LETTERS AND INVITED COMMENTARY The Use of Frozen Section in the Excision of Cutaneous Malignancy A Queensland Experience To the Editor: appreciate the careful work of Castley et al,1 but I believe that there are tantalizing data that readers would appreciate knowing. As the article had no flow chart, I assumed that the statement, “In 22 of the specimens, no residual tumor was seen on permanent paraffin sections, and these have been excluded from further analysis” meant that 22 of the patients referred for re-excision had no residual tumor when the pathologists reviewed the outside specimens so further surgery was done. On the basis of this assumption, I inserted the data from the text into a 2 by 2 contingency table to apply various statistical tests that are freely available on the Internet (Table 1).
REFERENCE 1. Castley AJ, Theile DR, Lambie D. The use of frozen section in the excision of cutaneous malignancy: a Queensland experience. Ann Plast Surg. 2013;71: 386–389.
A Bilobed Thoracoabdominal Myocutaneous Flap for Large Thoracic Defects
I
University of Miami School of Medicine Miami, FL [email protected]
To the Editor: e read with great interest the article of Charanek1 entitled “A bilobed thoracoabdominal myocutaneous flap for large thoracic defects.” The author presented a novel bilobed superior epigastric artery perforator flap, which added another arsenal in a reconstructive surgeon’s armamentarium in managing large thoracic defects. Latissimus dorsi myocutaneous, transverse rectus abdominis myocutaneous, vertical rectus abdominis myocutaneous, and anterolateral thigh flaps make up core workhorse flaps for reconstructions of large thoracic defects nowadays.2 Nevertheless, these complex procedures are relatively time consuming and require high skill; seeking for more expedient and convenient methods for patients with comorbid diseases never stops. The traditional thoracoabdominal (TA) flap was first described in 1975.3 Later, Deo et al4 demonstrated that TA flaps boast significant advantages of reduced blood loss, operating time, and hospital stay, compared with the previously mentioned myocutaneous flaps. Although the coverage extension of a traditional TA flap, which is much more like an enormous modified rotation flap, has not been clearly specified yet, the mean defect size is 180 cm2 in the study of Deo et al, much less than that of 327 cm2 in the pedicled bilobed propeller flap procedure of Charanek. Another disadvantage of the traditional TA flap is its inconvenience in performing the increasingly required immediate breast reconstruction,5 and a secondary W-plasty is frequently required to release contracture of the unpleasant oblique linear scar on the chest wall. Through the utilization of Charanekãs procedure, in comparison with the conventional treatment, the post-operative scars are left along the medial, upper and lateral borders of the chest, which may perfectly resolve this problem.
Conflicts of interest and sources of funding: none declared. Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503–0358 DOI: 10.1097/SAP.0000000000000029
Conflicts of interest and sources of funding: none declared. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503–0358 DOI: 10.1097/SAP.0000000000000306
TABLE 1. Proposed 2 by 2 Contingency Table
Positive margin paraffin Negative margin paraffin
Positive Margin Frozen
Negative Margin Frozen
7
1
2
118
Please answer these questions: 1. Is my table correct? If not, please correct it. 2. How would you categorize your data for the primary excisions with a 2 by 2 contingency table? 3. How would you categorize your data for the re-excisions with a 2 by 2 contingency table? 4. Was there a statistically significant difference in the validity of frozen section diagnoses for the primary versus the re-excised tumors?
M. Felix Freshwater, MD
358
www.annalsplasticsurgery.com
Besides, there are minor faults in the figure legends that may confuse the readers. First, Figure 5 demonstrates the defect of the left side of the thorax, which is the result of excision to the patient showed in Figure 4, although the legend shows the “right side.” Second, the legend of Figure 6 is “flap raised and rotated,” although it merely shows a preoperative patient with advanced breast tumor on the right side. Furthermore, the average size of the defects displays “327 cm2” in both Methods and Results, whereas it is “324 cm2” in the Discussion. We believe it is purely a typographical error. Nanze Yu, MD Ming Bai, MD Xiaojun Wang, MD
W
Department of Plastic and Reconstructive Surgery Peking Union Medical College Hospital Peking Union Medical College and Chinese Academy of Medical Science Beijing, China [email protected]
REFERENCES 1. Charanek AM. A bilobed thoracoabdominal myocutaneous flap for large thoracic defects. Ann Plast Surg. 2014;72:451–456. 2. Zhao R, Zeng A, Bai M, et al. [The reconstruction of large chest wall defect for 6 patients]. Zhonghua Zheng Xing Wai Ke Za Zhi. 2010;26:357–359. 3. Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric arcade. Plast Reconstr Surg. 1975;55:416–421. 4. Deo SV, Purkayastha J, Shukla NK, et al. Myocutaneous versus thoraco-abdominal flap cover for soft tissue defects following surgery for locally advanced and recurrent breast cancer. J Surg Oncol. 2003;83:31–35. 5. Cogliandro A, Cagli B, Filoni A, et al. Expander/ Implant breast reconstruction after reconstruction using an extended cutaneous thoracoabdominal flap: a case report. J Breast Cancer. 2013;16:438–441.
Self-Inflicted Burns in Soldiers The Singapore Experience To the Editor:
W
e read with interest the article by Gronovich et al1 on the high prevalence of atypical well-demarcated dorsal foot burns in Israeli soldiers with hot water scalding as the most common cause. We conducted a retrospective review of all conscripted Singaporean soldiers admitted in 2013 to our burns center (largest in Southeast Asia).
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503–0358 DOI: 10.1097/SAP.0000000000000495
Annals of Plastic Surgery • Volume 75, Number 3, September 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
REFERENCE 1. Castley AJ, Theile DR, Lambie D. The use of frozen section in the excision of cutaneous malignancy: a Queensland experience. Ann Plast Surg. 2013;71: 386–389.
A Bilobed Thoracoabdominal Myocutaneous Flap for Large Thoracic Defects
I
University of Miami School of Medicine Miami, FL [email protected]
To the Editor: e read with great interest the article of Charanek1 entitled “A bilobed thoracoabdominal myocutaneous flap for large thoracic defects.” The author presented a novel bilobed superior epigastric artery perforator flap, which added another arsenal in a reconstructive surgeon’s armamentarium in managing large thoracic defects. Latissimus dorsi myocutaneous, transverse rectus abdominis myocutaneous, vertical rectus abdominis myocutaneous, and anterolateral thigh flaps make up core workhorse flaps for reconstructions of large thoracic defects nowadays.2 Nevertheless, these complex procedures are relatively time consuming and require high skill; seeking for more expedient and convenient methods for patients with comorbid diseases never stops. The traditional thoracoabdominal (TA) flap was first described in 1975.3 Later, Deo et al4 demonstrated that TA flaps boast significant advantages of reduced blood loss, operating time, and hospital stay, compared with the previously mentioned myocutaneous flaps. Although the coverage extension of a traditional TA flap, which is much more like an enormous modified rotation flap, has not been clearly specified yet, the mean defect size is 180 cm2 in the study of Deo et al, much less than that of 327 cm2 in the pedicled bilobed propeller flap procedure of Charanek. Another disadvantage of the traditional TA flap is its inconvenience in performing the increasingly required immediate breast reconstruction,5 and a secondary W-plasty is frequently required to release contracture of the unpleasant oblique linear scar on the chest wall. Through the utilization of Charanekãs procedure, in comparison with the conventional treatment, the post-operative scars are left along the medial, upper and lateral borders of the chest, which may perfectly resolve this problem.
Conflicts of interest and sources of funding: none declared. Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503–0358 DOI: 10.1097/SAP.0000000000000029
Conflicts of interest and sources of funding: none declared. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503–0358 DOI: 10.1097/SAP.0000000000000306
TABLE 1. Proposed 2 by 2 Contingency Table
Positive margin paraffin Negative margin paraffin
Positive Margin Frozen
Negative Margin Frozen
7
1
2
118
Please answer these questions: 1. Is my table correct? If not, please correct it. 2. How would you categorize your data for the primary excisions with a 2 by 2 contingency table? 3. How would you categorize your data for the re-excisions with a 2 by 2 contingency table? 4. Was there a statistically significant difference in the validity of frozen section diagnoses for the primary versus the re-excised tumors?
M. Felix Freshwater, MD
358
www.annalsplasticsurgery.com
Besides, there are minor faults in the figure legends that may confuse the readers. First, Figure 5 demonstrates the defect of the left side of the thorax, which is the result of excision to the patient showed in Figure 4, although the legend shows the “right side.” Second, the legend of Figure 6 is “flap raised and rotated,” although it merely shows a preoperative patient with advanced breast tumor on the right side. Furthermore, the average size of the defects displays “327 cm2” in both Methods and Results, whereas it is “324 cm2” in the Discussion. We believe it is purely a typographical error. Nanze Yu, MD Ming Bai, MD Xiaojun Wang, MD
W
Department of Plastic and Reconstructive Surgery Peking Union Medical College Hospital Peking Union Medical College and Chinese Academy of Medical Science Beijing, China [email protected]
REFERENCES 1. Charanek AM. A bilobed thoracoabdominal myocutaneous flap for large thoracic defects. Ann Plast Surg. 2014;72:451–456. 2. Zhao R, Zeng A, Bai M, et al. [The reconstruction of large chest wall defect for 6 patients]. Zhonghua Zheng Xing Wai Ke Za Zhi. 2010;26:357–359. 3. Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric arcade. Plast Reconstr Surg. 1975;55:416–421. 4. Deo SV, Purkayastha J, Shukla NK, et al. Myocutaneous versus thoraco-abdominal flap cover for soft tissue defects following surgery for locally advanced and recurrent breast cancer. J Surg Oncol. 2003;83:31–35. 5. Cogliandro A, Cagli B, Filoni A, et al. Expander/ Implant breast reconstruction after reconstruction using an extended cutaneous thoracoabdominal flap: a case report. J Breast Cancer. 2013;16:438–441.
Self-Inflicted Burns in Soldiers The Singapore Experience To the Editor:
W
e read with interest the article by Gronovich et al1 on the high prevalence of atypical well-demarcated dorsal foot burns in Israeli soldiers with hot water scalding as the most common cause. We conducted a retrospective review of all conscripted Singaporean soldiers admitted in 2013 to our burns center (largest in Southeast Asia).
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7503–0358 DOI: 10.1097/SAP.0000000000000495
Annals of Plastic Surgery • Volume 75, Number 3, September 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
