Apart from the omission of this reference, the technicaldetails have been presented in an inadequate way. We wouldtherefore like to mention some of the finer aspects of thedesign of this technique as described in the original paper,2

for the benefit of the learned readers who wish to attempt it.

1. The shape of the opposite normal nostril is drawn onthe outer skin of the stenosed nostril (Fig. 1a). Thiswould form the margin of the new nostril.

2. An incision is marked along the long axis of the narethus marked, and is transacted by another incisiondrawn perpendicular to it, in the shape of a cross(Fig. 1a).

3. Incisions are extended slightly beyond the originalmargin drawn in step 1 so as to overcorrect the newmargin.

4. The four outer flaps are now raised, thinned and heldapart in sutures (Fig. 1b).

5. Another cross is now drawn at the mucosal aspect, off-set at 45� to the one drawn on the outer skin (Fig. 1c).

6. Deeper flaps are raised next, thinned and retractedin sutures again. It is important to thin these innerflaps aggressively to get rid of the hair follicles fromthe nasal vestibule which would otherwise line theoutside of the margin of the external nare, and growhairs.

7. The remaining scar tissue is trimmed back up to the car-tilage and the eight flaps are now inset in an interdigi-tating manner, allowed by the 45� offsetting betweenthe two sets of flaps (Fig. 1d).

8. The final shape of the nostril is determined by the ten-sion on the outer skin flaps and is therefore inset first.The deeper flaps are then inset to fill the gaps forminga continuous ‘W’ plasty at the margin.

In the senior author’s experience, this technique hasproved to be a versatile and reliable method in correctingnasal stenosis of different aetiology.

References

1. Tiwari VK, Sarabahi S. Starplasty: an ideal method for correctionof occluded external nares following burns. J Plast ReconstrAesthet Surg 2006;59:1105e9.

2. Naasan A, Page RE. The double cross plasty: a new technique fornasal stenosis. Br J Plast Surg 1992;45:165e8.

Manish SinhaCanniesburn Plastic Surgery Unit, Glasgow Royal Infirmary,

84, Castle Street, Glasgow G4 0SF, UKE-mail address: drmanish@hotmail.com

Anas NaasanDepartment of Plastic Surgery, Ninewell Hospital,

Dundee DD1 9SY, UK

ª 2007 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2007.06.021

Short reports and correspondence 1369

Clinical audit of the impact of information leaflets onoutcomes in patients with mallet finger injuries

A mallet finger is a common injury where rupture or divisionof the extensor mechanism at the level of the distalinterphalangeal joint of the finger prevents active exten-sion. These injuries are managed in a variety of settingssuch as accident and emergency departments, hand clinicsand occupational therapy centres. Treatment commonlyinvolves splinting of the finger for 6 or more weeks. Lessfrequently, surgical fixation is used to correct the de-formity. The patient outcome following either externalsplinting or surgical management is broadly similar andeach technique has its own advocates.1 Several forms of ex-ternal splinting have been described with the Stack splintbeing in common use.2 If the splint is worn correctly theoutcome is usually good. However, unsatisfactory outcomesare frequently encountered due to poor patient compliancewith the splint.3 In an effort to increase our success ratewith the management of mallet finger injuries we intro-duced patient information leaflets documenting the correctuse of the Stack and audited their impact on our outcomes.

We retrospectively audited outcomes for 63 patients withmallet finger injuries over a 2 year period from January 2003to December 2004 using patient records. Three possibleoutcomes were recorded at a point 8 weeks after initialpresentation: a successful or improved result defined as anextension loss of no more than 15�,4 an unsatisfactory resultwith an extension loss of greater than 15� or the patient lostto follow up (Did Not Attend, DNA). Patients with open in-juries, fractures of the distal phalanx, previous hand injuriesand multiple injuries to the affected hand were excludedfrom the study. Using a published series5 as a standard weset a target rate of 50% for successful outcomes at 8 weekspost presentation. Change was implemented by introducinga patient information leaflet describing the correct use ofthe mallet splint which was provided to the next 38 patientspresenting with a mallet finger injury from January 2005 on-wards. The patient information leaflet used was selected bythe following means. A Google internet search using theterms ‘mallet finger injury’ was performed; the 100 topranked sites originating from the UK were selected. Six ofthese sites had available patient information leaflets; thesepatient information leaflets were peer-reviewed by five cli-nicians from our institution’s plastic surgery and accidentand emergency departments, five occupational therapistsfrom our institution and five previous patients who hadbeen treated for mallet finger injuries. A consensus was ar-rived at and one leaflet* was selected and distributed toall new patients. The same measures and exclusion criteriawere used to prospectively re-audit patient outcomes,with the additional exclusion criteria of those patientswhose first language was not English.

Prior to the introduction of a patient information leaflet,the successful or improved outcome rate was 35% (22/63),the unsatisfactory outcome rate was 30% (19/63), and thelost to follow-up rate was 35% (22/63). Following thechange in practice the successful or improved outcome

* www.pncl.co.uk/wbelcher/information/EXT-I.pdf

‘Prefabricated’ and ‘prelaminated’ flaps: two verydifferent techniques

I read with interest the short report of ‘Prefabricated radialperitonefascial flap for vaginal agenesis’ by Prakash andTandan.1 The described technique is another addition tothe repertoire of gynaecological reconstructive surgeons.However, I would question the use of term ‘prefabricated’in their nomenclature of the flap.

Though the word ‘prefabricated’ was first used byBakamjian and Holbrook in 19732 to describe staged phar-yngoesophageal reconstruction, the term as it stands inthe current literature identifies with the concept that wasdescribed by Shen Tzu Yao in 1982.3 He reported a case3

where he implanted the lateral circumflex femoral arteryinto a skin flap on the medial side of the thigh in a burnpatient for resurfacing a neck contracture. He then success-fully performed a microvascular transfer of the ‘prefabri-cated’ flap, as he called it, after a delay of 6 weeks. Sincethe description of this technique, such flaps have beenperformed regularly and more commonly and the word‘prefabricated’ has become synonymous with Shen’s initialdescription of neovascularising tissues by implanting a vascu-lar pedicle. However, as stated by Paribaz and Fine, ‘(theterm) Prefabrication has lost much of its usefulness as aprefabricated flap can now seemingly describe any flapmodification’.4 They therefore proposed a new term ‘prela-mination’ to describe any flap modification that includedimplantation of tissue or other devices into a vascular terri-tory prior to its transfer.

They illustrated the two very techniques on the samepatient who underwent a complex upper and mid-facereconstruction. In the first attempt, prefabrication, asdescribed by Shen, was attempted to neovascularise themedial thigh and a microvascular transfer of the unit wasthen undertaken to reconstruct the forehead and nose.When the nasal reconstruction part of the flap did notsurvive, they then implanted auricular cartilage and fullthickness skin grafts in a radial forearm flap territory andlater successfully transferred it to reconstruct the nose asa ‘prelaminated’ flap. In recent years there have been

1370 Short reports and correspondence

rate was 32% (12/38), the unsatisfactory outcome rate was29% (11/38), and the lost to follow-up rate was 39% (15/38).

There is an increasing demand for the provision of patientinformation about their conditions and treatment. Theimportance of written patient information has been recog-nised by the Department of Health and the NHS Plan statesthat patient information is an integral part of the patientjourney.6 It has been shown that patients may forget half ofwhat they have been told within 5 min of a medical consulta-tion and retain only 20% of the information conveyed tothem, but patient retention of information can be improvedby 50% if supplemental written information is provided.7,8

Despite increased demand for patient information leaf-lets, their provision did not increase the number ofsatisfactory outcomes in our study. This may be due totwo reasons: firstly patient non-compliance with treatmentdue to poor understanding of the treatment and secondlypatient non-compliance despite an understanding of thetreatment. The outcome for our patients, in both groups,was disappointing. In addition to poor compliance otherfactors may have contributed to this. There are othermethods of treatment for mallet finger injuries includingother designs of splint.1 It is reasonable to suggest that theStack splint may not be the best method of treatment forthis type of injury.

Even with verbal instruction, reinforced with a writtenleaflet, a patient’s understanding of a treatment plan maybe limited. One possible way to overcome this is throughregular follow up to ensure understanding together withrepetition of instructions to reinforce an understanding.Though this may not be practical in a busy practice,individual patients who might be considered high risk couldbe identified and offered more regular follow-up appoint-ments. Frequent supervision of patients is certainly animportant factor, and may be of far more value thanwritten information.

A number of our patients in this series with unsatisfac-tory outcomes openly admitted they were not using theirStack splints as instructed. Upon questioning they accu-rately described the correct use of a Stack splint, butstated that they removed the splints on occasion as theyregarded them as uncomfortable or inconvenient. In thisgroup of patients the provision of information leaflets hadno impact on outcome. In our study the introduction ofpatient information leaflets did not increase the number ofsatisfactory outcomes. The audit loop was closed.

References

1. Handoll HH, Vaghela MV. Interventions for treating mallet fingerinjuries. Cochrane Database Syst Rev 2004;3. CD004574.

2. Stack HG. A modified splint for mallet finger. J Hand Surg [Br]1986;11:263.

3. Kinninmonth AW, Holburn F. A comparative controlled trial ofa new perforated splint and a traditional splint in the treatmentof mallet finger. J Hand Surg [Br] 1986;11:261e2.

4. Abouna JM, Brown H. The treatment of mallet finger. The resultsin a series of 148 consecutive cases and a review of the litera-ture. Br J Surg 1968;55:653e67.

5. Warren RA, Norris SH, Ferguson DG. Mallet finger: a trial of twosplints. J Hand Surg [Br] 1988;13:151e3.

6. Department of Health. The NHS Plan: A Plan for Investment,A Plan for Reform. London: HMSO; 2000.

7. Little P, Griffin S, Kelly J, et al. Effect of educational leafletsand questions on knowledge of contraception in women takingthe combined contraceptive pill: randomised controlled trial.BMJ 1998;316:1948e52.

8. Macfarlane J, Holmes W, Gard P, et al. Reducing antibiotic usefor acute bronchitis in primary care: blinded, randomised con-trolled trial of patient information leaflet. BMJ 2002;324:91e4.

Nicholas WhiteAtul Khanna

Department of Plastic Surgery, Sandwell General Hospital,Lyndon, West Bromwich, West Midlands B71 4HJ, UK

E-mail address: nickwhite@doctors.net.uk

ª 2007 Published by Elsevier Ltd on behalf of British Association ofPlastic, Reconstructive and Aesthetic Surgeons.

doi:10.1016/j.bjps.2007.04.007