1388 Correspondence and communications

without tethering the pedicle, this flap will have enoughreach to reconstruct the orbitomaxillary framework. Thedesired pedicle length can also be gained by additionaldissection of the pedicle. Accordingly, we have not seenany tethering or tension on the pedicle. When the naturalanatomic pedicle of the flap reaches the areas to bereconstructed, we do not prefer the use of free flaps.

As mentioned by Martin Kelly et al. it is possible toharvest free cranial bone segments and perform subsequentrigid fixation.5 As reported by Cutting et al., bone grafts areless resistant to infection and mechanical stress and havelow survival rates in poorly vascularised beds.6 As alreadyreported, at present, free composite flaps are widely beingused, but have the disadvantage of bulkiness.

Martin Kelly et al. suggested orbitomaxillary recon-struction with free cranial bone segments as the accuratemethod of choice and offered to transpose a temporalismuscle sling in order to nourish bone grafts for protectingthem from any ischemic injury or radiotherapy.5 But thistechnique requires the sacrifice of the temporalis muscle.

The criticism on legend 5 in the article7 was partiallyright, but since the patient tolerated well, it was negligible.

Near-anatomical reconstruction of the orbital floor isessential in order to avoid vertical diplopia and impaired lidfunction. In two of the four cases we considered, the boneswere fixed with a miniplate screw and wire. But, for theother two cases, this was not needed because the bonesegments fit well into the defect and were stable.7 Theother reason, not mentioned previously, as to why mini-plate screw and wire fixation were not chosen in the othertwo cases, was that these patients were certainly going toreceive adjuvant radiotherapy postoperatively.

Acknowledgements

We thank Dr. Martin Kelly, Dr. Simon Eccles and Dr. NiallKirkpatrick for theirkindand thought-provokingcomments.5,7

Conflict of interest statement

No funding source or sponsors existed for this study. Thisresearch protocol was approved by _Inonu University Scien-tific Ethical Committee.

None of the authors included in this study disclose anyfinancial and personal relationships with other people ororganisations that could inappropriately influence theirwork.

References

1. Nakajima H, Imanishi N, Minabe T. The arterial anatomy of thetemporal region and the vascular basis of various temporal flaps.Br J Plast Surg 1995;48:439e50.

2. Musolas, Columbini E, Michelena J. Vascularized full thicknessparietal bone grafts in maxillofacial reconstruction: the role ofthe galea and superficial temporal vessels. Plast Reconstr Surg1991;87:261e7.

3. Choung, Nam IW, Kim KS. Vascularized cranial bone grafts formandible and maxillary reconstruction. J Craniomaxillofac Surg1991;19:235e42.

4. Tellioglu AT, Ulusoy G, Celebioglu S, et al. The use of vascu-larized cranial bone in reconstruction of the maxilla andmandible. Eur J Plast Surg 1999;22:244e50.

5. Kelly M, Eccles S, Kirkpatrick N. Comment on ‘Reconstruction oforbital floor and maxilla with divided vascularised calvarial boneflap in one session’. J Plast Reconstr Aesthet Surg 2008;61:347.

6. Cutting CB, McCarthy JG, Berenstein A. Blood supply of theupper craniofacial skeleton: the search for composite calvarialbone flaps. Plast Reconstr Surg 1984;75:603e10.

7. Bilen BT, Kilinc H, Arslan A, et al. Reconstruction of orbital floorand maxilla with divided vascularised calvarial bone flap in onesession. J Plast Reconstr Aesthet Surg 2006;59:1305e11.

Bilge Turk BilenHıdır Kılınc

Serkan AslanGoktekin Tenekeci

Department of Plastic Surgery, _Inonu University,Medical Faculty, 44160 Kampus-Malatya,

TurkeyE-mail address: btbilen@inonu.edu.tr

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.06.008

Thrombophilia and free flaps

Sir

We read with interest the report by Uppal et al on a case ofthrombophilia adversely affecting a free flap anastomosis.1

We have also experienced such problems and haveprepared a study to investigate this phenomenon further.

We performed a free radial forearm flap reconstruction toresurface a floor of mouth and ventral tongue defect in a 53year old male with persistent recurrent oral melanoma. Hehad a history of ischaemic heart disease and was on aspirin.On post-operative day two the flap became congested andexploration confirmed the presence of a clot at the venousanastomosis. This extended within the flap and despitecontinuing arterial inflow for approximately 20 min fixedstaining persisted. An immediate second reconstruction wasthen performed using a free anterolateral thigh flap. On post-operative day five the flap became pale and explorationconfirmed the presence of clot at the arterial anastomosis.This could not be salvaged and the defect was ultimatelycovered with a split-thickness skin graft. All anastomoseswere performed by a consultant and proceeded well.

We considered the possibility of a hypercoagulablestate and performed a thrombophilia screen. This waspositive for anticardiolipin antibodies and advice wassought from the haemotologists. In retrospect a significantaspect of his background was his young cardiac patientstatus. We are also aware of the loss of a free flap in ourunit in a young lady with a history of recurrent miscar-riages, who subsequently informed us of her thrombophiliastatus.

Correspondence and communications 1389

The term ’thrombophilia’ is used to describe a tendencyto develop thrombosis on the basis of inherited or acquireddisorders of blood coagulation and fibrinolysis that increasethe risk of thrombosis. Thrombophilia is reported as havinga prevalence approaching 10%.2 We therefore share theconcerns reported by Uppal et al1 regarding the impact ofundiagnosed thrombophilia on microvascular anastomosis infree flap surgery, though we acknowledge this concern isnot shared by everyone.3 In our case this had consequencesfor both arterial and venous anastomoses.

We are investigating the effect of undiagnosedthrombophilias on free tissue transfer in an observationalstudy in our unit. This is a prospective double-blinded studyon all consenting patients having free flap reconstruction inCanniesburn and will run over a three year period.A thrombophilia screen will be sent at the time of pre-operative assessment and the primary aim is to correlatethe result with the outcome of free flap surgery. Neitherthe patient nor the surgeon will know, at the time ofsurgery, the result of the screen, but results will be avail-able two weeks later at the end point of the data collec-tion. We are happy to share our research protocol with anyinterested parties.

References

1. Uppal RS, Stillaert FB, Hamdi M. Antiphospholipid syndrome e

a rare cause of free flap thrombosis in perforator flap breastreconstruction. J Plast Reconstr Aesthet Surg 2008;61:347e8.

2. Mateo J, Oliver A, Borrell M, et al. Laboratory evaluation andclinical characteristics of 2132 consecutive unselected patientswith venous thromboembolism: results of the Spanishmulticentric study on thrombophilia. Thromb Haemost 1997;77:444e51.

3. Arnljots B, Soderstrom T, Svensson H. No correlation betweenactivated protein C resistance and free flap failures in 100consecutive patients. Plast Reconstr Surg 1998;101:1850e3.

Paul Andrew BakerBen Chew

Taimur ShoaibCanniesburn Plastic Surgery Unit,

Glasgow Royal Infirmary, Glasgow,Scotland G4 0SF, UK

E-mail address: paul_andrew_baker@hotmail.com

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.02.034

Extirpation of multiple truncal lipomas/angiolipomasby use of remote incisions and a light speculum

Figure 1

Extirpation of subcutaneous lipomas/angiolipomas is tradi-tionally made through skin incisions extending the length ofthe swelling.1,2 In multiple lipomatosis this creates a highnumber of scars. In a series of five cases of multiple lipomasor angiolipomas located on the trunck and thighs the senior

plastic surgeon (AQ) has successfully reduced scarring by useof remote incisions and a light speculum. The 16-cm-longlight speculum can be rotated 360� and, due to the elasticityof the tissue, lipomas a distance of about 20 cm from theincision can be extirpated (Figure 1).

Case report: A 36-year-old healthy man was referredwith multiple tender angiolipomas. The histopathologicaldiagnosis had been secured previously after conventionalexcision of some of the angiolipomas.

Preoperatively, all angiolipomas on the trunk wereidentified by palpation and marked on the abdominal andiliac regions. Incisions were planned in three suitable areaswith the consent of the patient: bilateral in the flanks (tobe concealed by the underpants) and one through anepigastric scar from a previous excision.

The extirpations were made through short incisions, justallowing a light speculum to enter the subcutis (Figure 1).Due to Klein’s solution, which was applied to the subcuta-neous tissue with a blunt cannula through the incisions, thebleeding was very sparse. The light speculum was held bythe assistant and the angiolipomas were easily extirpatedby digital or scissor dissection. The procedure was facili-tated by transdermal palpation. A total of 35 tumoursmeasuring up to 7� 7� 3 cm were extirpated (Figure 2).Drains were placed in each of the three underminedregions, the incisions were sutured intradermally with 4/0 polyglactin (Vicryl�) and 4/0 poliglecaprone (Monocryl�)and an abdominal belt was applied for 14 days. Thefollowing day the drains were removed and the patientdischarged. There were no complications. Histopathologyconfirmed the diagnosis of angiolipomas. The result wascosmetically satisfying at follow up after 3 months.

Excisional surgery of multiple lipomas and angiolipomasmay be cosmetically unacceptable in regard to the local-isation, number and length of scars created. Several tech-niques to reduce scarring have been reported. Keyholeincisions and squeeze delivery1 are in situ approaches,applicable mainly for solitary tumours in certain regions.Hitherto reported techniques for reducing and concealingscars by remote incisions are useful,2,3 but characterised by