Short reports and correspondence 89

12. To EWH, Pang PCW, Chu GM. The use of modified rhytidectomy for parotidectomy. Br J Plast Surg 2000; 53: 80.

13. Bugis SP, Young JEM, Archibald SD. Sternocleidomastoid flap following parotidectomy. Head Neck 1990; 12: 430-5.

14. Kornblut AD, Westphal P, Miehlke A. A reevaluation of the Frey syndrome following parotid surgery. Arch Otolaryngol 1977; 103: 258-61.

15. Casler JD, Conley J. Sternocleidomastoid muscle transfer and superficial musculoaponeurotic system plication in the preven- tion of Frey's syndrome. Laryngoscope 1991; 101: 95-100.

16. Seed S, Quraishi MS, Jennings CR, Bradley PJ. Frey's syndrome following parotidectomy: prevention using a rotation sternoclei- domastoid muscle flap. Clin Otolaryngol 1999; 24: 365-8.

17. Cesteleyn L, Smith RG, Akuamoa-Boateng E, Kovacs B, Peiffer R. Current diagnosis and therapy of parotid tumours. Acta Stomatol Belg 1991; 88: 157-70.

18. Timew GC. Sternocleidomastoid muscle flaps following parotidectomy. Br J Oral Maxillofac Surg 1994; 32: 262.

19. Rhee JS, Davis RE, Goodwin WJ Jr. Minimizing deformity from parotid gland surgery. Curt Opin Otolaryngol Head Neck Surg 1999; 7: 90-8.

20. Kim SY, Mathog RH. Platysma muscle-cervical fascia-sternoclei- domastoid muscle (PCS) flap for parotidectomy. Head Neck 1999; 21: 428-33.

21. Bonanno PC. Parotidectomy: a plastic approach. Aesthetic Plast Surg 2000; 24: 235.

doi: 10.1054/bjps.2001.3714

Emergency treatment of accidental infusion leakage in the newborn

Sir, It is with interest that we read the article by Casanova et al regarding neonatal extravasation injuries in 14 patients. 1 We would like to support their main conclusion that the most important factors in limiting the degree of tissue necrosis are early detection and treatment with attempts to remove the extravasant from the site of injury. Our experience in the Neonatal Unit at St George's Hospital of 82 neonatal extrava- sation injuries treated using a modification of Gault's aseptic saline flush-out technique 2 has previously been reported. 3 This technique involved flushing up to 500ml of normal saline subcutaneously at the site of extravasation to exit via several adjacent puncture wounds. In contrast to Casanova et al, all procedures were performed using local anaesthetic; liposuction was not employed. No episodes of skin or soft-tissue loss were recorded and no patient required reconstructive surgery. Furthermore, we have recently constructed a mouse model, using taxol as an extravasant, to calculate the optimal timing of flushout using the modified Gault technique. We found that if treatment was instigated within 1 h of injury, the ulcer size and healing time could be considerably reduced. If treatment is instigated within 4 h of injury, the size of the resulting ulcer can be decreased but the time to wound resolution remains the same as the untreated control. 4 We are currently re-evaluating the study using a variety of other extravasants and flush-out tech- niques to establish the optimum method of treatment.

Yours faithfully,

Victoria Rose MBBS, MRCS, Specialist Registrar in Plastic Surgery Matthew Turner MBBS, MRCS Paul A. Harris BSc, MD, FRCS Anthony L, H. Moss FRACS(Plast), FRCS

Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Road, London SW17 0QT, UK.

References

1. Casanova D, Bardot J, Magalon G. Emergency treatment of acciden- tal infusion leakage in the newborn: report of 14 cases. Br J Plast Surg 2001; 54: 396--9.

2. Gault DT. Extravasation injury. Br J Plast Surg 1993; 46: 91-6. 3. Harris PA, Bradley S, Moss ALH. Limiting the damage of iatrogenic

extravasation injury in neonates. Plast Reconstr Surg 2001; 107: 893-4.

4. Turner M, Rose V, Harris PA, Moss ALH. Management of extravasa- tion injury: determination of optimal timing and volume of dilu- tional agent. Presented at the British Association of Plastic Surgeons Summer Meeting July 2001.

doi: 10.1054/bjps.2001.3734

Continuous infusion of muscle relaxant facilitates closure of the TRAM-flap donor site

Sir, Although the deep inferior epigastric artery perforator (DIEP) flap is gaining in popularity, the majority of TRAM flaps are raised as pedicled flaps. The use of the pedicled TRAM flap minimises the risk of a disastrous complete flap loss. The high- er risk of partial flap loss associated with pedicled TRAM flaps is minimised either by using only ipsilateral abdominal tissue with unipedicled TRAM flaps or by having a low threshold for raising the flap in a bipedicled manner.

Closure of the abdominal donor site after the harvest of a TRAM flap is an important stage of the operation. Paying care- ful attention to detail whilst closing minimises donor-site mor- bidity. It is important to recognise that the internal and external oblique fasciae, which make up the anterior rectus fascia, often become separated. Failure to recognise this can result in only the external oblique fascia being repaired, which may result in a higher incidence of postoperative bulging or herniation. Incomplete muscle relaxation during the stage of rectus abdo- minis sheath closure can also cause great difficulties for the sur- geon. Residual rectus and oblique muscle tone may prevent direct closure of the rectus sheath and, hence, necessitate the use of synthetic mesh to achieve closure. Furthermore, tying sutures in an incompletely relaxed abdominal wall increases the risk of tearing the edges of the fascia and, therefore, may increase the likelihood of postoperative bulging and herniation.

For the last 3 years we have used a continuous intravenous infusion of atracurium during TRAM-flap harvesting. Atracurium, a non-depolarising muscle relaxant, undergoes spontaneous 'Hofmann degradation' at physiological temperature and pH, which is independent of hepatic and renal function. Its short duration of action, lack of cumulative effects and rapid recovery from neuromuscular blockade make it ideal for administration as a continuous intravenous infusion. Anaesthesia is induced in the usual way, and the patient is intubated with an intubating dose of atracurium. An infusion of atracurium is then commenced at 0.5 mg kg 1 h - i during maintenance of anaesthesia. When the TRAM flap is being raised, the rate of atracurium infusion is increased by about another 25% to ensure full ablation of the responses of Train-of-four nerve stimulation. This provides a predictable level of non-fluctuating and profound muscle relax- ation. Once the abdomen has been securely closed, the rate of atracurium infusion is reduced to maintenance levels again.

This simple safe approach greatly facilitates closure of the rectus fascial defect, and has reduced our use of synthetic mesh to augment closure. It provides a constant and controllable neu- romuscular block, with a predictable prompt recovery when the