experimental flap. The lateral perforator was found to bethe best among the four perforators. Thermal imaging hasbeen used to map different perforators in a free flap bySalmi et al.3 To our knowledge, this is the first time the per-fusion strength of different perforators supplying a free flaphas been objectively measured. Thermography is thereforea useful tool to identify the dominant perforator intra-operatively and can provide the surgeon with objectiveevidence about the perfusion strength of different perfora-tors. We were able to demonstrate that the difference inperfusion strength of each of the four perforators wasstatistically significant.

Thermobiological imaging technology has improved re-markably in recent years with the use of second generationthermal cameras and thermal imaging software. We feel itcan be a useful adjunct in the operating theatre as a tool toguide flap selection.

Acknowledgements

The authors thank Metrum Information Storage Limited,UK, for providing the thermal camera and other supportingequipment for the study. We also thank Mr Greg Ward andMr Scott Foster for their technical support with thermography.

References

1. Khouri RK, Cooley BC, Kunselman AR, et al. A prospective studyof microvascular free-flap surgery and outcome. Plast ReconstrSurg 2000;105:2279e80.

2. Kersh RA, Handren J, Hergrueter C, et al. Microvascular surgicalexperimental thrombosis model: rationale and design. PlastReconstr Surg 1989;83:866.

3. Salmi AM, Tukiainen E, Asko-Seljavaara S. Thermographic mappingof perforators and skin blood flow in the free transverse rectus ab-dominis musculocutaneous flap. Ann Plast Surg 1995;35:159e64.

4. Rand RP, Cramer MM, Strandness Jr DE. Color flow duplex scanningin the preoperative assessment of TRAM flap perforators: a reportof 32 consecutive patients. Plast Reconstr Surg 1994;93:453e9.

5. Adams F. The Genuine works of Hippocrates. Baltimore: Williamand Wilkins; 1939.

S. KalraA. DanceyR. Waters

University Hospital Birmingham NHS Foundation Trust,Selly Oak Hospital, Raddlebarn Road, Selly Oak,

Birmingham B29 6JD, UKE-mail address: mehak07@yahoo.co.uk

ª 2007 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2007.02.032

1368 Short reports and correspondence

Correction of nasal stenosis: the double cross plasty

We read with interest the article ‘Starplasty: an idealmethod for correction of occluded external nares followingburns’ by Tiwari and Sarabhai.1 The technique that the au-thors have claimed as new and devised by themselves has infact been described by the senior author (AN) in 1992 in thearticle titled ‘The double cross plasty: a new technique fornasal stenosis.2

Figure 1 Line drawing of the principle of the technique. Reproduced with kind permission from The British Association of PlasticReconstructive and Aesthetic Surgeons from Ref. 2.

Clinical audit of the impact of information leaflets onoutcomes in patients with mallet finger injuries

A mallet finger is a common injury where rupture or divisionof the extensor mechanism at the level of the distalinterphalangeal joint of the finger prevents active exten-sion. These injuries are managed in a variety of settingssuch as accident and emergency departments, hand clinicsand occupational therapy centres. Treatment commonlyinvolves splinting of the finger for 6 or more weeks. Lessfrequently, surgical fixation is used to correct the de-formity. The patient outcome following either externalsplinting or surgical management is broadly similar andeach technique has its own advocates.1 Several forms of ex-ternal splinting have been described with the Stack splintbeing in common use.2 If the splint is worn correctly theoutcome is usually good. However, unsatisfactory outcomesare frequently encountered due to poor patient compliancewith the splint.3 In an effort to increase our success ratewith the management of mallet finger injuries we intro-duced patient information leaflets documenting the correctuse of the Stack and audited their impact on our outcomes.

We retrospectively audited outcomes for 63 patients withmallet finger injuries over a 2 year period from January 2003to December 2004 using patient records. Three possibleoutcomes were recorded at a point 8 weeks after initialpresentation: a successful or improved result defined as anextension loss of no more than 15�,4 an unsatisfactory resultwith an extension loss of greater than 15� or the patient lostto follow up (Did Not Attend, DNA). Patients with open in-juries, fractures of the distal phalanx, previous hand injuriesand multiple injuries to the affected hand were excludedfrom the study. Using a published series5 as a standard weset a target rate of 50% for successful outcomes at 8 weekspost presentation. Change was implemented by introducinga patient information leaflet describing the correct use ofthe mallet splint which was provided to the next 38 patientspresenting with a mallet finger injury from January 2005 on-wards. The patient information leaflet used was selected bythe following means. A Google internet search using theterms ‘mallet finger injury’ was performed; the 100 topranked sites originating from the UK were selected. Six ofthese sites had available patient information leaflets; thesepatient information leaflets were peer-reviewed by five cli-nicians from our institution’s plastic surgery and accidentand emergency departments, five occupational therapistsfrom our institution and five previous patients who hadbeen treated for mallet finger injuries. A consensus was ar-rived at and one leaflet* was selected and distributed toall new patients. The same measures and exclusion criteriawere used to prospectively re-audit patient outcomes,with the additional exclusion criteria of those patientswhose first language was not English.

Prior to the introduction of a patient information leaflet,the successful or improved outcome rate was 35% (22/63),the unsatisfactory outcome rate was 30% (19/63), and thelost to follow-up rate was 35% (22/63). Following thechange in practice the successful or improved outcome

Short reports and correspondence 1369

Apart from the omission of this reference, the technicaldetails have been presented in an inadequate way. We wouldtherefore like to mention some of the finer aspects of thedesign of this technique as described in the original paper,2

for the benefit of the learned readers who wish to attempt it.

1. The shape of the opposite normal nostril is drawn onthe outer skin of the stenosed nostril (Fig. 1a). Thiswould form the margin of the new nostril.

2. An incision is marked along the long axis of the narethus marked, and is transacted by another incisiondrawn perpendicular to it, in the shape of a cross(Fig. 1a).

3. Incisions are extended slightly beyond the originalmargin drawn in step 1 so as to overcorrect the newmargin.

4. The four outer flaps are now raised, thinned and heldapart in sutures (Fig. 1b).

5. Another cross is now drawn at the mucosal aspect, off-set at 45� to the one drawn on the outer skin (Fig. 1c).

6. Deeper flaps are raised next, thinned and retractedin sutures again. It is important to thin these innerflaps aggressively to get rid of the hair follicles fromthe nasal vestibule which would otherwise line theoutside of the margin of the external nare, and growhairs.

7. The remaining scar tissue is trimmed back up to the car-tilage and the eight flaps are now inset in an interdigi-tating manner, allowed by the 45� offsetting betweenthe two sets of flaps (Fig. 1d).

8. The final shape of the nostril is determined by the ten-sion on the outer skin flaps and is therefore inset first.The deeper flaps are then inset to fill the gaps forminga continuous ‘W’ plasty at the margin.

In the senior author’s experience, this technique hasproved to be a versatile and reliable method in correctingnasal stenosis of different aetiology.

References

1. Tiwari VK, Sarabahi S. Starplasty: an ideal method for correctionof occluded external nares following burns. J Plast ReconstrAesthet Surg 2006;59:1105e9.

2. Naasan A, Page RE. The double cross plasty: a new technique fornasal stenosis. Br J Plast Surg 1992;45:165e8.

Manish SinhaCanniesburn Plastic Surgery Unit, Glasgow Royal Infirmary,

84, Castle Street, Glasgow G4 0SF, UKE-mail address: drmanish@hotmail.com

Anas NaasanDepartment of Plastic Surgery, Ninewell Hospital,

Dundee DD1 9SY, UK

ª 2007 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2007.06.021

* www.pncl.co.uk/wbelcher/information/EXT-I.pdf