264 British Journal of Plastic Surgery

Fig. 3

Figure 3~Agee endoscope inserted into carpal tunnel via existing laceration following reduction and wire-fixation of thumb fracture. Note bruising of palmar skin.

indicated. Here, it offered a means of release without com- promising further the injured soft tissues. It avoided a blind release and allowed a limited inspection of the nerve. It proved to be technically easy and simplified the management of this complex injury.

Yours faithfully,

S. W. Richards FRCS H. J. C. R. Belcher MS FRCS (Plast) Department of Plastic Surgery, Queen Victoria Hospital, Hottye Road, East Grinstead RH19 3DZ, UK.

References

1. Agee JM, McCarroli HR Jr, Tortosa RD, Berry DA, Szabo RM, Peimer CA. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg 1992; 17A: 987-95.

2. Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK, Olson JD. Endoscopic carpal tunnel release: a comparison of two techniques with open release. Arthroscopy 1993; 9(5): 498 508.

3. Worseg AP, Kuzbari R, Korak K, H6cker K, Wiederer C, Tschabitscher M, Holle J. Endoscopic carpal tunnel release using a single-portal system. Br J Plast Surg 1996; 49: 1-10.

4. Shinya K, Lanzetta M, Conolly WB. Risk and complications in endoscopic carpal tunnel release. J Hand Surg 1995; 20B: 222-7.

5. Agee JM, Peimer CA, Pyrek JD, Walsh WE. Endoscopic carpal tunnel release: a prospective study of complications and surgi- cal experience. J Hand Surg 1995; 20A: 165-71.

6. Weinstein S. Tactile sensitivity of the phalanges. Perceptual and Motor Skills 1962; 14: 351-4.

7. Mack GR, McPherson SA, Lutz RB. Acute median neuropathy after wrist trauma - the role of emergent carpal tunnel release. Clin Orthopaed 1994; 300:141 6.

A five-year review of islanded distally based fasciocutaneous flaps on the lower limb

Sir, We have read with great interest the article by Erdmann et aU The difficult problem of soft tissue cover to the lower one-third of the leg has been tackled by replacing 'like with like' using the distally based fasciocutaneous flap. The

authors have correctly pointed out the obvious disadvantage of this flap, which is the unsightly donor site. We therefore prefer the distally based adipofascial flap 2,3 to the fasciocuta- neous flap. The advantages of raising only the adipofascial layer of the flap are:

1. Since the skin is not incorporated in the flap, the adipofascial tissue becomes more supple and malleable. As a result of this the dog ears are less pronounced and the flap can be tailored to fit any wound to give a smooth and flat contour.

2. The adipofascial flap can be turned over and the underlying fascia can be grafted. This will increase the reach of the flap to cover defects on the foot, including the heel. The adipofascial flap is just as reliable as the fasciocutaneous flap as the blood supply is closely related to the fascia. Therefore the major vessels of the lower limb are also preserved.

3. The donor site skin is preserved thus preventing the unsightly donor site defect of the fasciocutaneous variation.

To enhance the survival of the dermal flaps, a meticulous surgical technique must be adhered to. It is important to leave a thin layer of adipose tissue on the dermis to prevent damage to the vascularity of these flaps. The flaps can be trimmed at the edges to prevent marginal necrosis. Minor donor site problems can be anticipated which can normally be treated conservatively.

We therefore feel that the distally based adipofascial flap is a refinement of the distally based fasciocutaneous flap.

Yours faithfully,

C. E. Koshy MS DNB FRCSI Specialist Registrar, K. O. Taams FCS(SA) M.MED(Wits) Consultant, Plastic and Reconstructive Surgery, Derriford Hospital, Plymouth, UK.

Editor's note: See also Lin et al, The distally based lateral adipofascial flap, Br J Plast Surg 1998, 51, 96-102.

References

1. Erdmann MWH, Court-Brown CM, Quaba AA. A five-year review of islanded distally-based fasciocutaneous flaps on the lower limb. Br J Plast Surg 1997; 50: 421-7.

2. Lin SD, Lai CS, Chou CK, Tsai CW, Tsai CC. Reconstruction of soft tissue defects of the lower leg with the distally based medial adipofascial flap. Br J Plast Surg 1994; 47: 132-7.

3. Gumener R, Zbrodowski A, Montandon D. The reversed fasciosubcutaneous flap in the leg. Plast Reconstr Surg 1991; 88: 1034-41.

Surgical correction of floppy eyelids

Sir, Progressive loosening of the skin of the eyelids with age is a physiological phenomenon and most elderly patients with lax eyelids are asymptomatic. However, patients with chronic ocular surface irritation associated with lax eyelids deserve our attention. The lax eyelid syndrome (LES) was suggested by van den Bosch and Lemij in 1994 for all patients with chronic papillary conjunctivitis, punctate epithelial keratitis and ocular discharge related to upper eyelid laxity. 1 The floppy eyelid syndrome (FES), however, was first described by Culbertson and Ostler in 19812 and should be reserved for a subgroup of patients presenting with a triad of symptoms: obesity; palpebral papillary conjunctivitis; and rubbery, floppy, easily everted upper eyelids. The surgical