Short reports and correspondence746

can be manipulated more freely. A loop is formed infront of the tubing (Fig. 1). The free end is passedbehind the tubing and through the loop severaltimes (Fig. 2). The knot is drawn tight (Fig. 3) untilit waists the tubing (Fig. 4). Finally, the drain issutured to the skin and the drain is held securely(Fig. 5).

The clinch knot is both elegant and reliable,resisting accidental traction and providing securefixation to drains of any size.

References

1. Milling MAP, Zoltie N. A method of secure fixation of suctiondrains. J R Coll Surg Edinb 1985;30:195.

2. O’ Neill T, Harrison S. A method of securing suction drains. BrJ Surg 1984;71:932.

3. Hormbrey E, Pandya A, Humzah D. Drain fixation madefoolproof. Ann R Coll Surg Engl 2000;82:290–2.

4. Wheat P. The Observer’s book of flyfishing. USA: FrederickWarne; 1977.

W.A. TownleyO.J.H. Harley

Department of Plastic and Reconstructive Surgery,St Thomas’ Hospital, Lambeth Palace Road,

London SE1, UKE-mail address: willtownley@hotmail.com

q 2005 The British Association of Plastic Surgeons. Published byElsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2005.02.009

A quaint archaism, but do we have a choice?

Although the art of skin grafting remains an intrinsicpart of everyday plastic surgery, opinions oftendiffer concerning the most appropriate method ofharvesting a split skin graft. Supporters of thetraditional hand-held knife maintain that it is areliable and efficient tool, vital to the reconstruc-tive armamentarium. A recent BJPS editorial,however, reflected the views of many that thehand-held knife is in fact an archaic method of graftharvest1 and use of the powered dermatome shouldbe encouraged.

To gain an understanding of the general avail-ability of powered dermatomes, we contacted 12randomly selected plastic surgery units, serving atotal of 28 peripheral hospitals with elective

operating lists. Skin graft harvest was commonlyperformed at all these peripheral hospitals. Derma-tomes were available at all 12 central units, butonly at 2 of the 28 peripheral hospitals (the hand-held knife being the only available tool at the other26 locations).

Although many may still prefer to use the hand-held knife, others may feel more confident with thepowered dermatome. We agree with the views ofthe editor that units should be encouraged to atleast offer a choice of instrument to the operatingsurgeon, although our survey suggests that theoption of the dermatome is still often unavailable.

References

1. Kay SP. Give and take (Editorial). Br J Plast Surg 2004;57:379.

H. TehraniA.J. Lindford

J. PowellDepartment of Plastic and Reconstructive Surgery,

Norfolk and Norwich University Hospital,Norwich, UK

E-mail address: hamid.tehrani@nnuh.nhs.uk

q 2005 The British Association of Plastic Surgeons. Published byElsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2005.02.014

The identification of amputated fingers

When faced with the clinical problem of a fourfinger amputation at the level of the proximalphalanx, it is often possible to correctly identify allof the fingers by taking into account length,fracture pattern, and the geometry of the lacera-tion. However, it has been claimed that thepresence of hairs on the dorsal middle phalangealskin can be used as an adjunct to the identificationof the ring versus the index finger, whose ampu-tated parts may be a similar length.1 Whilstreplantation of these fingers to the wrong sitemay produce no lasting functional deficit, it may beobvious and distressing to the patient. Numerousprevious studies of populations from diverse ethnicgroups concur that the most common finger topossess hair on the dorsal middle phalangeal skin isthe ring finger, and the least common the index

Short reports and correspondence 747

finger.2–5 No study has looked specifically at thedistribution of hair on the fingers of a cross sectionof the British public. We have undertaken a simplestudy to assess the sensitivity and specificity of thisphysical sign to predict whether an amputatedfinger is the index or ring finger.

One hundred adults drawn randomly fromfriends, colleagues, and patients of the authorswere asked for their verbal consent to participate inthe study. After agreement, their age and sex wererecorded. Ethnic origin data were self-recorded bythe participants using the Oxford Radcliffe NHSTrust ethnic monitoring form (data available onrequest). The authors recorded the presence orabsence of hair on the dorsal middle phalangeal skinof the index and ring fingers of both hands. If nohairs were identified with the naked eye, a 2!magnifying glass was used to confirm their absence.None of the subjects had undergone previoussurgery at any of the four sites.

Results

A total of 100 patients participated in the study, ofwhich 58 were female. The mean age was 39 years,with a range of 19–80 years. Hair was present on thedorsal middle phalangeal skin of 20/200 (10%) ofring fingers. In contrast, hair was present on thedorsal middle phalangeal skin of 0/200 (0%) of indexfingers. Sensitivity of the presence of hair identify-ing the ring finger 0.1. Specificity of the test was1.0. Positive predictive value was 1.0, and negativepredictive value was 0.53. Results were similarwhen data was stratified by sex and ethnic origin(data available on request) (Table 1).

The presence of hair on the dorsal middlephalangeal skin is therefore a very specific but notvery sensitive way of identifying the ring finger whenfaced with the clinical problem of a four fingeramputation. Our study is the first to observe thisanatomical feature in the British population. Webelieve this physical sign provides a useful adjunct tothe assessment of a patient with a four fingeramputation at the level of the proximal phalanx.

Table 1 Presence or absence of hair on the dorsalskin over the middle phalanx of the ring and littlefingers of all subjects

Finger

Ring Index

Hair Present 20 0Absent 180 200

References

1. Buntic RF, Buncke HJ. Replantation and revascularisation. In:Weinzweig J, editor. Plastic surgery secrets. 1st ed.Philadelphia: Hanley and Belfus Inc.; 1999. p. 513–6.

2. Hatiboglu MT. The hair distribution of the phalanges of thehand among Turks. J Anat 1983;137(3):537–40.

3. Singh JD. Distribution of hair on the phalanges of the hand inNigerians. Acta Anat (Basel) 1982;112(1):31–5.

4. Sinha DN, Asthana AK, Sharma D. Incidence, pattern anddirection of hair distribution on the dorsum of phalanges ofthe hands of male medical students of Uttar Pradesh, India.Anthropol Anz 1984;42(1):47–52.

5. Vona G, Porcella P. Middle phalangeal hair distribution in aSardinian population sample. Anthropol Anz 1989;47(1):79–85.

Dominic FurnissAkib Hafeez

Paul CritchleyDepartment of Plastic and Reconstructive Surgery,The Radcliffe Infirmary, Woodstock Road, Oxford

OX2 6HE, UKE-mail address: dominic.furniss@doctors.org.uk

q 2005 The British Association of Plastic Surgeons. Published byElsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2005.02.016

Reply to: Effect of liposuction on insulin resist-ance and vascular inflammatory markers in obesewomen

Sir,

Giugliano et al.,1 report the effects of liposuc-tion on insulin resistance and vascular inflammatorymarkers in obese women. We studied the metabolicconsequences of ultrasound-assisted megalipo-plasty (UAM) in 15 premenopausal overweightwomen (BMI 40.23G5.91 kg/m2). Megalipoplastywas defined as removal of more than 10 l oflipoaspirate in the same surgical time. Aspiratevolumes ranged from 10.0 to 26.3 l, with aninfiltrate to aspirate ratio of 0.67 (wet technique).The metabolic impact of the operation was assessedby the variation of different parameters includingbasal metabolic rate (BMR measured by indirectcalorimetry), insulin resistance (HOMA method),C reactive protein (CRP, Immunonefelometricassay; N CRP, Behring GmbH), Interleukin-6 (IL-6,Immunometric assay, Immulite 1000 IL-6, DPC Ltd)adiponectin (Human Adiponectine ELISA; B-Bridge