Letters and Viewpoints

1. Bhathena, H. M., and Kavarana, N. M. One stage total mandibular reconstruction with rib, pectoralis major osteo-myocutaneous flap. Head Neck 8: 211, 1986.
2. Kavarana, N. M., and Bhathena, H. M. Reconstructive surgery in head and neck cancer. Semin. Surg. Oncol. 5: 341, 1989.
3. Bhathena, H. M., and Kavarana, N. M. Primary recon­struction of head and neck cancer with anterior rib, osteo-myocutaneous composite flap (AROCF). Head Neck 14: 183, 1992.
4. Savant, D. N., Kavarana, N. M., Bhathena, H. M., Salkar, S., and Ghosh, S. Osteomyocutaneous flap recon­struction for major mandibular defects. J. Surg. Oncol. 55: 122, 1994.
5. Savant, D. N., Patel, S. G., Verghese, T., Bhathena, H. M., and Kavarana, N. M. Reconstruction of the mandi­ble with vascularized iliac crest free flap: Initial expe­rience at the Tata Memorial Hospital. Acta Chir. Plast. 37: 35, 1995.
6. Bhathena, H. M., Savant, D. N., Kavarana, N. M., Parikh, D. M., and Sanghvi, V. D. Reconstruction with dif­ferent free flaps in oro-facial cancer patients. Acta Chir. Plast. 38: 43, 1996.

VASCULARIZED FIBULA GRAFT AND
OSSEOINTEGRATED TEETH IMPLANTATION
AFTER SEGMENTAL MANDIBULECTOMY FOR
FIBROUS DYSPLASIA
Sir:
I read with great interest the Case Report by Yang-Ming Chang et al. entitled “Total Reconstruction and Rehabilita­tion with Vascularized Fibula Graft and Osseointegrated Teeth Implantation after Segmental Mandibulectomy for Fi­brous Dysplasia” (Plast. Reconstr. Surg. 113: 1205, 2004). I congratulate the authors for their well-explained and precise description of jaw reconstruction with a live fibula graft and primary osseointegrated implants for masticatory rehabilita­tion.

I have a humble experience with upper and lower jaw reconstruction using various types of vascularized live bone grafts following ablative surgery for fibrous dysplasia and head and neck cancer.1– 6 I would be highly obliged to know the rationale for bridging the defects between the two ends of the inferior alveolar nerve with a sural nerve in the case where the described lesion crosses the midline from the right ramus to the left first premolar. I wonder whether the distal end (stump) of the inferior dental nerve is available on the left side for sural nerve grafting to bridge the defects created after wide ablation of such lesions. If yes, is it enough to carry out the primary sensory nerve grafting in lesions with such a high recurrence rate? DOI: 10.1097/01.prs.0000184334.76234.24

RECONSTRUCTION IN WOMEN WITH
BILATERAL PROPHYLACTIC MASTECTOMY: A
DESCRIPTIVE STUDY
Sir:
The authors of the article entitled “Reconstruction in Women with Bilateral Prophylactic Mastectomy: A Descrip­tive Study” (Plast. Reconstr. Surg. 114: 360, 2004) surveyed the province of Ontario, Canada, for individuals who un­derwent prophylactic bilateral mastectomy (total mastec­tomy or subcutaneous mastectomy) who were determined to be at a higher than normal risk for the development of breast cancer. Apparently, 122 women were identified through a chart review process, and 73 of those women underwent reconstruction. Of this population, only 37 were deemed eligible to participate in this study. The au­thors concluded from this limited number of women who had undergone prophylactic mastectomy that the cosmetic outcome was satisfactory, and that this patient population was also found to have significant miscalibration of risk of developing breast cancer.

While it is nice that patients have improved body image following reconstructive breast surgery, the ultimate quality relates to the prevention of breast cancer in this situation. It is difficult to promote prophylactic mastectomy because of the cosmetic quality of the outcomes based on the experience of only 37 patients.

PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

REPLY

Sir:
In 2001, when I expanded my use of liposuction as a primary modality to treat breast hypertrophy, I saw the pos­sible effect of breast liposuction on mammographic cancer screening. I immediately began to assess this risk by reviewing my charts and those of my associate. A total of 50 patients were identified who had received preoperative mammography and who had undergone surgery at least 6 months earlier. Letters were sent asking for permission to obtain mammographic records and discuss cases with the radiologists involved. Nine patients had undergone repeated mammography after surgery and agreed to release their records. Many patients had not undergone repeated mammography and admitted that the only mammogram they had ever taken was done to comply with preoperative liposuction breast reduction guidelines and that, regrettably, future screening was unlikely. This finding has been mirrored in the literature, where screening rates of only 25 percent have been reported.1 The time from sur­gery to repeated mammography in this study ranged from 7 months to 22 months and averaged 12 months. Three pa­tients demonstrated no significant changes in their mammo-grams. Three patients were noted to have routine postoper­ative surgical changes with architectural distortion. Compression films were required in one of these patients and resolved any question of suspicious lesions within the distor­tion. Two patients were noted to have moderately dense tissue that may obscure a mammographic lesion, but this finding was noted on both preoperative and postoperative mammo-grams, signaling little or no change in the breast due to surgery. One patient did have a noticeable increase in overall breast density after surgery.

While this review was underway, di Giuseppe published his experience,2 which was cited by Dr. Brauman. This report noted microcalcifications and scarring less than, or compa­rable to, those produced by standard breast reduction pro­cedures. These findings, in conjunction with my own re­search, dispelled fears of countless breast calcifications or other catastrophic events that would render breast imaging useless or, worse, condemn patients to a series of sonograms and biopsies because of suspicious lesions on radiographs.

Dr. Brauman correctly notes that liposuction breast re­duction will, by its very nature, increase breast density. This is an incontrovertible fact. The question, however, is whether the degree of change is significant enough to discard a useful procedure. While Dr. Brauman hypothesized that liposuction breast reduction would “render mammographic imaging and interpretation difficult and seriously impede breast cancer detection” and that breast cancer would “be much more difficult to detect,” the facts, based on the literature and experience, show that neither situation exists. The articles cited by Dr. Bauman regarding the above statements3– 6 do point out that denser breasts make mammographic cancer detection more difficult, but the statistical significance is of­ten marginal, and at least one series reported no statistically significant cancer risks when comparing the breast densities of younger patients.7 A key aspect to consider is that all the above publications compare fatty breasts with dense breasts, often comparing the extremes classes of the Breast Imaging Reporting and Data System, orBI-RADS, classification against one another to gain statistical significance. Experience and the literature2,8 show that postoperative changes in liposuc-tion breast reduction are minimal to moderate and in few, if any, cases will a predominantly fatty breast turn into an ex­tremely dense breast. This means that while the breast will become more dense, that increase will not be statistically significant.

The idea of statistical significance is not a mathematical exercise, and we need to look at other aspects of our practice to appreciate the nuances. Traditional breast reduction has been shown to produce significant changes in breast archi­tecture and complicate screening mammography.9,10 Some of these changes have even been read as cancers on radiographs.11 Brown et al.12 noted that more than 50 percent of traditional breast reduction patients in their cohort of 42 women had asymmetric densities at 1 year and significant breast calcifications 2 years postoperatively. Ten percent of patients sustained fat necrosis, and 10 percent of patients required a breast biopsy (all benign) within 6 years of the reduction procedure. Handel et al.13 reported that augmen­tation mammaplasty significantly affected the amount of breast tissue visualized during mammographic screening, and Miglioretti et al.14 recently reported decreases in mam-mogram sensitivity after breast augmentation similar to those effects cited by Dr. Brauman in cases of fatty breasts versus dense breasts.6 Experience and clinical investigation, how­ever, have shown that traditional breast reduction and aug­mentation mammaplasty are indeed safe procedures and carry an acceptable degree of postsurgical mammographic distortion.

In many ways, the issue returns to Dr. Courtiss’ original answer to Dr. Brauman’s first letter of 1994; however, there is now a growing body of experience from which to draw conclusions. The “risk/reward” ratio must be considered. Liposuction breast reduction allows for a significant breast reduction in an outpatient setting under intravenous seda­tion in as little as 1 hour. I have operated on patients with myasthenia gravis and chronic obstructive pulmonary disease who were not candidates for traditional surgery and who did very well with liposuction breast reduction. In addition, many older patients forgo traditional breast reduction surgery and spend decades in pain because they fear the trauma and scarring of a major operation. Furthermore, liposuction re­duction avoids the unpredictable scars that may not be cor­rectable over a patient’s lifetime. Current data show that these benefits can be achieved with minimal and acceptable mam-mographic changes. I agree with Dr. Brauman that long-term prospective trials are needed, and such trials are being formed at this time. As a radiologist commented in one of Dr. Brauman’s citations,15 “It is entirely possible that the antici­pated problems will not materialize, but this requires a pro­spective study involving experienced mammographers.”

There are two final points to be made. The scientific investigations cited by Dr. Brauman into breast density as an inherent cancer risk (outside of mammographic detection in­terference) address the proliferation of ductal/glandular components of the breast through endogenous and exoge­nous hormonal action, and should have no relation to the formation of a denser breast by mechanical means. Finally, I do not use ultrasonic liposuctioninmypractice because Ifind that standard liposuction gives an excellent result without entering any of the questionable, though probably safe, issues introduced by other researchers.16 DOI: 10.1097/01.prs.0000184338.64912.8d

Martin Jeffrey Moskovitz, M.D.
81 Terrace Avenue West
Orange, N.J. 07052
drmjm@comcast.net

REFERENCES

1.  The   NCI   Breast   Cancer   Screening   Consortium.
Screening mammography: A missed clinical opportu­nity? Results of the NCI Breast Cancer Screening Con­sortium and National Health Interview Survey studies. J.A.M.A. 264: 54, 1990.
2.  di Giuseppe Santoli, M.    Ultrasound-assisted breast re-
duction and mastopexy. Aesthetic Surg. J. 21: 493, 2001.
3.  Crystal, P., Strano, S. D., Shcharynski, S., and Koretz, M.
J. Using sonography to screen women with mammo-graphically dense breasts. Am. J. Roentgenol. 181: 177, 2003.
4.  Carney, P. A., Miglioretti, D. L., Yankaskas, B. C., et
al. Individual and combined effects of age, breast density, and hormone replacement therapy use onthe accuracy of screening mammography. Ann. Intern. Med. 138: 168, 2003.
5.  Saarenmaa, I., Salminen, T., Geiger, U., et al.    The effect
of age and density of the breast on the sensitivity of breast cancer diagnostic by mammography and ultra-sonography. Breast Cancer Res. Treat. 67: 117, 2001.
6.  Mandelson, M. T., Oestreicher, N., Porter, P. L., et
al. Breast density as a predictor of mammographic detection: Comparison of interval- and screen-de­tected cancers. J. Natl. Cancer Inst. 92: 1081, 2000.
7.  Kerlikowske, K., Grady, D., Barclay, J., Sickels, E. A., and
Ernster, V. Effect of age, breast density, and family history on the sensitivity of first screening mammog-raphy. J.A.M.A. 276: 33, 1996.
8.  Gray, L. N.    Update on experience with liposuction
breast reduction. Plast. Reconstr. Surg. 108: 1011, 2001.
9.  Danikas, D., Theodorou, S. J., Kokkalis, G., Vasiou, K.,
and Kyriakopoulou, K. Mammographic findings fol­lowing reduction mammaplasty. Aesthetic Plast. Surg. 25: 283, 2001.
10.  Mendelson, E.    Evaluation of the postoperative breast.
Radiol. Clin. North Am. 30: 107, 1992.
11.  Miller, J. A., Festa, S., and Goldstein, M.    Benign fat
necrosis stimulating bilateral breast malignancy after reduction mammaplasty. South. Med. J. 91: 765, 1998.
12.  Brown, F. E., Sargent, S. K., Cohen, S. R., and Morain, W.
D. Mammographic changes following reduction mammaplasty. Plast. Reconstr. Surg. 80: 691, 1987.
13.  Handel, N., Silverstein, M. J., Gamagami, P., Jensen, J. A.,
and Collins, A. Factors affecting mammographic visualization of the breast after augmentation mam-maplasty. J.A.M.A. 268: 1913, 1992.
14.  Miglioretti, D. L., Rutter, C. M., Geller, B. M., et al.
Effectofbreast augmentationonthe accuracyofmam-mography and cancer characteristics. J.A.M.A. 291: 442, 2004.
15.  Hutton, L. C.    Breast imaging after ultrasonic assisted
breast liposuction (Reply). Can. Assoc. Radiol. J. 49: 351, 1998.
16.  Topaz, M.    Possible long-term complications in ultra-
sound assisted liposuction induced by sonolumines-cence, sonochemistry, and thermal effects. Aesthetic Surg. J. 18: 19, 1998.

TERMINOLATERAL FIBER COUNT

Sir:
We read with great interest the recent end-to-side neuror-rhaphy experience of Hayashi etal..1 We applaud their efforts at designing a novel, noninjurious terminolateral coaptation model to clarify the mechanism by which end-to-side nerve regeneration occurs. Though we share their enthusiasm for the clinical potential of end-to-side neurorrhaphy, we must take issue with the regenerated median fiber counts pre­sented in the study.

In the model, an end-to-side neurorrhaphy was performed with a 4-cm sciatic nerve graft extending from the right to the left median nerve. The left median nerve was sutured to the graft in a standard end-to-end fashion. Three groups were involved. The first two were meticulously designed to avoid injury to the underlying axons at the site of the end-to-side coaptation. In the third group, which served as a control, the repair was achieved with a perineural window and partial neurectomy. Sixty days after the operation, Hayashi’s group observed robust regeneration in the midgraft cross-sections. Regenerating nerve fiber counts ranged from 6134 ± 1704.19 to 6378.2 ± 1905.52 for the three groups. There were no statistically significant differences in the fiber counts among the three groups.

While we agree that collateral sprouting may have oc­curred at the three coaptation sites, we would expect the midgraft counts to be much lower. In fact, our work with rat peripheral nerves has consistently yielded control median nerve fiber counts in the range of 4148 ± 663. These results were obtained via analysis of 1-mm-thick cross-sections stained with toluidine blue dye and analyzed with morpho-metric software. Recent research by Tos etal.4yielded control rat median nerve fiber counts of 4687 ± 153. Given the lower number of native median nerve fibers, we find it difficult to conceptualize a model where 150 percent of the native me­dian nerve fibers successfully regenerate into a noninjuriously coapted graft.

Previous researchers have indeed concluded that collat­eral sprouting occurs in the absence of an epineurial window. In fact, Viterbo’s group sectioned the peroneal nerve and coapted it to the tibial nerve without a window in 1992.2 Zhao et al.3 demonstrated that regenerating nerve fibers of an end-to-side neurorrhaphy have the ability to penetrate en-doneurium, perineurium, and epineurium. Our own work with a rat posterior tibial end-to-side repair to the peroneal nerve with and without an epineural window yielded regen­erated fiber counts of 327 ± 264 and 408 ± 443, respectively.5 To our knowledge, the robust regeneration of nerve fibers beyond that of the native nerve has not previously been re­ported and begs further interpretation, possibly with pregraft and postgraft sectioning. The falsely elevated midgraft num­bers observed in the study could be explained in part by contamination from regenerating nerve fibers originating from the distal median nerve stump (Fig. 2 from Hayashi et al.’s article).
Terminolateral neurorrhaphy is an exciting area of re­search. We look forward to future animal and clinical studies on the topic. DOI: 10.1097/01.prs.0000184341.22692.8f

Jason R Hess, M.D. Terence M. Myckatyn, M.D. Daniel A. Hunter, B.S. Susan E. Mackinnon, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Washington University School of Medicine St. Louis, Mo.
Correspondence to Dr. Mackinnon
Division of Plastic and Reconstructive Surgery
Washington University of School of Medicine
660 South Euclid Avenue
Campus Box 8238
St. Louis, Mo. 63110
hessj@msnotes.wustl.edu
mackinnon@msnotes.wustl.edu

REFERENCES
1.  Hayashi, A., Yanai, A., Komuro, Y., et al.    Collateral
sprouting occurs following end-to-side neurorrhaphy. Plast. Reconstr. Surg. 114: 129, 2004.
2.  Viterbo, F., Trindale, J. C., Hoshino, K., et al.    Latero-
terminal neurorrhaphy without removal of the epineurial sheath: Experimental study in rats. Rev. Paul. Med. 10: 267, 1992.

3.  Zhao, J., Chen, Z. W., and Chen, T.     Nerve regeneration
after terminolateral neurorrhaphy: Experimental study in rats. J. Reconstr. Microsurg. 13: 31, 1997.
4.  Tos, P., Calcagni, M., Gigo-Benato, D., et al.    Use of
muscle-vein-combined Y-chambers for repair of mul­tiple nerve lesions: Experimental results. Microsurgery Online (early view) .
5.  Tarasidis, G., Watanabe, O., Mackinnon, S. E., et al.
End-to-side neurorrhaphy resulting in limited sensory axonal regeneration in a rat model. Ann. Otol. Laryn-gol. 106: 506, 1997.

REPLY

Sir:
I thank Dr. Hess and his colleagues for their brief com­munication with regard to my article. As they mention in their comment, the number of the regenerated nerve fi­bers in our study was greater than that in other reports. This was due to the accidental error of the software I used to count the number of regenerated nerve fibers. It was very difficult for us to make the software calculate the exact number of fibers. Therefore, the standard deviations of these data were very large (±1602.73 to ±1905.52). I think the relative number of regenerated fibers was available to compare each group.
Using these data, I could only show that the nerve was regenerated even in the noninjuriously coapted graft model, and that the number of regenerated fibers was not so differ­ent from that in the usual end-to-side model. DOI: 10.1097/01.prs.0000184341.22692.8f

Ayato Hayashi, M.D.
Department of Plastic and Reconstructive Surgery Juntendo University School of Medicine Tokyo, Japan ayato@rb3.so-net.ne.jp

VIEWPOINTS

CONCERNS OVER THE USE OF TISSUE
ADHESIVE IN FACIAL LACERATIONS:
RECOMMENDATIONS AND A SUGGESTION TO
INCREASE LAG BOND STRENGTH

Sir:
We have recently noticed a slight rise in the number of cases of facial wound dehiscence, primarily related to the use of tissue adhesives. The use of such glues has increased dra­matically over the last decade, with a reduction in the cost of adhesives and increased familiarity with their use. Such ben­efits are not without drawbacks, however, with multitrial re­views indicating an increased rate of dehiscence in compar­ison to sutures.1 One trial noted a dehiscence rate of 8 percent in pediatric facial wound closure.

With this in mind, we recently evaluated and reported 200 cases of facial lacerations seen in an emergency department in the United Kingdom.3 The vast majority of cases (96 per­cent) were treated by emergency staff, with only 4 percent referred to plastic surgical services. Almost one quarter (24 percent) of all wounds treated in the emergency department were closed with tissue adhesive. Of these cases, 13 percent involved wounds for which there is no clinical trial evidence of the use of tissue adhesive. These included wounds over 4 cm in length and nonlinear lacerations, which have been specifically excluded from trial designs.

Although technological advances in cyanoacrylate tissue adhesives are to be applauded, it is suggested that facial laceration closure by glue be chosen carefully and be limited to linear lacerations less than 4 cm in length. Furthermore, in the cases of wound dehiscence that we have managed, the failure appears to be at the lag bond (skin-glue interface) rather than due to a direct failure of the glue (Fig. 1). This is supported by preliminary tests in our department that have indicated that delamination occurs at the glue periphery before failure. Therefore, careful skin preparation is essential to optimize lag bond adherence, and it is suggested that skin edges be prepared with an alcohol wipe before glue appli­cation to minimize oil interposition. In addition, a bio-oc-clusive dressing may reduce delamination at the glue edges. We are currently evaluating both the mechanics of adhesive failure and methods of enhancing lag bond strength in our department. DOI: 10.1097/01.prs.0000184343.18693.b9

Steven Lo, M.R.C.S.(Glasg.)
Keith Cullen, F.R.C.S.
Department of Plastic Surgery
Queen Victoria Hospital
East Grinstead, United Kingdom
Henk Giele, F.R.C.S., F.R.A.C.S.
Department of Plastic Surgery
Radcliffe Infirmary
Oxford, United Kingdom
Paul Buckley, M.A., D.Phil.
Department of Mechanical Engineering
University of Oxford
Oxford, United Kingdom
Correspondence to Dr. Lo 8A Lucerne Road, Upper Flat Summertown, Oxford OX2 7QB United Kingdom stevelo@doctors.org.uk

REFERENCES

1. Farion, K., Osmond, M. H., Hartling, L., et al.    Tissue
adhesives for traumatic lacerations in children and adults. Cochrane Database Syst. Rev. (3)CD003326, 2002.
2. Quinn, J. V., Drzewiecki, A., Li, M. M., et al.    A random-
ised, controlled trial comparing a tissue adhesive and suturing in the repair of pediatric facial lacerations. Ann. Emerg. Med. 22: 1130, 1993 Jul.
3. Lo, S., and Aslam, N.    A review of tissue glue use in facial
lacerations: Potential problems with wound selection in accident and emergency. Eur. J. Emerg. Med. 11: 277, 2004.

USING A ROLLER-BOTTLE FILLED WITH
ADHESIVE SOLUTION TO FIX SILK TAPE ON
THE FACE

Sir:
In the routine practice of plastic surgery, we affix catheters, intubation and nasogastric tubes, and nasal casts. A few types of tape are available, and we usually use silk tape to affix these materials. Silk tape shows poor adhesion to moist surfaces, how­ever, especially facial skin. We therefore use adhesive solutions to affix the silk tape. It is important to use these solutions min­imally and only on a limited area of the face. Figure 1 shows a roller bottle filled with adhesive solution used to affix silk tape to the face, to secure tubes and nasal casts.

We did not find any correspondence about using a roller bottle filled with adhesive solution to affix silk tape and wanted to share this idea. In summary, applying adhesive solutions with a roller bottle provides a safe method of affixing materials. It is easier to limit the surface application and protect the eyes from the extra amount of adhesive solution. DOI: 10.1097/01.prs.0000184344.30856.fe

Abdullah Etoz, M.D.
Umut Tuned, M.D.
Ramazan Kahveci, M.D.
Department of Plastic and Reconstructive Surgery
Faculty of Medicine
Uludag University
Bursa, Turkey

Correspondence to Dr. Etoz
Department of Plastic and Reconstructive Surgery
Medical Faculty of Uludag University
16059 Gorukle, Bursa, Turkey
etoz@yahoo.com

PRELIMINARY RESULTS AFTER FACE PEELS USING ALDARA CREAM 5% (IMIQUIMOD)

Sir:
Aldara cream (3M, Maplewood, St. Paul, Minn.), or imi-quimod, acts as a immune-response modulator when applied to the skin.1 Its mechanism of action has only been partially elucidated, but it acts as an antitumoral, antiviral, and im-munoregulator agent.2 On the skin, Aldara enhances the production of local cytokines and is used extensively by dermatologists3,4 to treat genital and perianal warts, mollus-cum contagiosum, herpes simplexes, basal cell carcinomas, actinic keratosis, Bowen’s disease, melanoma, and cutaneous T-cell lymphomas.4 –13 As a spinoff of the former treatments, Aldara has been used for keloids, hemangiomas, and tattoo removal14–17 and to ameliorate surgical scars.

Focusing on Aldara’s mechanism of action, which is not totally understood, we started using the 5% imiquimod cream for total face peels after postulating that its use would induce the production of proinflammatory cytokines in the skin, mainly interferon-alpha, tumor necrosis factor-alpha, and interleukins. These cytokines would stimulate a cell-mediated response through cytotoxic effectors of the skin against different noxas, such as virus (warts), tumors (basal cell carcinomas or actinic keratosis), and the aging process (our hypothesis). The purpose of this study was to determine the cosmetic effects of Aldara on facial skin and the cream’s possible antiaging properties.

Over a period of 6 months (from March to August of 2004), we recruited 12 female patients who consented to use Aldara 5% cream as a total face application on a daily basis for 12 weeks. Their ages ranged from 41 to 72 years. High-quality digital photographs were taken before and 12 weeks after treatment. Treatment consisted of gently rubbing two sachets (12 g each) of the cream on the entire face for 3 to 5 minutes every day over a period of 3 months.

Objective grading systems used to evaluate cosmetic results are scarce, mostly because peels are not strictly surgical proce­dures. To control subjective biases, we used two scales that eval­uate cosmetic surgical results as well as scarring (Strasser’s and Beausang’s scales). Strasser’s scale19,20 correlates malpositions, distortions, asymmetries, contour defects, and scars and gives points if they are perfect, noticeable, obvious, or deforming; Beausang’s scale21 incorporates the evaluation of color and matte or shiny matrices and gives ascending points if the skin is perfect or if the color mismatch is slight, obvious, or gross.

These two scales were used by a blinded plastic surgeon,   the   patient,   and   the   surgeon   to   rate   the photographic appearance of the skin at day 0 and at 12 weeks.

All patients demonstrated evident changes in their facial skin color and texture at 12 weeks, with absolute coincidence in the evaluation of the two surgeons and the patient (Figs. 1 through 4). The skin, while smooth, shiny, and sometimes pink, was never considered to be perfect (Beausang), but it rated 0 points for contour deformities, scars, or distortions (Strasser).

Four patients experienced a moderate burning sensation with pinpoint redness of the skin and had to suspend product application for 2 or 3 days, but they were able to complete the 12-week treatment. In one patient, postinflammatory pigmentation had to be treated with kjocic acid. The photographic results are reminiscent of and concordant with other clinical results obtained with TCA and erbium laser peels.

The expanded use of Aldara cream is a fact. In observing the impressive results of our dermatology colleagues after they treated basal cell carcinomas with Aldara cream, we saw that the normal skin surrounding the tumor excision site was always shiny, and in some cases there were no wrinkles. This was one of the reasons we started this study. We have postu­lated that this new face peel can be considered an “immune chemical peel.” The 5% imiquimod cream stimulates the skin with a florid reaction that traduces its results in redness, tightness, and a mild burning sensation during the first 3 weeks of treatment. This could be related to the production of cytokines in response to the noxa that we have thought could be the aging process and, in some of our cases, the concomitant presence of actinic keratosis. We believe the increase in interferon production through local cytokines increases collagen breakdown, and that this agent acts as an antiaging peel on damaged skin. Another effect was the skin lightening seen after 12 weeks of treatment

Biopsy studies and longer follow-ups should be incorpo­rated in future investigations, but for the moment we think that Aldara cream should be included in our skin care programs22 or simply used for skin rejuvenation.

None of the authors have a financial relationship with Aldara products or its manufacturer. DOI: 10.1097/01.prs.0000184345.09254.61

REFERENCES

1. Skinner, R. B., Jr.    Imiquimod. Dermatol. Clin. 21: 291, 2003.
2. Stanley, M. A.    Imiquimod and the imidazoquinolones:Mechanism of action and therapeutic potential. Clin. Exp. Dermatol. 27: 571, 2002.
3. Sauder, D.    New immune therapies for skin disease: Imi-
quimod and related compounds. J. Cutan. Med. Surg. 5: 2, 2001.
4. Berman, B., Poochareon, V. N., and Villa, A. M.    Novel
dermatologic uses of the immune response modifier imiquimod 5% cream. Skin Ther. Lett. 7: 1, 2002.
5. Hengge,    U.    R.,    Esser,    S.,    Schultewolter,    T.,    et
al. Self-administered topical 5% imiquimod for the treatment of common warts and molluscum contagio-sum. Br. J. Dermatol. 143: 1026, 2000.
6. Liota, E., Smith, K. J., Buckley, R., Menon, P., and Skel-ton, H. Imiquimod therapy for molluscum conta-giosum. J. Cutan. Med. Surg. 4: 76, 2000.
7. Gilbert, J., Drehs, M. M., and Weinberg, J. M. Topical imiquimod for acyclovir-unresponsive herpes simplex virus 2 infection. Arch. Dermatol. 137: 1015, 2001.
8. Drehs, M. M., Cook-Bolden, F., Tanzi, E. L., and Wein-berg, J. M. Successful treatment of multiple super­ficial basal cell carcinomas with topical imiquimod: Case report and review of the literature. Dermatol. Surg. 28: 427, 2002.
9. Stockfleth, E., Meyer, T., Benninghoff, B., and Christo­phers, E. Successful treatment of actinic keratosis with imiquimod cream 5%: A report of six cases. Br. J. Dermatol. 144: 1050, 2001.
10. Mackenzie-Wood, A., Kossard, S., de Launey, J., Wilkin-
son, B., and Owens, M. L. Imiquimod 5% cream in the treatment of Bowen’s disease. J. Am. Acad. Derma-tol. 44: 462, 2001.
11. Smith, K. J., Germain, M., and Skelton, H.    Squamous
cell carcinoma in situ (Bowen’s disease) in renal trans­plant patients treated with 5% imiquimod and 5% 5-fluorouracil therapy. Dermatol. Surg. 27: 561, 2001.
12. Ahmed, I., and Berth-Jones, J.    Imiquimod: A novel treat-
ment for lentigo maligna. Br. J. Dermatol. 143: 843, 2000.
13. Steinmann, A., Funk, J. O., Schuler, G., and von den
Driesch, P. Topical imiquimod treatment of a cu­taneous melanoma metastasis. J. Am. Acad. Dermatol. 43: 555, 2000.
14. Berman, B., and Villa, A.    Imiquimod 5% cream for
keloid management. Dermatol. Surg. 29: 1050, 2003.
15. Suchin,  K.  R.,  Junkins-Hopkins,  J.  M.,  and  Rook,  A.
H. Treatment of stage Ia cutaneous T-cell lymphoma with topical application of the immune response mod­ifier imiquimod. Arch. Dermatol. 138: 1137, 2002.
16. Martinez, M. I., Sanchez-Carpintero, I., North, P. E., and
Mihm, M. C., Jr. Infantile hemangioma: Clinical res­olution with 5% imiquimod cream. Arch. Dermatol. 138: 881, 2002.
17. Solis, R. R., Diven, D. G., Colome-Grimmer, M. I., Snyder,
N., IV, and Wagner, R. F., Jr. Experimental nonsurgical tattoo removal in a guinea pig model with topical imi-quimod and tretinoin. Dermatol. Surg. 28: 83, 2002.
18. Prado, A., Andrades, P., Benitez, S., and Umana, M.
Scar management after breast surgery: Preliminary results of a prospective, randomized and double-blind clinical study with Aldara cream 5% (imiquimod). Plast. Reconstr. Surg. 115: 966, 2005.
19. Strasser, E. J.    An objective grading system for the eval-
uation of cosmetic surgical results. Plast. Reconstr. Surg. 104: 2282, 1999.
20. Strasser, E. J.    Application of an objective grading sys-
tem for the evaluation of cosmetic surgical results. Plast. Reconstr. Surg. 109: 1733, 2002.
21. Beausang, E., Floyd, H., Dunn, K. W., Orton, C. I., and
Ferguson, M. W. A new quantitative scale for clin­ical scar assessment. Plast. Reconstr. Surg. 102: 1954, 1998.
22. Carraway, J. H.    Using Aldara, copper p, and niaci-
namide for skin care. Aesthetic Surg. 24: 83, 2004.

MARRIAGE OF AUTOGENOUS BONE AND
HYDROXYAPATITE CEMENT FOR
RECONSTRUCTION OF FRONTAL BONE DEFECT

Sir:
Contour deformity is fairly common after depressed frac-tureof the frontal region. Although many depressed fractures of the frontal area do not require neurosurgical intervention, they may still require reconstruction for aesthetic restoration of the contour defect.
Our patient had a depressed fracture with an intact inner table following a vehicular accident about a year earlier. The depression had sloping edges and there was gross contour deformity (Fig. 1). We decided to correct the deformity with a combination of a cranial bone graft and a paste of hydroxy-apatite cement mixed with collagen. The area was ap­proached through a coronal incision, the bony defect was freshened with a contouring burr, and the depression, in the form of a slope, was filled with the hydroxyapatite paste until it leveled off. Split cranial bone grafts were placed over the defect and affixed with plates and screws. The irregularities were smoothened out with the hydroxyapatite paste (Fig. 2). The postoperative result was very satisfactory. The patient was last seen 1 year postoperatively (Fig. 3). We have found this combination of hydroxyapatite paste along witha split cranial graft to be a useful adjunct in the management of contour deformities of the frontal region.

There are many reports of using cranial bone grafts1 and hydroxyapatite2 cement for cranioplasty. We find that these two methods can be used in conjunction with each other for better control ofcontour deformities inexposed regions such as the frontal area. The depression can be filled with hy-droxyapatite cement paste on which the cranial bone graft can be placed, very much as a mason would put bricks on a cement mixture. The paste can be used to fill the crevices between the autografts. The combination gives very smooth contours. The hydroxyapatite cementis replacedby bone and provides good, long-lasting results. DOI: 10.1097/01.prs.0000184346.93269.14

Ramesh Kumar Sharma, M.D.
Department of Plastic Surgery
Postgraduate Institute of Medical Education and Research
Chandigarh 160012, India
drsharmark@yahoo.com

REFERENCES
1.  Maggie, W. P., Ajkay, N., Freda, N., et al.    Use of fast
setting hydroxyapatite cement for craniofacial con­touring. Plast. Reconstr. Surg. 114: 289, 2004.
2.  Artico, M., Ferrante, L., Pastore, F. S., et al.    Bone au-
tografting of the calvaria and craniofacial skeleton: Historical background, surgical results in a series of 15 patients and review of literature. Surg. Neurol. 60: 71, 2003.

former investigators and the environment of the era. Thus, the date of publication is not important in some situations. We would like to show an example that we found when we were reviewing articles on reconstruction of the head and neck region.

In 1985, Browne and McQuarrie1 described a regional bone flap harvested from the lower margin of the mandible that was vascularized with masseter muscle. In 1997, Pereira et al.2 reported the same idea for reconstruction of the central portion of the mandible after ablation of progressive intraoral cancer.

Reconstruction of the mandible after segmental resection often requires a vascularized bone graft using microvascular anastomosis or pedicled rib transfer. This is a complicated and time-consuming procedure, even for an experienced physician. If we could avoid microvascular anastomosis in the vascularized bone graft, mandibular reconstruction would be safer and easier.

We believe these two groups of authors, working com­pletely separately, successfully applied their idea to pa­tients and submitted their articles to different journals. We applaud these authors again for their genius inspiration and hope to have an opportunity to apply this procedure in our patients. DOI: 10.1097/01.prs.0000184347.99280.c0

Masao Kakibuchi, M.D., Ph.D. Kenji Fukeda, M.D., Ph.D. Division of Plastic Surgery Hyogo College of Medicine Nishinomiya, Japan

Correspondence to Dr. Kakibuchi 1-1, Mukogawa-cho, Nishonomiya Hyogo 663-8501, Japan mkaki@hyo-med.ac.jp

To alleviate these problems, a simple appliance can be prepared using ice cream sticks, which are made of soft wood. The sticks are bunched and held together with a rubber band, forced between the upper and lower molars, and kept in place for 10 to 15 minutes, or for as long as the patient can tolerate it.

Good mouth opening is achieved with this device.

This is done every hour while the patient is awake. De-pendingon the increasein mouth opening, one stick is added every second day. The force of the sticks slowly stretches the mastication muscles and fibrous tissue, which helps in the gradual and controlled opening up of the mouth. The in-terincisal distance can be increased in a relatively short period of time, despite a significantly reduced mouth opening.

The device is made from soft wood, so there is little fear of injury to the mucosa or oral tissues or tooth movement. Both the patient and physician can measure the exact progress by count­ing the number of wooden sticks. This appliance can be used easily, even in children, without hurting soft tissues. It does not require complicated fabrication and can be made quickly and easily at home. It can be nicely retained in a patient with limited mouth opening. We have been using this method for last 10 years with satisfactory results and no complications.

In summary, restricted mouth opening is a big problem, especially after maxillofacial trauma or following submucous fibrosis. A simple device can be prepared using ice cream sticks, which are made of soft wood. A few sticks are held together with a rubber band and forced between the upper and lower molars, to gradually aid in opening up the mouth. The interincisal distance can be increased in a relatively short period of time, despite significantly reduced mouth opening. This simple appliance is cheap, easily fabricated, and very effective in opening up the mouth. DOI: 10.1097/01.prs.0000184348.95943.d3

2. Lubit, E. C. An appliance for jaw dilation in prolonged posttraumatic and postsurgical trismus and fibrosis. J. Oral Surg. 38: 541, 1980.

Hemant Saraiya, M.S., M.Ch.(Plastic)
Sushrut Plastic Surgery Research Center
M. P. Shah Cancer Hospital
Apollo Hospital
SAL Hospital
Raj Hospital
Ahmedabad, India
Correspondence to Dr. Saraiya 10, Avanti Apartments Bhagvan Nagar No Tekro, Paldi Ahmedabad 380 007, Gujarat, India drhemantsaraiya@hotmail.com
REFERENCES
1. Wichelhaus, A., Haas, R., Sander, F. G., and Kreidler, J. F. The influence of the spring activator on the mo­bility of the lower jaw in traumatically injured patients. J. Orofac. Orthop. 59: 340, 1998.

TEMPOROMANDIBULAR JOINT DISLOCATION IN AN INFANT AFTER VOMITING

Sir:
Temporomandibular joint dislocations can occur as the result of trauma or simply from opening the mouth, such as during a yawn or vomiting. Although the incidence of tem-poromandibular joint displacement peaks during puberty, patients ranging in age from 21 to 802 years have been re­ported. It is extremely rare for an infant to experience a temporomandibular joint dislocation, and there is only one such a case in the literature.3 We present the case of a 12-month-old infant who sustained a bilateral temporomandib-ular joint dislocation with no spontaneous reduction after vomiting.

A 12-month-old girl was brought to the emergency de­partment by her parents. She was drooling and had been unable to close her mouth for 4 hours after an episode of forceful  vomiting (Fig.  1,  above, left), but  was  otherwise healthy. This had not been experienced by the family before. Anterior dislocations of the mandibular condyles were obvi­ous on radiographs (Fig. 1, above, right). Manual reduction was accomplished easily after mild sedation by applying gen­tle downward force at the lower alveolus followed by a back­ward pressure toplace the condyle into the glenoid fossa (Fig. 1, below, left and right). An elastic bandage was then wrapped around the infant’s chin and vertex to restrict wide jaw open­ing for 24 hours. No recurrence was observed in the following few months.

Vomiting is a frequent event among children. It is ex­tremely rare, however, to see a temporomandibular joint dislocation as a result, especially in an infant. Because the joint is relatively flat at birth, the articular eminence is not formed well enough to maintain a dislocation in an infant.4 Acute dislocations generally result in spontaneous reduction. Occasionally, masticatory muscle spasms impede posterior motion of the condyles and necessitates manual reduction,5 as in this case. Physical examination reveals an inability to close the mouth, drooling, and possible suffocation. Treat­ment is quite simple, but parents should be aware of possible future recurrences. DOI: 10.1097/01.prs.0000184349.76828.e3

Yener Demirtas, M.D.
Ismail Kucukoduk, M.D.
Department of Plastic, Reconstructive, and Aesthetic Surgery
Ayse Ceyda Oren, M.D.
Department of Pediatrics
Cemalettin Celebi, M.D.
Department of Plastic, Reconstructive, and Aesthetic Surgery
Gazi University Faculty of Medicine
Ankara, Turkey
Correspondence to Dr. Demirtas Meric¸ Sokak, Kardes¸ Apt. No. 25/6 Bes¸tepe, Ankara, Turkey yenerdemirtas@hotmail.com

REFERENCES
1.  Atherton, G. J., and Peckitt, N. S.    Bilateral dislocation
of the temporomandibular joint in a 2-year-old child: Report of a case. J. Oral Maxillofac. Surg. 56: 646, 1997.
2.  Smally, A. J., and DelGross, C.    Spontaneous temporo-
mandibular joint dislocation in an 80-year-old man. J. Fam. Pract. 40: 395, 1995.
3.  Whiteman, P. J., and Pradel, E. J.    Bilateral temporo-
mandibular joint dislocation in a 10-month-old infant after vomiting. Pediatr. Emerg. Care 16: 418, 2000.
4.  Paesani, D., Salas, E., Martinez, A., and Isberg, A.     Prev-
alence of temporomandibular joint disk displacement in infants and young children. Oral Maxillofac. Surg. 87: 15, 1999.
5.  Bessette, R. W.    TMJ dysfunction. In C. A. V. Kolk (Ed.),
Plastic Surgery Indications, Operations, and Outcomes. Vol. 2. Philadelphia, Pa.: Mosby, 2000. Pp. 897-909.

ANGLED BLADE FOR CLEFT PALATE SURGERY

Sir:
Surgery for cleft palate requires carefully placed incisions and elevation of flaps. The challenge arises because we have to work with restricted access due to the limitations imposed by the oral commissure and the narrow cleft anteriorly.

We would like to share our experience with a blade (Alcon Inc.) that we have found to be useful in palate operations. This knife is used by ophthalmologists to make incisions at the corneoscleral junction in cataract surgery. It has an angle between the cutting edge and the handle (Fig. 1) that is very convenient in operations on the palate. We have found this blade to be beneficial during incision at the cleft margin in the anterior part and for dissecting the palatal muscles during intravelar veloplasty. The angle of the blade makes the dis­section very convenient, and dissection is simplified because both edges of the blade are used for cutting (Fig. 2).
The blade isalso beneficial when incising the ligament that tethers the oral mucoperiosteum to the posterior part of the hard palate. This ligament is represented by the depression in the oral mucoperiosteal flaps when gentle traction is ap­plied to the flap to move it toward the cleft. We have also used the blade in fistula closure. The small size and the angulation of the blade allow the oral layer to be incised and elevated off the nasal layer.
The cost of this disposable knife is only about 300 rupees ($6) only. We believe it is a useful tool for palate surgery, especially in dissections under the microscope. DOI: 10.1097/01.prs.0000184350.73811.f0

Two Dermacarriers are placed end to end and held in place by four 12 X 100-mm Steri-Strips (3M Health Care, St. Paul, Minn.). One Steri-Strip is applied longitudinally to join the short sides of the Dermacarriers on the smooth posterior surface; three strips are then applied horizontally (Fig. 1). The graft is then placed on the ridged anterior surface and meshed in the normal way, with care taken at the junction of the two carrier boards. This simple technique allows a graft longer than 20 cm to be meshed neatly without damaging the graft (Fig. 2). DOI: 10.1097/01.prs.0000184351.61633.39

Adesola Adekunle, M.R.C.S.
Susan Turner, R.G.N.
Roderick Dunn, D.M.C.C., F.R.C.S., F.R.C.S.(Plast.)
Department of Plastic Surgery
St. James’s Hospital
Leeds, United Kingdom

Correspondence to Dr. Adekunle
Department of Plastic Surgery
St. James’s Hospital
Beckett Street
Leeds LS9 7TF, United Kingdom
s_adekunle@yahoo.co.uk

REFERENCE
1. Verlande, P. N. L., and Zoltie, N.    How to get large meshed split skin grafts. Burns 15: 55, 1989.

DISPOSABLE NIPPLE MARKER

Sir:
Precise marking of the nipple in breast surgery requires accurate marking of an appropriately sized circular nipple-areola complex. To this end, the reusable nipple marker is the widely used standard, but this metal cylinder, with its center marker and markers at 3, 6, 9, and 12 o’clock, is occasionally unavailable in all units. In these circumstances, traditional practice has been to approximate the nipple-are-ola complex by drawing it free-hand. This is not always ideal, as it may result in asymmetry, imperfect shape, and poor cosmesis. Other methods of marking utilize circular operat­ing room instruments, such as gallipots and inkwells. Because these implements are opaque, there may be poor results because of the inability to properly center the nipple. We describe the use of a clear plastic cup as a cheap and readily available alternative to the standard nipple marker, which avoids the problems outlined above.
The base diameter of these cups is exactly the same as the diameter of the standard nipple marker (Fig. 1), and because these cups are transparent, the nipple can be centered with perfect symmetry. Although these cups can be difficult to sterilize, nipples can be marked preoperatively. We did not find any information in the literature about using a clear plastic cup as a nipple marker, and we wanted to share this idea. By using a clear plastic cup, nipple marking is accurate and simplified. This alternative tool should also be useful in lowering the cost of surgery.
DOI: 10.1097/01.prs.0000184352.43467.30

Amir Nakhdjevani, M.R.C.S.
Simon P. Mackey, M.R.C.S.
Chetan Patel, F.R.C.A.
John Pereira, F.R.C.S.(Plast.)
Department of Plastic Surgery
Queen Victoria Hospital
East Grinstead, West Sussex, United Kingdom
Correspondence to Dr. Mackey
Department of Plastic Surgery
Queen Victoria Hospital
Holtye Road
East Grinstead, West Sussex
RH19 3DZ United Kingdom
simonmackey@hotmail.com

CONSULT FOR EXPOSED HARDWARE

Sir:
Chronically exposed hardware should be removed. This is traditional teaching. If presented with such a scenario in a board examination situation, this hardware is likely to be infected and strong consideration must be given to its removal. If necessary, an external fixator may provide for stabilization while the bone heals. It is not unusual, how­ever, for a general plastic surgeon to be faced with the situation of exposed hardware that cannot or will not be removed, either because of the consulting surgeon’s in­sistence or the patient’s desire. There are cases when hard­ware removal can result in loss of joint function, such as with knee and shoulder prostheses or spinal instability and neurologic compromise in spinal fusion devices. The plas­tic surgery literature describes the use of muscle and mus-culocutaneous flaps for the salvage of such exposed hard­ware. The gastrocnemius muscle has been used to cover a total-knee prosthesis,1,2 the pectoralis major muscle has been used for a shoulder prosthesis,2 and the paraspinal, trapezius, latissimus, and gluteus maximus muscles have been used to cover spinal fusion devices.

After reading the article entitled “Comparing Minimally Invasive Funnel Chest Repair versus the Conventional Tech­nique: An Outcome Analysis in Children” and the discussion that followed (Plast. Reconstr. Surg. 114: 668, 2004) by Donald Nuss, the developer of the minimally invasive repair that bears his name, I harkened back to my first, albeit peripheral, encounter with this procedure.

My patient was a 19-year-old man who had undergone a Nuss pectus excavatum repair that was initially complicated by a post­operative bleed that required reoperation for evacuation of hematoma, control of plexus bleeding, and transfusion of 5 U of packed red blood cells. Later, the repair was complicated by wound breakdown over the ends of the cross-bar in the mid-axillary line (Fig. 1). These wounds failed to respond to local wound care and intravenous antibiotics over a 2-month period. I counseled the patient regarding the removal of this chronically exposed and infected hardware, but the patient was adamant about not removing it. Thus, I brought him to the operating room for washout and coverage of hardware with a serratus anterior muscle flap (Fig. 2). This procedure was complicated by a seroma that responded to two needle aspirations. He has been event-free for more than a year.

If exposed hardware must be preserved for maintenance of form or function, then one must adhere to the principles of adequate wound de´bridement, culture-specific antibiotics, and adequate hardware coverage using reliable muscle or musculocutaneous flaps. Muscle flaps bring a robust blood supply that is able to deliver higher antibiotic and oxygen concentrations in addition to components of the host defense (immunoglobulins, complement, and neutrophils), thus im­proving the killing of bacteria.4 My adherence to these prin­ciples has not yet left me disappointed. DOI: 10.1097/01.prs.0000184353.96663.d1

Michael S. Wong, M.D.
Division of Plastic Surgery
University of California Davis Medical Center
2221 Stockton Boulevard, 2nd Floor
Sacramento, Calif. 95817
michael.wong@ucdmc.ucdavis.edu

REFERENCES

1. Greenberg, B., LaRossa, D., Lotke, P. A., Murphy, J. B.,
and Noone, R. B. Salvage of jeopardized total-knee prosthesis: The role of the gastrocnemius muscle flap. Plast. Reconstr. Surg. 83: 85, 1989.
2. Lesavoy,M.A., Dubrow,T.J., Wackym,P.A., and Eckardt,
J. J. Muscle-flap coverage of exposed endoprosthe-sis. Plast. Reconstr. Surg. 83: 90, 1989.
3. Hochberg, J., Ardengy, M., Yuen, J., et al.    Muscle and
musculocutaneous flap coverage of exposed spinal fusion devices. Plast. Reconstr. Surg. 102: 385, 1998.
4. Mathes, S. J., Alpert, B. S., and Chang, N.    Use of the
muscle flap in chronic osteomyelitis: Experimental and clinical correlation. Plast. Reconstr. Surg. 69: 815, 1982.

FURTHER USES OF A SIMPLE SYRINGE

Sir:

In continuation of the reports of the extended uses of a simple syringe,1,2 we would like to share our experience using this humble aid in liposuction. Manual liposuction is

REFERENCES

1.  Al-Ani, S. A.    Constructing your own suction drainage
system. Plast. Reconstr. Surg. 114: 614, 2004.
2.  Ellabban, M., Oudit, D., and Juma, A.      The use of a
simple syringe as a stent for McIndoe vaginal con­struction. Plast. Reconstr. Surg. 114: 622, 2004.

ANOTHER USE FOR A MEASURING CALIPER

Sir:
Exact distances and precise measurements are very im­portant during our daily practice as plastic surgeons. Tape measures gain elasticity with use and time and can some­times be imprecise. Metallic or plastic calipers are auto-clavable and are frequently used as measuring instruments during surgery.

When we finish a lipoplasty procedure, we stop the suction based on a thorough clinical observation of symmetry, our aesthetic feeling, and the endpoint of a manual pinch test,1 whichisavery subjective measure whenwe try to compare one side with the other.
To obtain more objective data, we use sterilized calipers (Fig. 1) for a precise measure of the pinch test exerted on the tissues before and after suction-assisted lipoplasty. Using the calipers, we can compare exactly the sides we have operated on. This instrument has been useful in providing a smooth
result in our liposuction cases.
DOI: 10.1097/01.prs.0000184358.46278.92

Arturo S. Prado, M.D. Paulo F. Castillo, M.D. Division of Plastic Surgery School of Medicine University of Chile Santiago, Chile

Correspondence to Dr. Prado
School of Medicine
Postgraduate School
Division of Plastic Surgery
University of Chile
Manquehue Norte 1701, Ofic 210
Vitacura
Santiago, Metropolitana, Chile
pradoplast@yahoo.com

REFERENCE

1. Rohrich, R. J., and Mathes, S. J. Suction lipectomy. In M. J. Jurkiewicz, T. J. Krizek, and S. J. Mathes (Eds.), Plastic and Reconstructive Surgery: Principles and Practice. St. Louis, Mo.: Mosby, 1988.

A NOVEL METHOD FOR SEROMA DRAINAGE

Sir:

Seroma formation is a common complication following drain removal after groin dissection or harvest of latissimus dorsi flaps. The seroma can be extensive, leading to in­terference with wound healing and discomfort for the pa­tient. Although it is usual practice to aspirate such collec­tions percutaneously with a needle and 50-ml syringe, this can be a cumbersome and inefficient process involving filling, emptying, and reconnecting syringes multiple times. We have found that a vacuum drain provides a quick, clean, and efficient method of draining such seromas. The tubing connector of the drain is simply cut off with scissors to allow the hub of a needle to fit snugly in the drain tube (Fig. 1). The drain bottle can hold up to 500 ml of fluid without the need for a change of any connections. We have found that our patients prefer this method. As with all percutaneous drainage, the operator should remain aware of underlying vascular anatomy to avoid iatrogenic injury.

DOI: 10.1097/01.prs.0000184359.76914.b3

M. Klusmann, M.B.B.S.
H. Tehrani, M.R.C.S.Ed.
Department of Plastic and Reconstructive Surgery
Norfolk and Norwich Hospital
Norfolk, United Kingdom

Correspondence to Dr. Klusmann
Department of Plastic and Reconstructive Surgery
Norfolk and Norwich Hospital
Norfolk NR4 7FP, United Kingdom

mklusmann@doctors.org.uk

TELFA AS DONOR-SITE DRESSING

Sir:

Wound care after cutaneous surgery can play an integral role in wound healing. Wound care regimens have changed dra­matically over the last 35 years, as the physiology of wound healing has become better understood. Foremost is the im­provement in wound healing achieved by keeping the wound occluded and moist. This observation has led to an explosion of a whole new category of occlusive dressings at the surgeon’s disposal in healing postoperative wounds. These dressings have numerous applications, as discussed previously. Generally, for acute surgical wounds, occlusive dressings are most useful for split-thickness wounds, such as at the graft donor site.

Occlusive dressings may have greater benefit for the treat­ment of pediatric wounds of various types. In children, pref­erence is given to dressings that are readily available and inexpensive but also less painful to remove, for less psycho­logical trauma to children. Our experience ina busy pediatric burn unit led us to use a Telfa-type dressing combined with a topical antibiotic ointment in some cases as the standard donor-site dressing.

When a patient presents for a donor-site dressing change after 2 weeks, the time it takes to remove the dressing and apply another is considerably reduced, and not much anal­gesia and sedation, which children usually require, are needed. Topical antiseptics also help reduce skin infections.

Povidone-iodine (Betadine) and chlorhexidine gluconate (Hibiclens) have emerged as the two agents of choice. Antisep­tics have been shown to be toxic to healing tissue, however, and should not be used on open wounds. In contrast, topical anti­biotic ointments are safe to use on open wounds and effective in preventing wound infections, and they promote wound heal­ing by maintaining a moist wound environment.2 Other impor­tant features of Telfa dressings are their outward appearance and their good absorption of local anesthetic drug at the time of surgery after the split skin graft is taken.

We recommend that all of our colleagues working in the pediatric setting consider using Telfa as a donor-site dressing. DOI: 10.1097/01.prs.0000184360.75312.3b

Asif Zubair Bhatti, F.R.C.S., F.C.P.S.
Plastic Surgery
Derriford Hospital
Plymouth NHS Trust
Plymouth, Devon
United Kingdom PL6 8DH
asif1025@yahoo.com

REFERENCES

1.  Cho, C. Y., and Lo, J. S.    Dressing the part. Dermatol. Clin.
16: 25, 1998.
2.  Wilson, Pr.    Dressed to heal: New options for graft site
dressing. Aust. J. Dermatol. 37: 157, 1996.
3.  Davey, R. B.     The use of an “adhesive contact medium”
(Hypafix) for split skin graft fixation: A 12-year review. Burns 23: 615, 1997.

ATYPICAL LOCATION OF CHICKENPOX VESICULAR LESIONS AFTER FINGERTIP INJURY

Sir:
Varicella, or chickenpox, is classically a highly contagious systemic infection of young children that begins with a pro­drome of fever and malaise. A period of 3 to 5 days of superficial spots and pruritic vesicular rash on the trunk and head typically begins within 2 weeks of exposure to the virus. The spots and rash then migrate to the extremities (centrif­ugal). It results from primary infection with the varicella virus. Except in immunocompromised patients, involvement of dis­tal parts of the extremities is unusual.

We report the case of a 7-year-old girl who presented to the emergency service with a kitchen blender injury to the second, third, and the fourth fingertips of her left hand (Fig. 1). Primary suturation after thorough exploration of the lesion was carried out under general anesthesia. At the end of the second postoperative week, she returned to us with vesicular lesions on the three injured fingers that had occurred a day earlier. After a detailed physical examina­tion, several of the same vesicular lesions were detected on her face and trunk. The lesions were accompanied by a fever of 38.5°C and hyperemia of the throat. Her blood cell count, serum electrolyte and glucose levels, and renal and liver function tests were within normal ranges. It was ob­served that the intensity of the vesicular lesions on the fingers was closely related to the severity of the injury on each finger. There was no vesicular rash on the uninjured hand. The diagnosis (varicella) was based primarily on clinical findings and a history of recent exposure to varicella at her school. Symptomatic treatment was given for fever reduction and associated itch.

We want to emphasize the importance of a detailed preop-erative history and physical examination of any patient. As the incidence of varicella has decreased, the diagnosis has become more difficult and challenging. Many young practitioners have little or no experience with varicella. Nevertheless, epidemio-logic information, such as history of recent exposure and phys­ical examination, continues to be useful. Illnesses mimicking varicella-zoster virus infections, including generalized herpes simplex, rickettsial pox, impetigo, allergic reactions (Stevens-Johnson syndrome), contact dermatitis, other viral infections (coxsackie), and insect bites, have to be kept in mind for dif­ferential diagnosis. Diagnostic techniques, such as demonstra­tion of specific viral antigens by immunofluorescence or poly-merase chain reaction from skin scrapings or vesicular fluid, are used increasingly but not readily available at most physicians’ offices. Because there is still some controversy regarding the use of oral acyclovir for the treatment of noncomplicated varicella patients, supportive care, including cool compresses, acetamin­ophen, and antipruritics, seems to be the logical treatment option. Immunocompromised patients benefit from both symp­tomatic and antiviral therapy. The affected person should be isolated from contact with the general public and family mem­bers with no personal history of chickenpox until the rash has completely crusted over.

This case called our attention to the relationship between the varicella rash and physical factors such as trauma, which a limited number of reports have pointed out before.1–3 This case also demonstrates the positive correlation between the severity of the trauma and the intensity of the viral lesions. DOI: 10.1097/01.prs.0000184361.68981.f5

Kemal Findikcioglu, M.D.
Fulya Findikcioglu, M.D.
Sebahattin Y. Kandal, M.D.
Osman Latifoglu, M.D.
Department of Plastic, Reconstructive, and Aesthetic Surgery
Gazi University Medical School
Ankara, Turkey
Correspondence to Dr. Findikcioglu 38 Cad. No. 4/8 Yuzuncuyil, Ankara, Turkey kemaldoctor@yahoo.com

REFERENCES

1.  Serrano, G., Aliaga, A., Bonillo, J., Pelufo, C., and Otero,
D.    Photodistribution of varicella exanthem: Report of two cases. Pediatr. Dermatol. 3: 215, 1986.
2.  Belhorn, T. H., and Lucky, A. W.    A typical varicella
exanthems associated with skin injury. Pediatr. Derma-tol. 11: 129, 1994.
3.  Shelley, W. B., and Shelley, E. D.    Immunization, abra-
sion, and sunburn as localizing factors in chicken pox. Pediatr. Dermatol. 4: 102, 1987.

A SIMPLE, EFFECTIVE, AND LIBERATING METHOD TO PROTECT CASTS AND SPLINTS

Sir:

A time-honored method of keeping an upper extremity cast or splint dry during bathing is to cover the involved extremity with a common plastic trash bag. While effective in maintaining the aridity of the dressing, this method leaves the injured bather with only one usable hand or arm. This limitation not only renders the bathing process quite cumbersome but also restricts mechanical cleansing only to those areas accessible to the free limb, thereby excluding that limb’s axilla from a proper scrubbing. The exclusion of such a critical area of hygienic concern might lead one to argue that the bath may as well not be undertaken in the first place.

A considerable improvement in bathing efficacy can be achieved with the use of an inexpensive and easily obtainable product: the veterinary insemination glove. Constructed of a thin polymer, this glove provides the same aquatic barrier as the common plastic trash bag, with the benefit of retaining independent mobility of the fingers. Thus liberated, the mending limb’s hand may freely grasp a washcloth or scrub brush and impart to the contralateral axilla the thorough cleansing itsodemands. As it is designed to correspond to the enormous depth of the bovine or equine uterus, the insem­ination glove easily reaches the upper arm of most adult humans, thereby providing protection even for long-arm casts and splints. The svelte, above-elbow glove is modeled in Figures 1 and 2, in repose and during lithesome scrubbing.

Those who have tried the insemination glove report that their overall bathing experience is incomparably enhanced. Available from veterinary hospitals or directly from manufac­turers such as Ag-Tek (www.ag-tek.com), the gloves can be pur­chased for as little as $15 per bag of 100, and can be re-used several times, making them eminently affordable. Being so cheap, they also make the perfect get-well gift for your patients. We highly recommend the veterinary insemination glove for the protection of upper extremity casts and splints. DOI: 10.1097/01.prs.0000184361.68981.f5

Matthew J. Concannon, M.D.
Steven L. Henry, M.D.
Division of Plastic Surgery
University of Missouri Hospital and Clinics
Columbia, Mo.

Correspondence to Dr. Henry
Division of Plastic Surgery
University of Missouri Hospital and Clinics
One Hospital Drive, M349
Columbia, Mo. 65212
henryst@health.missouri.edu

cotton or dressing material may be applied inside the splint for additional comfort. After the injured extremity is properly placed inside the folded journal, the splint is either held by hand (Fig. 1) or secured with a bandage, if available.

Splinting with the aid of a newspaper or a magazine is very simple and effective. Newspapers are available in most in­stances and lightweight. This splint will be most effective for fractures of the forearm and leg, but it may also be used for a larger bone fracture if a larger magazine is available. When properly applied, we believe this technique may be helpful in emergency settings and should be kept in the surgeon’s ar­mamentarium. DOI: 10.1097/01.prs.0000184331.62717.04

Teoman Dogan, M.D., Ph.D.
P. S. Clinic
Department of Anatomy
Maltepe University School of Medicine
Istanbul, Turkey

REFERENCE

1. Mathewson, C. Management of the injured patient. In J. E. Dunphy and W. W. Lawrence (Eds.), Current Surgical Diagnosis and Treatment. 2nd Ed. Los Altos, Calif.: Longs Medical Publications, 1975. Pp. 206-226.

USE OF A NEWSPAPER FOR A SPLINT IN EMERGENCY SETTINGS

Sir:

“Splint ‘em where they lie” is a time-honored rule of emer­gency care of fractures. Recognition of major fractures and immobilization of all injured parts before transportation are crucial in early management.1 Stabilization of the fracture avoids further injury to the soft tissues, especially to the major vascular structures, and relieves pain. Several different types of splint are available in any emergency ward, but improvised splints have to be fashioned in the accident area before transportation. This is a critical time, not only for the victim but also for the surgeon, and finding a suitable material to simply immobilize and hold the extremity in a safe position may be very difficult. I would like to introduce a very simple method of splinting an injured ex­tremity with a newspaper or magazine.

Any kind of newspaper, journal, or magazine of suitable size is simply rolled in half. If available, soft material such as

MALIGNANT BLUE NEVUS: A CONFUSING DIAGNOSIS FOR THE SURGEON

Sir:

Malignant blue nevus is a rarely seen melanocytic cutane­ous neoplasm that was first described by Allen and Spitz in 1953.1 Since then, only a few cases have been reported and neither of the publications had large series. The most com­mon site for this lesion is the scalp, and men in the fourth and fifth decades of life form the biggest risk group. Because of the limited number of published cases, the exact origin of the lesion, its prognosis, criteria for pathological diagnosis, and its treatment algorithm are not yet clear. We present a case and discuss the controversies of this diagnosis.

A 35-year-old man, who since his childhood had a pig-mented lesion with a diameter of 0.5 cm on his left buttock, was concerned about a recent enlargement of the lesion, which had expanded up to 5 X 5 cm in the past 2 years. His lesion was totally excised elsewhere with an unknown margin. Since the pathological examination revealed malignant mel­anoma (Clark level V, Breslow thickness 1.89 mm), the pa­tient was referred to our hospital for further evaluation and treatment. During his physical examination, a 3-cm incisional scar was appreciated on his left buttock. Although no palpa­ble lymph nodes were detected in either inguinal region, when using the ultrasound modality, several nonspecific su­perficial inguinal nodes of about 0.5 X 0.5 cm were detected. Following a lymphoscintigraphy, the left groin was found to be the lesion’s site of lymphatic drainage. Further radiolog­ical investigation gave no clue about any distant metastasis. The histopathological slides were examined by our patholo­gist while the patient was investigated for systemic metastasis. During the histopathological examination, the diagnosis was changed to malignant blue nevus because of the specimen’s cellular characteristics. The literature was reviewed before a definitive treatment was designed, and it was found that there are still controversies about diagnosis and treatment. Due to the unclear prognosis of this particular situation, an aggressive treatment route was decided on. The margin of the excision was widened to 3 cm, followed by primary closure and dissection of the left inguinal superficial lymph node. No postoperative complications were seen and the patient was discharged on the fifth day. The excisioned material was free of tumor, and there was no metastatic lymph node on pathological evaluation.

Once the plastic surgeon encounters the pathological diagnosis of malignant blue nevus, he or she might be confused by its unknown origin and prognosis as well as a lack of an established treatment protocol. The confusion begins during the histopathological attempt to establish a diagnosis. Differentiating between malignant and benign lesions is a relatively easy task for a pathologist, but when dealing with cutaneous melanocytic tumors, this could prove to be a challenging task. Malignant melanoma and its subtypes, malignant blue nevus, benign blue nevus, Spitz nevus, and dysplastic nevus, show quite similar histological features.2 Malignancy criteria, such as cellular atypia, ple-omorphism, and mitotic activity, should help with selecting the differential diagnosis, but familiarity and experience with these lesions are still needed. Due to the earlier men­tioned similarities, we are still uncertain of the origin of malignant blue nevus. Some authors describe the pathol­ogy as a variant of melanoma, while others describe it as a distinct entity. Although there is little knowledge about this lesion, its clinical behavior and molecular studies point to a different, distinct pathology.

The prognosis of malignant melanoma and its subtypes is very well known, but different series show various metastasis and survival rates for malignant blue nevus. It is known that it has an aggressive character, with a metastasis rate of up to 83 percent and a mortality rate of 67 to 73 percent.4,5 Some reports show a long latency period before metastasis.6 There are discrepancies in the reported metastasis rates depending on the study, but it is clear that it has a poor prognosis and necessitates early detection and excision, with wide safety margins depending on the depth of the lesion. A systemic search for any metastatic lesions is also needed. As with other melanocytic malignancies, the regional lymph node plays an important role in prognosis and survival. Sentinel lymph node biopsy could be a choice that is widely accepted for staging and treatment of regional nodes in cutaneous malignancies.7 However, because of indefinite biological be­havior and poor prognosis with a probable long latency pe­riod before metastasis, we prefer elective regional lymph node dissection and highly recommend aggressive treatment and long-term follow-up until the controversies, with regard to both diagnosis and treatment algorithms, are solved. DOI: 10.1097/01.prs.0000184333.20088.73

Serhan Tuncer, M.D.
Kemal Findikcioglu, M.D.
Selahattin Ozmen, M.D.
Seyhan Cenetoglu, M.D.
Department of Plastic, Reconstructive, and Aesthetic Surgery
Gazi University Faculty of Medicine
Ankara, Turkey
Correspondence to Dr. Tuncer Harbiye mah. Veznedar sok. 24/9 Dikmen 06450 Ankara, Turkey serhantuncer74@yahoo.com

Established plastic surgeons will be familiar with the Fos­ter-Gillies or Gillies-mini needle holder. This instrument combines a needle holder and scissors but is not par­ticularly ergonomic for finer sutures. Furthermore, it does not have a ratchet for a firmer grip, costs up to three times more, and hence is not commonly seen in the plastic sur­geon’s standard “toolbox.”
We demonstrate step by step a method of palming a pair of small, fine, straight suture-cutting scissors while holding a Webster or Halsey needle holder, then swinging the scissors around to cut the suture in one deft movement without releasing the needle holder.

Dr. Chan is formerly of the Department of Plastic Surgery, Royal Free Hospital, London, United Kingdom.