Clive D. Reid

The vascular territory of the acromiothoracic axis

The precise vascular territory and the variations of the acromio-thoracic axis were investigated in a series of 60 fresh cadavers and 50 formalin fixed specimens using dissection, ink injection and barium radiographic studies. The sternocostal portion and the clavicular head of the pectoralis major were found to have virtually independent vascular and nerve supplies. The pectoral artery supplied the former, whereas the deltoid artery nourished the latter. The dominant supply from the pectoral artery to the rib cage was found to enter around the fourth rib in the mid clavicular line. This supply is associated with a previously undescribed origin of the pectoralis major muscle in this region. The supply to the sternum was determined as indirect via the captured territory of the internal mammary system. The dominant supply to the skin from the pectoral artery arose laterally along the free lower border of the muscle as fasciocutaneous branches. The deltoid artery supplies the skin over the shoulder by numerous small branches which emerge from the intramuscular septa of the deltoid muscle. In addition a large axial artery was noted. In most cases this arose from the deltoid artery or its acromial branch and coursed laterally. It is noteworthy that the majority of skin paddles of the pectoralis major myocutaneous flap currently used in clinical practice are designed medially and inferiorly around the perimeter of the muscle and onto the rectus sheath. In these situations such flaps are not supplied directly by the pectoral artery. In fact, they are supplied indirectly by cutaneous branches belonging to the internal mammary/superior epigastric system which are captured by arterial connections with the pectoral artery. These occur predominantly in the pectoralis major muscle. Suggestions, based on these anatomical studies, are offered to improve the versatility and safety of flaps designed in this area.

An atraumatic technique for harvesting cancellous bone for secondary alveolar bone grafting in cleft palate

Secondary alveolar bone grafting in cleft palate patients has been popularised by the Oslo group. Harvesting of the bone graft has been carried out by techniques developed initially for cranio-facial surgery. This paper describes a more refined technique applicable to the requirements of alveolar bone grafting. The Craig bone biopsy set is used to trephine cores of autogenous particulate marrow and cancellous bone from the iliac bone. The method was tested in a cadaver and then applied in 10 clinical cases. The aesthetic and functional results of this technique proved to be superior to the conventional approach.

The clavicular head of pectoralis major musculocutaneous free flap

A new free flap is described based on the deltoid vessels of the acromiothoracic axis. The flap is comprised of the clavicular head of pectoralis major muscle with overlying skin. It is also possible to harvest vascularised clavicular bone with the flap. The vascular anatomy is reviewed and the technique of raising the flap described. Its clinical application is illustrated with five cases. Four of these were intra-oral reconstructions and the fifth a composite osteo-musculocutaneous flap to a lower limb following trauma.

Malignant melanoma, evaluation of clinical follow up by questionnaire survey

Abstract A retrospective questionnaire study, by post, revealed that 69% of patients, still living following first tumour recurrence, had detected the recurrence themselves prior to routine clinic appointments. Nearly 90% developed their first recurrence in the first 5 years following primary surgical treatment. Not only could the length of routine clinic follow-up after primary melanoma treatment be shortened, but with further education of the patient and involvement of the general practitioner it seems likely that patients can be trusted to detect their own recurrences and seek appropriate advice.

Plastic surgery audit codes: are the results reproducible?

The effective coding of data to produce a medical audit relies on agreement between the coders. This study was designed to assess whether coders can agree on codes for diagnosis and operations in a plastic surgery unit. Information from 50 patients was presented to a panel of six coders who were required to code the data using the International Classification of Diseases (ICD-9) and the Office of Population Census Studies (OPCS-4) systems. The results show that agreement between all the panellists occurred in only 32 out of 50 patients for one diagnostic code and 30 out of 50 for one operation code. When a patient had more than one diagnosis or operation, agreement was very much worse. Expert coders produced better results than the medical coders. The results are discussed with reference to other coding systems.

Nasal reconstruction and lengthening with local flaps

A technique for nasal lengthening is described in 3 cases using nasolabial flaps for lining and an island forehead flap for skin reconstruction. It is basically a 2-stage procedure with short hospitalisation.

A comparison of the use of polythene sheet and Jelone® as temporary dressings for excised wounds

This paper reports our experience of the use of polythene sheet as a temporary dressing for excised wounds. A prospective randomised double-blind trial was conducted to see whether or not polythene dressing was less painful to remove than our traditional dressing of Jelonet. Polythene was found to be less painful (p less than 0.01). Other advantages of the use of polythene are presented.

A simple penile dressing following hypospadias surgery

A single layer of surgical gauze applied with adhesive provides a simple and inexpensive dressing for use following hypospadias repair. It splints the penis to the abdomen, supports the wound and secures the catheter while permitting observation and wound care.