stages of breast carcinoma. Ann Surg Oncol 2002;9(5):462—6.

4. Coutinho M, Southern S, Ramakrrishnan V, et al. The aestheticimplication of scar position in breast reconstruction. Br JPlast Surg 2001;54(4):326—30.

5. Skoll PHD. Skin-sparing mastectomy using a modified wisepattern. Plast Reconstr Surg 2001;110(1):214—7.

6. Toth BLP. Modified skin incisions for mastectomy: need forplastic surgical input in preoperative planning. Plast ReconstrSurg 1990;87(6):1048—53.

7. Schur PSD, Petty P, Hanson T, Weaver A. Reductionmammaplasty: an outcome study. Plast Reconstr Surg 1997;100(4):875—83.

8. Hammond D, Capraro P, Ozolins E, et al. Use of a skin sparingreduction pattern to create a combination skin-muscle flappocket in immediate breast reconstruction. Plast ReconstrSurg 2002;110:206—11.

Paolo Matteucci, Le Roux FourieDepartment of Plastic Surgery, Pinderfields

General Hospital, Aberford Road,Wakefield WF1 4DG, UK

doi:10.1016/j.bjps.2003.12.018

Painless steroid injections for hypertrophic scarsand keloids

We have been following with interest the originalletter by Azad and Sachs,1 and the ensuingcorrespondence from Mandal and Imran,2 andNduka et al.3 Fear of pain is certainly an importantconsideration for prospective patients undergoingsurgical procedures under local anaesthesia,additionally compounded by needle phobia. Factorswhich influence the perception of pain duringinjection include the type of solution, pH, fluidtemperature, tissue puncture, fluid pressure andflow rate of solution.

At our centre, we have been using a computer-controlled local anaesthetic delivery system (Com-puDente; CompuMede, The Wandw; MilestoneScientific, Inc., Livingstone, NJ) to administerlocal anaesthetic to patients with dental phobia,including paediatric dental patients. This systemhas been used extensively in dentistry.4

The system consists of a micro-processor driven

Figure 2 Wise pattern and semicircular dermal flap marked out.

Short reports and correspondence 475

injection device that delivers a controlled infusionof local anaesthetic solution, using standard 1.8 mlglass cartridges. The microprocessor monitors andadjusts infusion pressure, delivering the anaes-thetic via sterile tubing at a controlled flow rate. Atone end of the tube is the rigid pen-like ‘Wandw’handpiece, to which is attached a 0.5 inch 30 Gneedle via a Luer-lock. At the other end is theanaesthetic cartridge receptor, which locks to thepump, with an electronically controlled pistonpushing the solution through the tubing. Both thesterile tubing and Wandw apparatus are disposable.

More recently, we have successfully adapted thistechnology to the administration of local anaes-thetic to patients with hypertrophic and keloidscars attending our centre, prior to the injection ofsteroid. We are also currently conducting a trial tocompare the efficacy and patient acceptability ofinjecting local anaesthetic and steroid, eitherseparately, or in combination as a mixture in asingle cartridge.

Incidentally, this device has also been used todeliver local anesthetic for procedures as diverse as

nasal surgery,5 hair transplantation,6 anal anaes-thesia,7 and podiatry!8

References

1. Azad S, Sachs L. Painless steroid injections for hypertrophicscars and keloids. Br J Plast Surg 2002;55:534.

2. Mandal A, Imran D. Painless steroid injections for hyper-trophic scars and keloids. Br J Plast Surg 2003;56:79.

3. Nduka C, van Dam H, Davis K, Shibu M. Painless steroidinjections for hypertrophic scars and keloids. Br J Plast Surg2003;56:842.

4. Grace EG, Barnes DM, Reid BC, Flores M, George DL.Computerized local dental anaesthetic systems: patient anddentist satisfaction. J Dent 2003;31:9—12.

5. Swanepoel PF, Heystek P, Fysh R. Computer-assisted localanaesthetic application for nasal surgery. Presented at theEighth AAFPRS International Symposium March 2002.

6. True RH, Elliott RM. Microprocessor-controlled local anaes-thesia versus the conventional syringe technique in hairtransplantation. Dermatol Surg 2002;28:463—8.

7. Tan PY, Vukasin P, Chin ID, Ciona CJ, Orteg AE, Anthone GJ,Corman ML, Beart RW. The WAND local anaesthetic deliverysystem: a more pleasant experience for anal anaesthesia. DisColon Rectum 2001;44:686—9.

Figure 3 Thin dermal flap raised as marked.

Short reports and correspondence476

8. Bartel BF. Painfree podiatry injections. Podiatry ManagementSeptember 2002.

Kelvin LimDepartment of Oral and Maxillofacial Surgery,

National University of Malaysia (UKM), 56000Kuala Lumpur, Malaysia

doi:10.1016/j.bjps.2004.01.001

Issues arising from the presentation of synchro-nous cutaneous malignant melanoma and senti-nel node biopsies: a case report and discussion

After many studies demonstrating its use andefficacy sentinel node biopsy (SNB) is fast gainingacceptance as a standard of good practice inmelanoma care and arguably also in the care ofother head and neck malignancy. Currently studiesare ongoing to elucidate its potential role in themanagement of breast and gynaecological malig-nancy also.

Up to 5% of patients may get multiple cutaneousprimary melanomata1 although the clinical diag-nosis of synchronous melanomata is rare.2 To thebest of our knowledge, the diagnosis of synchronousprimary melanomata, followed by synchronous SNBhas not previously been described and, we wouldlike to present our experience of this combinationand describe a clinical problem that arises, andwhich we feel will require a solution as SNBbecomes increasingly commonplace.

A 66-year-old lady was referred for wide local

excision after an excision biopsy of a lesion on thedorsum of her foot revealed a melanoma of Breslowthickness 2.5 mm. During her consultation a furtherlesion with clinical features suggestive of malignantmelanoma was noted on her ipsilateral shin. Thissecond lesion was excised for histology and wasshown to be a further primary malignant melanomaof Breslow thickness 1.5 mm (and definitely not ametastatic deposit).

In our hospital at the time, both lesions were of athicknesses to warrant SNB. Our practice was (andstill is) to map sentinel nodes using pre-operativelymphoscintigraphy and to localise them intrao-peratively using visualised isosulphan blue dye(Lymphazurine, Tyco Healthcare) and a hand heldgamma probe. Ideally, for two synchronoustumours, two colours of dye would be used so thatdifferent sentinel nodes might be distinguished. Ittranspired that this was impossible because onlypatent blue dye was manufactured and no othercolour was made or licensed for use.

Our approach was to subject the patient to twoseparate lymphoscintigraphy studies3 on consecu-tive days followed by wide local excision of bothmelanomata the following day.

Fig. 1 shows lymphoscintigrams from bothstudies and demonstrates that two sentinel nodeswere highlighted with both nodes positive in bothstudies, but interestingly showing activity in adifferent order and with differing prominenceeach day. A line has been added to the scans todenote the position of the inguinal ligament. Atsurgery both nodes were identified with ease usingvisualisation and a hand held gamma probe.4,5

Subsequent histopathological analysis demon-strated no melanoma deposits in either node andour patient died of colonic carcinoma after more

Figure 1 Lymphoscintigrams from both studies.

Short reports and correspondence 477