Dermoid cysts rarely appear in the lower extremity and must be included in the differential diagnosis of cystic lesions of the lower limb.

Purpose: The vascularised corticoperiosteal flap was introduced by Sakai and Doi, in 1991, as a means to achieve bony union under unfavourable conditions. Few reports have been presented in the English literature. Our purpose is to present our experience with this flap in six patients with complex and/or multioperated nonunions of the upper limb. Material and methods: In five cases a long bone was involved (two humerus, two ulnae, one radius). All have had several surgeries prior to referral (3-7 times). Two of the non-unions were secondary to infection, and the rest had had prior conventional grafting 2 to 3 times previously. In each case an atrophic non-union was noticed; the bed, which was fibrotic and poorly vascularised, was debrided en bloc. After stabilising the bony segments by means of a LCP or DCP plate a bony gap of 0 to 3 cm at its minimal aspect and 2 to 3.5 cm at its maximal were recorded. The defect was filled with spongiosa taken from the femoral condyle while the corticoperiosteal flap was wrapped around the defect opposite the plate. In the sixth case a corticoperiosteal graft was used to promote healing in a complex carpo-carpal-metacarpal dislocation, in which the very poor bed made us expect failure. Results: All of the flaps survived without complications and all of the bones healed radiologically in less than 3 months. Three patients achieved a normal range of motion and two obtained a functional range of motion with only slight limitations. The carpometacarpal arthrodesis was healed soundly at 5 weeks. Conclusions: Our study confirms that the corticoperiosteal flap is an excellent tool for dealing with multioperated non-unions in the upper limb.

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W e read with much interest the recent paper by Bailey et al. 1 We congratulate them on highlighting the fact that ''preventative measures to reduce the seroma rate would greatly improve the postoperative morbidity of this workhorse reconstructive flap.'' 1 Seroma rates of more than 80% have been reported in the literature.The senior author (G.D.S.) has performed more than 250 cases of breast reconstruction using the extended latissimus dorsi (ELD) flap in the last 10 years. For several years, the technique has involved using quilting sutures and fibrin sealant to reduce seroma rates; this has been described in detail previously. 2 Bailey et al used two 15 French Blake drains for a prolonged time, with a mean duration of 13.9 days with a range up to 38 days in the quilting and sealant group and for a mean duration of 21.5 days with a range up to 69 days in the quilting alone group. 1 We believe it is misleading for them to quote seroma rates of 4% to 5% when they keep the drains for such a long time, more than 2 months in some cases.Previously, we tended to use a single 12-French drain in the donor site and we reported that the combination of fibrin glue and quilting, compared to quilting alone, led to reduced drainage in the immediate postoperative period, 13 mL compared with 170 mL; reduced average total drainage volume, 330 mL compared with 645 mL; reduced time the drains stayed in, 4 days compared with 5 days. 2 However, in some cases, we also noted an increase in the daily drainage in the postoperative period after 48 hours, which we speculated may have been because of the irritant effect of the drain tubing acting as a foreign body. 2 This was one of the reasons we decided to change our practice. We now firmly believe drains are no longer required in unilateral cases, and we alluded to this in our previous publication. 2 The technique used in our institution for quilting and application of fibrin to the donor site has been described in detail elsewhere, 2 but it differs from the technique described by Bailey et al 1 in several important ways.Bailey et al 1 describe quilting using Vicryl sutures around 5 cm apart, but our technique involves using interrupted 2/0 polydioxanone sutures (Ethicon, Johnson & Johnson, Livingston, Scotland) approximately 2.5 cm apart. Although this means that more sutures would be used, we believe that time spent meticulously closing the dead space and using a more long-lasting suture material reduces seroma formation. The narrower gaps between the quilting sutures still allow for the easy application of the fibrin sealant.Bailey et al 1 use a thin short applicator and do not spray the fibrin sealant. Our technique involves using a long rigid laparoscopic cannula to spray the fibrin with great control to even the furthest areas, coating the entire cavity. This is then followed by milking the area gently to further ensure that the fibrin has spread to all areas within the wound and to remove any air. We believe this technique leaves no raw patches to produce serous fluid.In December...