178 British Journal of Plastic Surgery

3. Jarvis PM, Galvin DAJ, Blair SD, McCollum CN. How does calcium alginate achieve haemostasis in surgery? Proceedings of the 1 lth International Congress on Thrombosis and Haemostasis 1987; 80.

doi: 10.1054/bjps.2001.3775

Useful instrument for retracting a patient's tongue

Sir, Retracting a patient's tongue can be very challenging, especially when the tongue is large and the surgical procedure involves areas next to or close to the tongue. Common tongue depressors are widely used for retraction, and are very good for applying direct pressure to the dorsum of the tongue to inspect the oropharynx. Since they are usually narrow, difficulties can be experienced when retracting a rather large tongue, especially if surgery involves the posterior lateral part of the oropharynx or the floor of the mouth.

To overcome the problem of recurrent adjustments and the consequent interruptions of surgery, we introduced a very useful and inexpensive tool for retraction, which is generally available: a soup spoon. It comes in different sizes, and can be sterilised in the usual way if it is made of stainless steel.

We have used this instrument on various occasions and found it extremely helpful. Owing to its size and contour, it per- fectly adapts to the anatomical shape of the tongue, which can then be safely retracted. The spoon not only protects the tongue from iatrogenic accidental damage but also provides excellent exposure over a wide area, especially in critical areas such as the posterolateral floor of the mouth and the parapharyngeal area.

Yours faithfully,

C. J. Siegmund MD, DMD, Clinical Fellow in Oral and Maxillofacial Surgery M. Devlin FDS, FRCS, Specialist Registrar in Oral and Maxillofacial Surgery

Department of Oral and Maxillofacial Surgery, South Glasgow University NHS Trust, Victoria Infirmary, Langside, Glasgow G42 9TY, UK.

doi: 10.1054/bjps.2001.3786

Variant mattress suture for skin closure

Sir, We would like to offer our skin-closure technique for consider- ation. The buried vertical mattress suture is effectively a combination of a buried subcutaneous suture and a vertical mat- tress suture. The suture commences in the subcutaneous plane, and is passed up through the surface of the skin. Unlike in the standard mattress suture, the needle is reintroduced through the same hole, and continues into the dermis of the opposing wound edge, where the procedure is repeated in reverse (Fig. 1). The knot, being tied deep, is thus well concealed, can be employed with absorbable materials, obviating the need for removal, and should give fewer problems with extrusion. As it leaves no marks on the skin, it can be used in conjunction with the more durable absorbable suture materials, such as Monocryl, and is particularly useful in areas of tension. If there is accurate re-entry, no puckering occurs, but there may, on occasion, be a small 'pinched' point in the skin, which clears as

Figure 1--Variant mattress suture.

the sutures decrease in strength. We have employed this tech- nique in a wide variety of situations, particularly in closure of the scalp. It confers all the advantages of the standard mattress suture, but requires no removal, and is of particular benefit in children. Long-term marking of non-hair-bearing skin has not been encountered.

We make no claim to originality, but have not seen this suture published before, and offer it for those who may wish to try it.

Yours faithfully,

MG Berry FRCS, Locum Registrar L, Ion FRCS(Plast), Consultant Plastic Surgeon

Chelsea and Westminster Hospital, 369 Fulham Road, Chelsea, London SW10 9NH, UK.

doi: 10.1054/bjps.2001.3787

Sterilisation of Elastoplast adhesive tape

Sir, Elastoplast adhesive tape is widely used in plastic surgery. It has a variety of uses, and we have found it to be particularly helpful in defining the inframammary fold following breast reconstruction (Fig. 1).

The use of Elastoplast is not without problems. Cutaneous infections have been reported, with, on occasion, serious sequelaeJ It has, therefore, previously been recommended that Elastoplast should not be used on surgical wounds. 2 It has been suggested that Elastoplast can be sterilised, before use, in ethylene oxide. However, only single strips can be sterilised in this way, as ethylene oxide penetrates rolls of tape poorly. 3

A study was set up to evaluate the efficacy of a porous load steriliser in the sterilisation of a roll of Elastoplast adhesive tape.

The tape was inoculated at ten random points, between layers of the roll of tape, with a suspension of Bacillus stearothermophilus spores (Bacillus stearothermophilus spores are resistant to high temperatures and are recommended for vali- dating a steam sterilisation procedure). The tape was then double wrapped (Fig. 2), and sterilised at 134 ~ for 3 min in a porous load steriliser. The process was repeated for two other rolls of tape. A fourth, control, roll of tape was inoculated, double wrapped and left at room temperature for the equivalent time.

Short reports and correspondence 179

References

1. Mead JH, Lupton GR Dillavou CL, Odom RB. Cutaneous rhizopus infection. Occurrence as a postoperative complication asso- ciated with an elasticized adhesive dressing. JAMA 1979; 242: 272-4.

2. Everett ED, Pearson S, Rogers W. Rhizopus surgical wound infection with elasticized adhesive tape dressings. Arch Surg 1979; 114: 738-9.

3. Bauer E, Densen E Infections from contaminated Elastoplast. N Engl J Med 1979; 300: 370.

Figure 1--Elastoplast adhesive tape can be used to define the infra- mammary fold following breast reconstruction.

Figure 2--The roll of tape was double wrapped before being sterilised.

Nutrient broth was then injected into the tapes and plated out onto a nutrient media to recover any viable spores. No viable spores were recovered from any of the three rolls that had been processed in the porous load steriliser. In contrast, a count of 5 x 106cfuml - I was recovered from the control roll of tape.

Following this processing, a slight shrinkage of the Elastoplast was noted, but the structural integrity and adhesive- ness remained. In fact, the tape appeared to become more adherent. We have had no problems with the application of this technique, and use the sterile Elastoplast in a variety of clinical situations, particularly in helping to define the inframammary fold in breast reconstructive and aesthetic surgery.

Yours faithfully,

E. C. A. Barret t MB, ChB, FDSRCS, Senior House Officer in Plastic Surgery C. C. Kat FRCSEd, FRCS(Plast), Consultant Plastic Surgeon

Department of Plastic Surgery, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QH, UK.

doi: 10.1054/bjps.2001.3751

The bra-strap injury: should men have lessons?

Sir, Many mechanisms have been documented in association with collateral ligament injuries of the digits. We report a mechanism of forced extension, not previously cited in the literature, and question whether patient education could prevent such cases in the future.

A 27-year-old right-handed man presented to the casualty department with a painful left middle finger. Although the history underlying the trauma was initially difficult to elicit, after some persuasion he explained that the damage had occurred the previous night at the culmination of a convivial and alcoholic evening with an attractive female companion. Whilst attempting, in the throes of passion, to undo her bra, he caught his left middle finger between the double straps that extended inferiorly from the acromion to the left breast, and, in so doing, sustained a forced ulnar abduction rotatory injury of the proximal interphalangeal joint. Although aware of some pain, he continued with the activity at hand, and sometime later remembered to buddy-strap the finger to its neighbour. No reduction was, however, necessary.

Clinical examination revealed a swollen joint with maximal tenderness radially and gross instability on passive ulnar abduc- tion. Radiological examination revealed an avulsion fracture of the volar lip of the middle phalanx, which was confirmed at operation, where, through a radial midlateral incision, complete rupture of the radial collateral ligament and an avulsion fracture of the entire volar plate were found. The volar plate was advanced distally, and the small avulsed bony fragment was reduced and fixed by means of a pull-through suture tied over a button on the dorsal aspect of the middle phalanx. The radial collateral ligament was repaired; the interphalangeal joint was splinted postoperatively in a dorsal blocking splint for 3 weeks, after which the finger was mobilised under the supervision of the hand therapist. At follow-up 6 weeks after the injury the finger had returned to almost full function.

Several aetiologies have been described for collateral liga- ment injuries of the proximal interphalangeal joint. A review of 50 cases suggested that the majority are work-related injuries.I Other authors suggest that sporting injuries are the most common mechanism for disrupting the proximal interphalangeal joint. 2'3 In sports where the hand is held in front of the athlete it acts as a shock absorber, particularly in ball-handling sports, where hyperextension injuries are common. Rock climbing, in which uncontrolled tensile and compressive forces are borne by the interphalangeal joints, has also been implicated. 4 To date, the mechanism of injury that we have discussed has not been described.

In view of the considerable enjoyment associated with the initial damage, and the minor nature of the long-term sequelae,