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460 British Journal of Plastic Surgery B This technique of a partial subcuticular suture is related to that described by McGregor for suturing two tissue corners to a straight edge. t Using the same principle, the technique can, therefore, also be used to close the upper edges of the areotar-vertical limb upper 'T' junction and to incorporate this into the continuous suture. Yours faithfully, Lok Ituei Yap MB, FRCSEd(Plast), Craniofacial Fellow Great Ormond Street Hospital for Children, London WC 1N 3JH, UK. Tariq Ahmad MA, FRCS(Plast), Consultant Plastic Surgeon James D. Watson MB, FRCS(Glas)(Plast), FRCSEd, Consultant Plastic Surgeon Department of Plastic Surgery, St John's Hospital, Howden Road West, Livingston EH54 6PP, UK. Reference 1. McGregor IA, The three-point suture. In Fundamental Techniques of Plastic Surgery, 8th ed. London: Churchill Livingstone, t989: 15. Figure 1--(A) The circular suturing of the areola to the breast skin after a reduction mammaplasty. The suture line moves from right to left along the distal edge of the circulm wound. The three-dimensional arrows indicate the direction of suture passage as applied by a right- handed surgeon. (B) The subcuticular turnaround segment is shown in interrupted outline. (C) The turnaround completed, with the direction of suture insertion now the same (supination) for the proximal edge as for the distal edge of the areola. surgeon has to arm the needle holder in reverse for part of the circumference of the circular wound in order to preserve the direction of passage of the sutures (skin to areola or areola to skin, as the case may be). We describe a technique that allows the operator to maintain the direction of forearm and wrist movement during the appli- cation of a circular running suture. Commencing with a simple knot, a continuous suture is started along one edge of the areola. The direction of suturing is indicated in Figure 1A by the three-dimensional arrows, from right to left for a right-handed surgeon, supinating the forearm and wrist for the suture bites. As the suture approaches the equator of the areola, a turn- around manoeuvre is executed. The turnaround is initiated by passing the suture needle through the skin. The suture is then passed horizontally in the subcuticular plane of the correspond- ing areolar segment and continued back through the breast skin (Fig. IB). The suture is then continued as normal from left to right, with the advantage of preserving the direction of suture movement at the wrist and forearm (supination for the tissue bites) (Fig. 1C). doi:10.1054/bjps.2002.3883 The pillowcase sling after hand surgery Sir, We would like to present a simple, easy to use, cheap and effi- cient upper-limb bedside sling, which can be assembled from a pillowcase and adhesive plaster tape. One of the accepted methods of controlling swelling in the hand following surgery is upper-limb elevation, a-3 In clinical practice, this is achieved by using an L-shaped designer bedside sling, with Velcro fasteners (the Bradford Sling, Ventures & Consultancy Bradford Ltd, UK). In our unit, emergency procedures in hand patients are fre- quently undertaken during the on-call service. In this period, staff involved in the care of patients are limited, and delays in patients leaving theatre can occur. If a designer bedside sling has not arrived in the operating theatre with the patient, formal elevation may be delayed until the patient returns to the ward. Inadequate elevation during this time risks further tissue swelling in the hand and may lead to adverse effects on hand function and rehabilitation thereafter. The pillowcase sling is a helpful and cheap interim measure that achieves the same goals as the widely used designer alternative. We claim no originality in the use of the pillowcase sling, hut simply describe it as a useful method. One of the comers of the closed end of a standard hospital pillowcase is invaginated into the other. This produces a right- angled triangular sling with short, long and open sloping sides. The patient's elbow is flexed and placed into the trough of the shorter side, so that it is held in the comer of the triangle of tile pillowcase sling; the longer side envelopes the remaining part of the forearm and hand. Elevation is achieved by fixing suffi- cient adhesive plaster tape around the fi'ee end of the sling, and looping it over a drip-stand and back onto the sling. The limb may then be held securely in the pillowcase sling by a small strip of adhesive plaster tape midway (Fig. 1). Once on the ward, the patient's limb may be placed appropriately in the definitive sling. We have found the pillowcase sling to be easy to make from readily available hospital materials, and considerably cheaper
