650 British Journal of Plastic Surgery

doi: 10.1054/bjps.2001.3653

Transparent-film dressing as an aid to flap monitoring

Sir, We present a simple solution to the problem of how to monitor a flap without disturbing its dressing and exposing the wound. Numerous methods have been devised for postoperative flap monitoring but, undoubtedly, the most commonly used, and the gold standard against which other methods are measured, is clinical monitoring by an experienced nurse.1

Observations of colour, swelling, surface temperature and capillary refill as well as Doppler monitoring of the pedicle all require some part of the flap to be exposed. For a flap with a cutaneous component this is not difficult, although exposure may increase the risk of infection. However, for muscle or adipofascial flaps where a meshed skin graft has been applied, each time the dressing is lifted to examine the flap, shear forces are transmitted to the graft. Leaving a window in the dressing leads to desiccation of the wound and prolonged healing with a significant risk of infection. Moreover, the dressing tends to be displaced during observations, which again interferes with both graft take and the underlying flap.

A simple answer lies in the use of a transparent-film dress- ing such as Opsite (Smith and Nephew) or Tegaderm (3M Healthcare). The dressing is applied to the flap as normal, but where a window is created for monitoring, a small piece of film dressing is placed over the site, overlapping onto the surrounding dressing. This film dressing adheres to the underlying skin or graft, stops the surrounding dressing from moving and provides a clear window for flap monitoring. It allows testing for capil- lary refill and temperature and Doppler monitoring without affecting the sterility of the wound. It provides a suitable envi- ronment for moist wound healing.

Should it be necessary to test for bleeding, a needle can be introduced through the dressing and the pinprick site sealed off easily without disturbing the rest of the dressing. After a few days a pool of exudate may accumulate, but this can be aspirated through the dressing if necessary.

We feel that this provides a simple but efficient method of gaining access to flaps for monitoring without reducing the sterility of the wound or disturbing its healing.

Yours faithfully,

G. D. Smith FRCSEd, Specialist Registrar in Plastic Surgery O. G. Titley FRCS(Plast), Consultant Plastic Surgeon

Department of Plastic and Reconstructive Surgery and Burns, Selly Oak Hospital, Raddlebarn Road, Birmingham B29 6JD, UK.

Reference

1. Neligan PC. Monitoring techniques for the detection of flow failure in the postoperative period. Microsurgery 1993; 14: 162-4.

doi: 10.1054Bojps.2001.3654

The flexor-tendon repair simulator

Sir, We have read the recent article by Rhodes et all with interest and agree with their conclusions. They are to be congratulated upon their ingenuity. Feeding tubes and catheters can also be

used to simulate tendon repair if tendons are not available, although tendons are undoubtedly best. There is little new in this world of change, but a thorough search of the medical liter- ature by the authors would have revealed that this has been done before. 2 The abstract of this earlier article reads as follows:

'When summarising the principles behind successful zone II flexor tendon repair surgery, technical perfection through experience appears of prime importance. The authors present a device intended to allow inexperienced surgeons to gain the necessary skill in a laboratory environment. The details of the practicalities regarding construction and use of this 'surgical training simulator' are specifically addressed. Conclusions are drawn after four years of experience with the device, and extension of the simulated training concept to other fields in hand surgery is recommended.'

Yours faithfully,

A. E Stewart Flemming FRCS, Consultant Hand and Plastic Surgeon J. L. Hoeyberghs MD

Hand Surgery Unit, St Andrew's Centre for Plastic and Burn Surgery, East Wing, Broomfield Hospital, Court Road, Broomfield, Chelmsford, Essex CM1 7ET, UK

References

1. Rhodes ND, Wilson PA, Southern SJ. The flexor-tendon repair simu- lator. Br J Plast Surg 2001; 54: 3734.

2. Hoeyberghs JL, Flemming AFS. Flexor tendon repair in perfect safety: a model for student practice. Eur J Plast Surg 1994; 17: 215-17.

doi: 10.1054/bjps.2001.3644

An easy method of preparing hands for surgery

Sir, The traditional method for preparing a hand prior to surgery is inefficient, awkward and time-consuming. It involves an assis- tant supporting and rotating the arm whilst the surgeon applies antiseptic solution to the volar and dorsal surfaces of the hand as well as to the ulnar and radial borders of all the digits using two swabs clamped in Rampley's sponge-holding forceps.

We present an alternative method of hand disinfection that has been used successfully in our hand-management unit over a considerable period of time. Approximately 30 ml of prepara- tion fluid is poured into a transparent polythene bag. As previ- ously, an assistant supports the arm. The surgeon then places the bag over the hand and rubs it around the digits until all the surfaces are coated. The bag is then removed and discarded. The remainder of the forearm can be prepared as normal.

We have found this method effective and time conserving. The bag can be applied by a non-sterile assistant whilst the sur- geon scrubs, thus further economising on time. The polythene bags we use in our department are pathology specimen bags, which are inexpensive and readily available in all theatres. Provided that the hand is adequately coated with the antiseptic solution, there is no requirement for the bags to be sterile.

Yours faithfully,

Victoria Rose, Registrar in Plastic and Reconstructive Surgery Dominique M. Moloney, Specialist Registrar in Plastic and Reconstructive Surgery

Short reports and correspondence 651

Baljit S. Dhensa, Specialist Registrar in Plastic and Reconstructive Surgery

St George's Hospital, Blackshaw Road, Tooting, London SW17 4PQ, UK.

doi: 10.1054/bjps.2001.3643

A useful technique for securing nails: the figure-of-eight suture

Sir, When a nail has been avulsed from the nail fold or a nail has been surgically removed, it needs to be replaced into the nail fold in order to prevent the nail fold becoming adherent to the nail bed. 1'2 Adherence may lead to deformity of future nail growth. The nail, therefore, should be cleaned, replaced under the fold and secured. Several techniques commonly used for securing the nail involve piercing the nail with the suture needle or a hypodermic needle in order to hold it securely in place with two eponychial sutures (Fig. 1). This can be difficult in adults with thick or onychogryphotic nails, and awkward in a paedi- attic nail-bed injury with small nail folds. The use of tissue adhesive has also been advocated)

However, we find that when the nail is replaced in the fold, a simple figure-of-eight suture passing through the hyponychium and the hypernychium (Fig. 2) and tied without tension will successfully hold the nail. If difficulty is encountered with the suture material slipping off the nail laterally then two small ver- tical cuts may be made in the nail for the suture to catch upon. This technique also takes tension off an underlying nail-bed repair, helping to prevent dehiscence. Using either 6/0 vicryl in children or prolene in adults, this suture will hold the nail in place until a new nail starts to form.

Figure 2--Simple figure-of-eight suture in place.

We have found this method of securing nails to be comfort- able for patients, easy to use and teach, and to work well. We recommend its use.

Yours faithfully,

Lee Marcus Jeys MB ChB, MRCS, Senior House Officer in Plastic Surgery Richard Khafagy MB ChB, Senior House Officer in Plastic Surgery

Department of Plastic Surgery, South Manchester University Hospitals, Nell Lane, West Didsbury, Manchester M20 8RL, UK.

References

1. Schiller C. Nail replacement in finger tip injuries. Plast Reconstr Surg 1957; 19: 521.

2. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg 1984; 9A: 247-52.

3. Richards AM, Crick A, Cole RP. A novel method of securing the nail following nail bed repair. Plast Reconstr Surg 1999; 103: 1983-5.

Figure 1--Frequently used eponychial sutures.