Correspondence and communications 137

Conflict of interest statement

The authors have no conflict of interest.

Acknowledgement

None.

References

1. Loop FD, Lytle BW, Cosgrove DM, et al. J. Maxwell Chamberlainmemorial paper. Sternal wound complications after isolatedcoronary artery bypass grafting: early and late mortality,morbidity, and cost of care. Ann Thorac Surg 1990;49(2):179e86. discussion 186e177.

2. Weinzweig N, Yetman R. Transposition of the greater omentumfor recalcitrant median sternotomy wound infections. Ann PlastSurg 1995;34(5):471e7.

3. van Garderen JA, Wiggers T, van Geel AN. Complicationsof the pedicled omentoplasty. Neth J Surg 1991;43(5):171e4.

4. Tansley P, Kakar S, Withey S. A novel modification ofomental transposition to reduce the risk of gastrointestinalherniation into the chest. Plast Reconstr Surg 2006;118(3):676e80.

5. Varga G, Cseke L, Kalmar K, Horvath OP. Laparoscopic repairof large hiatal hernia with teres ligament: midterm follow-up: a new surgical procedure. Surg Endosc 2008;22(4):881e4.

Thet Su WinSt Andrews Centre for Burns and Plastic Surgery,

Broomfield Hospital, Chelmsford CM1 7ET, UKE-mail address: thetsuwin1@gmail.com

Declan P. CollinsSt Thomas’ Hospital, London SE1 7EH, UK

Naguib El-MuttardiSt Andrews Centre for Burns and Plastic Surgery, Broom-

field Hospital, Chelmsford CM1 7ET, UK

ª 2011 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2011.07.032

Figure 1 A. Pre-operative markings of the modified rotation flap.the small back-cut into the flap, which introduces a ‘lengtheningfrom the surrounding inset.

Reply to: Reconstruction oftrochanteric pressure sores withpedicled anterolateral thighmyocutaneous flaps. J PlastReconstr Aesthet Surg 2011May;64(5):671e6

We read with interest the paper by Chen et al. reportingtheir experience with the pedicled myocutaneous antero-lateral thigh flap in reconstruction of trochanteric pressuresores.1 While the results are clearly excellent and theirwork congratulated it is worthwhile commenting upon thefundamental difference in body habitus that exists betweenthe Asian population, which is generally more slender, andthe UK population which, in our experience, negates someof the advantages presented. While the aesthetic advan-tages are clearly described with supporting figures, we feelthat these are lost, even in the paraplegic and medicallydebilitated patient. We found the flap to be bulky,and often necessitated an unsightly split skin graft to thedonor site.

The senior authors approach to the reconstruction oftrochanteric defects is similar to that presented by KapSung-Ho et al. in relation to sacral sores.2 We found thatusing a simple fasciocutaneous rotation flap, into whichperforators form the lateral circumflex femoral arterycan be incorporated, provides a robust and well vascu-larised flap that can be raised quickly, contours welland can be easily re-rotated in cases of recurrence. Asa slight variation, a z-plasty is incorporated into the flapat the time of reconstruction, which avoids unnecessaryexcision of healthy tissue and helps to ‘lock’ the flap inplace, taking any tension from the distal inset (Figure 1).

The reconstruction of pressure sores is a challengingproblem. The high recurrence rate associated with thissurgery necessitates techniques that are robust and can bere-utilised if required. The correct reconstruction musttherefore be selected for each individual.

Financial disclosure

We declare no conflict of interest (personal or financial) inthe publication of this paper.

B. Following rotation and inset. The circled area demonstratesand locking’ component and negates excision of normal tissue

138 Correspondence and communications

Conflict of interest/funding

None.

References

1. Wang CH, Chen SY, Fu JP, et al. Reconstruction of trochantericpressure sores with pedicled anterolateral thigh myocutaneousflaps. J Plast Reconstr Aesthet Surg 2011;64:671e6.

2. Lee HJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Perforator-basedbilobed flaps in patients with a sacral sore: Application of a sche-matic design. J Plast Reconstr Aesthet Surg 2011;64:790e5.

A. AboodW. BhatN. Hart

L. FouriePinderfields General Hospital, Wakefield, UK

E-mail address: wbhat@hotmail.com

ª 2011 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2011.07.030

Digital intraneural ganglia

Figure 1 Reinterpretation of the published MRI by Han et al.1

Sagittal T2-weighted MR image of the wrist showing the jointorigin of the intraneural ganglion cyst (asterisk) from theregion of the distal carpal row (arrows) with the typical elon-gated tail extending from the joint to the larger portion of thecyst. Joint fluid is present at the 3rd CMC joint (arrowhead).There is no fat suppression present and the visible imagingparameters indicate significant partial volume effect due tolarge (4 mm) interslice gap and suboptimal resolution.

The recent report by Han et al. demonstrates a rare case ofa digital intraneural ganglion cyst in a thumb.1 No jointconnection was identified in this case 1,2 or the other onesinvolving digital nerves of the hand reported by othergroups.3,4 Reinterpretation of their original published imagehowever shows evidence of a joint connection; indeed, the“proximal tail” of the cystic intraneural mass noted but notexplained by the authors, clearly extends and connects toa small joint in thewrist (Figure 1), possibly the capitohamatejoint or the 3rd carpometacarpal joint. Without access toother images and different planes, it is impossible for us tocomment further or confidently on the exact joint of origin.

While the authors acknowledged our unifying articular(synovial) theory for intraneural ganglia in the lowerextremity,they did not cite the robust evidence of its applicability in theupper limbe not only in distal5 but also proximal nerves.6 Thearticular theory can be extrapolated to all synovial joints fromthe hand to the toes and everywhere in between.6

Conflict of interest/funding

None.

References

1. Han K-J, Lee Y-S, Lee D-H, Chung N-S. Intraneural ganglion inthe digital nerve of the thumb: a case report. J Plast ReconstrAesthetic Surg 2011. epub ahead of date.

DOI of original article: 10.1016/j.bjps.2011.05.024.

2. Park DY, Lee SY, Han K-J. Intraneural ganglion of the digitalnerve of the hand –a case report. J Korean Soc Microsurg 2011;65:78e81 [Korean].

3. Giele H, Le Viet D. Intraneural mucoid cysts of the upper limb. JHand Surg (Eur) 1997;22B:805e9.

4. Sakamoto A, Yoshida T. Intraneural mucoid cyst in the digitalnerve. J Hand Surg (Eur) 2009;34B:283e5.

5. Wang H, Terrill RQ, Tanaka S, Amrami KK, Spinner RJ. Adher-ence of intraneural ganglia of the upper extremity to the prin-ciples of the unifying articular (synovial) theory. NeurosurgFocus 2009;26:E10.

6. Spinner RJ, Scheithauer BW, Amrami KK. The unifying articular(synovial) origin of intraneural ganglia: evolution-revelation-revolution. Neurosurgery 2009;65:A115e24.

Robert J. SpinnerMayo Clinic,

Departments of Neurologic Surgery and Orthopedics,Gonda 8-214 South, Rochester,

MN 55905, USAE-mail address: spinner.robert@mayo.edu