Short reports and correspondence 267

Department of Plastic Surgery, The Royal London Hospital, Barts and The London NHS Trust, Whitechapel, London E1 1BB, UK.

References

1. Davey RB. The use of an 'adhesive contact medium' (Hypafix) for split skin graft fixation: a 12-year review. Burns 1997; 23: 615-19.

2. Tang Y-W. Intra- and postoperative steroid injections for keloids and hypertrophic scars. Br J Plast Surg 1992; 45: 371-3.

3. Mercer NSG. Silicone gel in the treatment of keloid scars. Br J Plast Surg 1989; 42: 83-7.

4. Gahankari D. An unusual complication following intralesional tri- amcinolone injections. Plast Reconstr Surg 1996; 97: 1076.

doi: 10.1054/bjps.2002.3806

Emancipation from surgical log-book data entry

Sir, The Specialist Advisory Committee (SAC) for plastic surgery is responsible to the three surgical colleges in the UK for outlin- ing the requirements for higher specialist training in accordance with the recommendations of the Calman report. Paragraph 1.4 of the SAC document is entitled 'log books' and states: 'The trainee will keep a record of his experience in a log book in a form approved by the SAC and the British Association of Plastic Surgeons. He will be required to produce this at his annual assessments and to the SAC before the granting of a CCST'. Every higher trainee in the country should be familiar with this document. It is provided in the form of a Microsoft Excel spreadsheet by the SAC, and made available on the Joint Committee on Higher Surgical Training's website at http:// www.jchst.org/. Filling in all the data for each operation is noto- riously laborious and time consuming, especially the descriptive information, such as patient age and hospital number.

At Exeter, we have devised a time-saving alternative, by using an Excel spreadsheet, instead of Microsoft Word, for our department's blank operating-list template. This can be modified slightly before pasting directly into the surgeon's SAC spreadsheet. The template is filled out by the secretaries, and circulated within the department much as before; however, it is then either saved on disk or e-mailed as an attachment to the surgeon(s) concerned, who can extract it easily. The new system will save many hours of data entry for each trainee in the department. It has been successfully adopted by our secretarial staff, after a short learning curve, and is now used routinely. We also took the opportunity to improve the information content and format of our operating lists, after consultation with ward and theatre staff.

The spreadsheet is available for free download at www.plasticsurgeryoperations.com.

doi: 10.1054/bjps.2002.3807

The Koebner phenomenon in a myocutaneous flap following immediate breast reconstruction

Sir, The Koebner phenomenon is the development of an isomorphic pathological lesion in the spatially distinct traumatised previ- ously uninvolved skin of a patient with pre-existing cutaneous disease. It is called an isomorphic response because it has the same configuration as the injury. Traumatic and other exoge- nous factors that may initiate the Koebner response include burns, drug reactions, excoriation, surgical incision, pressure, radiation, skin tests and vaccination. Non-infectious cutaneous conditions associated with the Koebner phenomenon include psoriasis, eczema, lichen planus, lichen nitidus, vitiligo, cuta- neous macrocystis and pyoderma gangrenosum, while known infectious associations include warts, herpes zoster and mollus- cum contagiosum.

Our patient was treated by skin-sparing mastectomy, performed through a circumareolar incision, and axillary dissection, for cancer of the right breast, with immediate recon- struction using a latissimus dorsi flap and implant. She had a pre-existing diagnosis of psoriasis, which flared up 3 months after her breast reconstruction. New areas of psoriasis devel- oped in the circular suture line, the skin paddle forming the neo-areolar area of the reconstructed breast (Fig. 1 A) and the

Yours faithfully,

Bruce Elliott FRCS, MRCP, Senior House Officer in Plastic Surgery John H. Palmer FRCS, FRCS(Plast), Consultant Plastic Surgeon

Department of Plastic Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK.

Figure 1--The Koebner phenomenon; (A) psoriasis involving the skin of the neo-areolar area after skin-sparing mastectomy and immediate breast reconstruction using a latissimus dorsi flap, and (B) psoriatic involvement of the donor-site scar.

268 British Journal of Plastic Surgery

linear donor-site scar on the back (Fig. 1B). These responded to topical clobetasol-propionate ointment and resolved completely.

The Koebner phenomenon was initially described in 1872 to be associated with psoriasis. 2 Its reported incidence varies between 20% and 76% of patients with psoriasis. The interval between the insult and the development of the psoriasis varies individually. The skin of patients with psoriasis is thought to harbour a predisposition, usually hereditary but sometimes acquired. The isomorphic response evolves in a patient with psoriasis when the disease is in a reactive phase. The Koebner phenomenon is clinically indistinguishable from spontaneous lesions, apart from its shape, which closely follows the trauma- tised area. The main determinant of an isomorphic eruption is the activity of the disease, variously described as eruptive, florid, progressive or active. 3 Both the epidermis and the dermis are involved in the injury. 4 When it presents, it occurs as an 'all-or-none event'. All these features were seen in our patient.

Surgeons should be aware of this condition and its implica- tions, especially in aesthetic procedures, where outcome can be affected, and it should be fully discussed as a possible compli- cation during the process of informed consent. 5 The effect is, fortunately, transient and should not affect any long-term aesthetic outcome.

Yours faithfully,

Kasim A. Behranwala MS, FRCSEd, FRCS(Glas), Clinical Fellow Gerald P. It . Gu | MS, FRCS, FRCSEd, Consultant Surgeon

Academic Surgery (Breast Unit), Royal Marsden NHS Trust, Fulham Road, London SW3 6J J, UK.

Figure 1--Measurement of flexion and extension deficits.

References

1. Miller RAW. The Koebner phenomenon. Int J Dermatol 1982; 21: 192-7.

2. Waisman M. Historical note: Koebner on the isomorphic phenome- non. Arch Dermatol 1981; 117: 415.

3. Rosenberg EW, Noah PW. The Koebner phenomenon and the microbial basis of psoriasis. J Am Acad Dermatol 1988; 18: 151-8.

4. Bizzozero E. Sur le phrnom~ne de K~ebner daus le psoriasis. Ann Dermatol Sypilol 1932; 3: 510.

5. Mendez-Fernandez MA. Koebner phenomenon: what you don't know may hurt you. Ann Plast Surg 2000; 44: 644-5.

doi: 10.1054/bjps.2002.3801 I

Tongue depressor as an aid to rehabilitation after hand surgery

Sir, The moment a patient is admitted with a hand injury, he or she relinquishes autonomy, and may become passive in the recovery process. Motivation is critical for recovery of normal function, and can be encouraged by the setting of realistic goals, 1,2

Composite active finger movement can be readily clinically assessed by measuring the flexion and extension deficits. These represent the minimum distances that a patient can flex and extend a fingertip to the palm and tabletop, respectively (Fig. 1). 3

We provide patients with a standard wooden tongue depres- sor to allow them to take one or both of these measurements. The exercise is explained, and an initial measure is marked on the depressor (Fig. 2). The depressor is placed, by the patient, either in the distal palmar crease or on the tabletop, and move- ment is marked on a regular basis with a pen. This acts as an

Figure 2--A tongue depressor marked over a 9 day period, showing a diminishing flexion deficit.

inducement to exercise, as patients are asked to aim for daily improvement. The tongue depressor can be reviewed in the clinic to demonstrate progress, but more importantly is a visible guide for the patients to monitor their own rehabilitation.

This simple technique focuses patients' rehabilitation efforts, and provides them with visible targets instead of the vague con- cept of normal function.

Yours faithfully,

A. Athanassopoulos MA, MBBS, Senior House Officer H. J. C. R. Belcher MB, MS, FRCS(Plast), Consultant

Department of Plastic Surgery, The Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RHl 9 3DZ, UK.

References

1. Haese JB. Psychological aspects of hand injuries their treatment and rehabilitation. J Hand Surg 1985; 10B: 283-7,

2. Boyes JH. We are first physicians, then surgeons: a view of the .whole patient. J Hand Surg 1980; 5A: 103--4.

3. Swanson AB, G/Sran-Hagert C, de Greet Swanson G. Evaluation of impairment in the upper extremity. J Hand Surg 1987; 12A: 896-926.