- Email: [email protected]
Routine histological examination of the mastectomy scar at the time of breast reconstruction
1248 reconstructions. Indeed this report rather reinforces the gulf between the ideals of the office bound academic and the realities facing the practicing surgeon and one can only wonder what Gillies and his contemporises would have made of what can best be described as the ‘Politicization of Plastic Surgery’! The failure rate of form filling, ‘ascertainment’, is over twice the failure rate of the reconstructive surgery that is being assessed and even the authors acknowledge that the power of analysis is such that it would take years to achieve any meaningful data if more realistic levels of unacceptable flap failure were used, i.e. >10%. The authors must, however, be congratulated in presenting honest data which serve to illustrate the conceptual and practical difficulties of assessing surgical performance by simple audit.
References 1. Cole RP, Browne JP. Towards performance measurement in reconstructive surgery: a multicentre pilot study of free and pedicled flap procedures. J Plast Reconstr Aesthet Surg 2006;59:257e62. 2. Clinical Effectiveness Unit.
Andrew Burd Department of Surgery and Plastic Surgery, The Chinese University of Hong Kong, Shatin, Prince of Wales Hospital, Hong Kong E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.005
A cost effective training tool for flexor tendon repair: Pig’s trotters Wright et al.1 have reported a model for flexor tendon repair using pig’s trotters. The usage of pig’s trotters has been part of the surgical curriculum for many years. All trainees must successfully complete the Basic Surgical Skills Course (BSS) by the Royal College of Surgeons of England, before appearing for the final Membership examination. The usage of pig’s trotters has been well described in the Trauma and Orthopaedics section of the BSS Participants Handbook and hands on experience is provided during the course. We acknowledge the author’s time and effort to promote this technique
Short reports and correspondence in their training curriculum, but one should not forget that this has been part of the Surgical Curriculum2 for the past 10 years.
References 1. Wright TC, Widdowson D, Khan M, et al. A cost-effective training tool for flexor tendon repair: Pig’s trotters. Journal of Plastic, Reconstructive & Aesthetic Surgery 2006;1:107e8. 2. The Royal College of Surgeons of England. Basic surgical skills: participant handbook. The Royal College of Surgeons of England; 1996. p. 38e9.
Amit Pabari P. Lim A. Linford P.M. Gilbert Plastic Surgery, McIndoe Burns Centre, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, United Kingdom E-mail address: [email protected] ª 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2006.03.063
Routine histological examination of the mastectomy scar at the time of breast reconstruction We read with interest the paper titled ‘Routine histological examination of the mastectomy scar at the time of breast reconstruction: important oncological surveillance?’ by Soldin et al.1 and the subsequent reply to that by Zambacos et al.2 We have audited our own experience on the above subject (January 2006) at the breast unit at Warwick Hospital and report our results on the subject. We identified 33 cases of delayed reconstructions over an eight-year period (1997e2005). Nineteen patients had their mastectomy scar analysed by routine H and E staining at the time of reconstruction. None of the 19 scars submitted for histological analysis showed any evidence of microscopic recurrence. More importantly, none of the patients from the group who did not have their scar analysed developed any local recurrence. We agree with Soldin et al. that the incidence of recurrence detected from the routine mastectomy scar analysis is very low and agree that histological examination of the mastectomy scar is of no benefit. Following our audit, we do not send mastectomy scars for routine histology at the time of delayed reconstruction.
Short reports and correspondence
References 1. Soldin MG, Grob M, Dawson A, et al. Routine histological examination of the mastectomy scar at the time of breast reconstruction: important oncological surveillance? Br J Plast Surg 2004 Mar;57(2):143e5. 2. Zambacos GJ, Wilson PA, Miminas D, et al. Routine histological examination of the mastectomy scar at the time of breast reconstruction. Br J Plast Surg 2005 Jan;58(1):122.
V. Mathen S. Khan M. O’Brien L. Jones S. Harries D. Clarke Department of Breast and Reconstructive Surgery, Warwick General Hospital, 26 Remburn Gardens, Lakin Road, Warwick, Warwickshire CV34 5BW, United Kingdom E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.010
Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects e a simple solution for a complex problem We read with interest the article by Kamath et al.1 They presented a marvelous series of clinical cases that introduced the idea of local flap (either proximal or distal based) with perforators included for reconstruction of the soft tissue defect in the pretibial region. We found the title using ‘perforatorbased flap’ may confuse the readers with the real perforator-based flap (usually island-designed with perforator as the only source of perfusion) that had been used in a number of articles for long time.2,3 In addition, some authors had proposed new nomenclature for perforator flaps.4,5 Strictly speaking, this flap was a local flap including a perforator that perpendicularly penetrates the flap base. In fact, these flaps were ‘double-based’, simultaneously nourished by the perforator and the skin paddle that bridged the flap. We had experience with this kind of flap that can be converted to real perforator-based island flap or true local flap, fortunately, without serious complication. The advantage of local flap including perforator against real perforator-based island flap or local flap is the double insurance for blood perfusion, on the
1249 contrary, it also pays the price in reduced flap excursion that was important for pedicle flaps used in lower limb reconstruction. The tug of war between perfusion and excursion of perforator-included local flap challenges the surgeon’s judgement. In summary, we would like to clarify simply the concept of ‘perforator-included local flaps’, they are flaps of double basesdperforator and skin paddle bridge. However, perforator-based flap should be used for flaps in which the perforators were responsible for the perfusion alone.
References 1. Kamath BJ, Joshua TV, Pramod S. Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects e a simple solution for a complex problem. J Plast Reconstr Aesthet Surg 2006;59:515e20. 2. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 3. Meltem ¸ c., Esra ¸ c., Hasan F, et al. The gluteal perforatorbased flap in repair of pressure sores. Br J Plast Surg 2004; 57:342e7. 4. Kim JT. New nomenclature concept of perforator flap. Br J Plast Surg 2005;58:431e40. 5. Sharma RK, Mehrotra S, Nanda V. The perforator ‘plus’ flap: a simple nomenclature for locoregional perforator-based flaps. Plast Reconstr Surg 2005;116:1838e9.
Jui-Tien Lee Hung-Tao Hsiao Kwang-Yi Tung Department of Plastic and Reconstructive Surgery, Mackay Memorial Hospital, Taitung Branch, Mackay Junior College of Nursing, No.1, Lane 301, ChangSha Street, Taitung 950, Taipei, Taiwan E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.009
A novel approach for the application of the vacuum assisted closure device to the difficult anatomy Vacuum assisted closure (VAC) devices have significantly improved our ability to accelerate wound healing in chronic and difficult to treat wound by drawing wounds to closure, removing excess exudate, reducing localised oedema, reducing bacterial load at the wound base, and encouraging angiogenesis, growth of granulation tissue and epithelial
References 1. Cole RP, Browne JP. Towards performance measurement in reconstructive surgery: a multicentre pilot study of free and pedicled flap procedures. J Plast Reconstr Aesthet Surg 2006;59:257e62. 2. Clinical Effectiveness Unit.
Andrew Burd Department of Surgery and Plastic Surgery, The Chinese University of Hong Kong, Shatin, Prince of Wales Hospital, Hong Kong E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.005
A cost effective training tool for flexor tendon repair: Pig’s trotters Wright et al.1 have reported a model for flexor tendon repair using pig’s trotters. The usage of pig’s trotters has been part of the surgical curriculum for many years. All trainees must successfully complete the Basic Surgical Skills Course (BSS) by the Royal College of Surgeons of England, before appearing for the final Membership examination. The usage of pig’s trotters has been well described in the Trauma and Orthopaedics section of the BSS Participants Handbook and hands on experience is provided during the course. We acknowledge the author’s time and effort to promote this technique
Short reports and correspondence in their training curriculum, but one should not forget that this has been part of the Surgical Curriculum2 for the past 10 years.
References 1. Wright TC, Widdowson D, Khan M, et al. A cost-effective training tool for flexor tendon repair: Pig’s trotters. Journal of Plastic, Reconstructive & Aesthetic Surgery 2006;1:107e8. 2. The Royal College of Surgeons of England. Basic surgical skills: participant handbook. The Royal College of Surgeons of England; 1996. p. 38e9.
Amit Pabari P. Lim A. Linford P.M. Gilbert Plastic Surgery, McIndoe Burns Centre, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, United Kingdom E-mail address: [email protected] ª 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2006.03.063
Routine histological examination of the mastectomy scar at the time of breast reconstruction We read with interest the paper titled ‘Routine histological examination of the mastectomy scar at the time of breast reconstruction: important oncological surveillance?’ by Soldin et al.1 and the subsequent reply to that by Zambacos et al.2 We have audited our own experience on the above subject (January 2006) at the breast unit at Warwick Hospital and report our results on the subject. We identified 33 cases of delayed reconstructions over an eight-year period (1997e2005). Nineteen patients had their mastectomy scar analysed by routine H and E staining at the time of reconstruction. None of the 19 scars submitted for histological analysis showed any evidence of microscopic recurrence. More importantly, none of the patients from the group who did not have their scar analysed developed any local recurrence. We agree with Soldin et al. that the incidence of recurrence detected from the routine mastectomy scar analysis is very low and agree that histological examination of the mastectomy scar is of no benefit. Following our audit, we do not send mastectomy scars for routine histology at the time of delayed reconstruction.
Short reports and correspondence
References 1. Soldin MG, Grob M, Dawson A, et al. Routine histological examination of the mastectomy scar at the time of breast reconstruction: important oncological surveillance? Br J Plast Surg 2004 Mar;57(2):143e5. 2. Zambacos GJ, Wilson PA, Miminas D, et al. Routine histological examination of the mastectomy scar at the time of breast reconstruction. Br J Plast Surg 2005 Jan;58(1):122.
V. Mathen S. Khan M. O’Brien L. Jones S. Harries D. Clarke Department of Breast and Reconstructive Surgery, Warwick General Hospital, 26 Remburn Gardens, Lakin Road, Warwick, Warwickshire CV34 5BW, United Kingdom E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.010
Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects e a simple solution for a complex problem We read with interest the article by Kamath et al.1 They presented a marvelous series of clinical cases that introduced the idea of local flap (either proximal or distal based) with perforators included for reconstruction of the soft tissue defect in the pretibial region. We found the title using ‘perforatorbased flap’ may confuse the readers with the real perforator-based flap (usually island-designed with perforator as the only source of perfusion) that had been used in a number of articles for long time.2,3 In addition, some authors had proposed new nomenclature for perforator flaps.4,5 Strictly speaking, this flap was a local flap including a perforator that perpendicularly penetrates the flap base. In fact, these flaps were ‘double-based’, simultaneously nourished by the perforator and the skin paddle that bridged the flap. We had experience with this kind of flap that can be converted to real perforator-based island flap or true local flap, fortunately, without serious complication. The advantage of local flap including perforator against real perforator-based island flap or local flap is the double insurance for blood perfusion, on the
1249 contrary, it also pays the price in reduced flap excursion that was important for pedicle flaps used in lower limb reconstruction. The tug of war between perfusion and excursion of perforator-included local flap challenges the surgeon’s judgement. In summary, we would like to clarify simply the concept of ‘perforator-included local flaps’, they are flaps of double basesdperforator and skin paddle bridge. However, perforator-based flap should be used for flaps in which the perforators were responsible for the perfusion alone.
References 1. Kamath BJ, Joshua TV, Pramod S. Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects e a simple solution for a complex problem. J Plast Reconstr Aesthet Surg 2006;59:515e20. 2. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 3. Meltem ¸ c., Esra ¸ c., Hasan F, et al. The gluteal perforatorbased flap in repair of pressure sores. Br J Plast Surg 2004; 57:342e7. 4. Kim JT. New nomenclature concept of perforator flap. Br J Plast Surg 2005;58:431e40. 5. Sharma RK, Mehrotra S, Nanda V. The perforator ‘plus’ flap: a simple nomenclature for locoregional perforator-based flaps. Plast Reconstr Surg 2005;116:1838e9.
Jui-Tien Lee Hung-Tao Hsiao Kwang-Yi Tung Department of Plastic and Reconstructive Surgery, Mackay Memorial Hospital, Taitung Branch, Mackay Junior College of Nursing, No.1, Lane 301, ChangSha Street, Taitung 950, Taipei, Taiwan E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.009
A novel approach for the application of the vacuum assisted closure device to the difficult anatomy Vacuum assisted closure (VAC) devices have significantly improved our ability to accelerate wound healing in chronic and difficult to treat wound by drawing wounds to closure, removing excess exudate, reducing localised oedema, reducing bacterial load at the wound base, and encouraging angiogenesis, growth of granulation tissue and epithelial