e. 7. Jackson IT, Helden G, Marx R. Skull bone grafts in maxillofacial and craniofacial surgery. J Oral Maxillofac Surg 1986;44:949e55.
Halil Ibrahim Canter Ian T. Jackson Providence Hospital, Craniofacial Institute, Southfiled, Michigan, USA E-mail address: [email protected] ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.08.010
The study group consisted of 181 patients with primary melanomas of the trunk and extremities with tumour thicknesses 1 mm (for exceptions see results). Informed consent was given by all patients. Documentation included the following parameters: age, tumour location, tumour thickness and Clark level, number of SLN basins, number of excised nodes, complications. For lymphoscintigraphy 18e48 MBq TC-99 m microcolloid was injected intradermally around the scar 1 day before surgery. Diazepam 5e10 mg on the evening before and 1 h before surgery, or midazolam 7.5 mg only before surgery were given as sedation. During administration of SIA heart rate, arterial oxygen saturation and blood pressure were monitored. Location of SLN was checked with a hand-held gamma probe (C-Trak) and then SIA was infiltrated. Routinely we use a 0.2% solution containing 450 ml of Ringer solution, 50 ml of lidocaine hydrochloride 2%, and 0.5 ml epinephrine (recommended maximum doses of 0.2% solution: 300e400 ml, of 0.1% solution: 600e1000 ml, dependent on body weight). For overweight patients with more than one SLN basin we prefer to use 0.2% solution initially and then switch to 0.1% solution to reduce the total amount of lidocaine hydrochloride applied. Maximum dosages of lidocaine of 35 mg/kg are described in the literature for tumescent
*
Results of this study were presented at the 5th Biennial International Sentinel Node Society Meeting in Rome, November 1e4, 2006 as a poster presentation.