Background: Dynamic infrared thermography (DIRT) is a noninvasive imaging technique that can provide indirect and real-time information on skin perfusion by measuring skin temperature. Although used in flap surgery, there are no reports on its value in procedures using a pedicled thoracodorsal artery perforator (TDAP) flap. The aim of this study was to assess the usefulness of DIRT in preoperative perforator mapping and in monitoring intra- and postoperative flap perfusion of pedicled TDAP flaps. Methods: This prospective study comprised 21 patients (21 flaps) scheduled for reconstructive surgery with a TDAP flap. Perforator mapping was done by DIRT, handheld unidirectional Doppler ultrasound, and computer tomography angiography. Intra- and postoperative flap perfusion was assessed by clinical signs and with the use of DIRT and handheld unidirectional Doppler ultrasound. Results: Perforator mapping with DIRT showed that first-appearing bright hotspots were always associated with arterial Doppler sounds and suitable perforators intraoperatively. Computer tomography angiography presented useful information on the thoracodorsal artery branching pattern but was less beneficial for perforator mapping. Intra- and postoperative flap monitoring with DIRT was more useful than handheld unidirectional Doppler ultrasound and clinical signs to detect early arterial and venous perfusion problems. DIRT demonstrated that TDAP flap perfusion is a dynamic process with an increase in perfusion during the first operative days. Nineteen flaps survived, of which 3 sustained distal necrosis. Two flaps were lost due to inadequate blood perfusion. Conclusion: DIRT provides valuable real-time information for perforator mapping and for monitoring TDAP flap perfusion intra- and postoperatively.

The usefulness of a skin biopsy punch to remove sea urchin spinesa ns_5296 383..390 Sea urchins are spiny marine animals commonly found along the coastline in both tropical and tempered waters. There are hundreds of species. All are roughly spherical in shape and characterized by spines made up of fragile calcium carbonate crystals. On contact and penetration of the skin, the spines often break, resulting in deposition of foreign material in the cutis or subcutaneous tissues. The recent development of sea urchin aquaculture has resulted in an increasing number of people at risk for injuries, in addition to those traditionally injured during leisure or marine sports activities. Painful wounds with local inflammation or infection are commonly seen, sometimes taking considerable time to heal. Complications, such as arthritis or granuloma formation related to the foreign-body reaction, can result in disabling conditions. 1 Early excision of the spines is favoured, rather than waiting for spontaneous recovery. A number of different methods have been described, including advanced techniques for surgical removal. 2-4 We introduce a new and simple technique to remove the spines by a dermal biopsy punch.A 25-year-old man was referred to our outpatient clinic, after having stepped on a green sea urchin (Strongylocentrotus drobachiensis) the previous day. On admission, multiple remnants of sea urchin spines were seen in the skin on the plantar side of his right heel.The area was cleaned and anesthetized with combined lidocain 10 mg/mL and epinephrine 5 mg/mL (Xylocain, AstraZeneca, Oslo, Norway). A biopsy punch with a diameter of 2 mm (Miltex, Inc., York, PA, USA) was used to cut out each spine including a small piece of surrounding dermal tissue to support the fragile remnants of calcium carbonate. Further crushing of the fragile material was thereby prevented and the spines could be completely removed using forceps and scissors (Fig. 1). There were no post-operative complications and the wounds healed uneventfully within the following 2 weeks.We think that a dermal biopsy punch, commonly found in most medical offices, is a simple and handy tool to solve this problem and thereby reducing the morbidity of the patient.Letters to the editor 383

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An expert panel consisting of six mental health chaplains from several European countries was convened to ascertain the specific contribution of mental health chaplains to suicide prevention, and to generate good practices for suicide prevention. Three themes emerged: (1) the importance of timing; (2) fundamental attitudes of the chaplain towards the patient, and (3) appropriate interventions.