London, UK. Annual Scientific Congress (joint meeting of theRoyal Australasian College of Surgeons and the Royal College ofSurgeons of Edinburgh), 11–15th May 2002, Adelaide, Australia.Third National NHS Intellectual Property Conference (posterpresentation), March 2003.

S.H. Liew, J. McPhail, J.D. Morton, C.M. Darcy,R. Alvi, K.E. Graham

Department of Plastic Surgery, Whiston Hospital,Prescot, Merseyside L35 5DR, UK

doi:10.1016/j.bjps.2003.11.027

Controlling the stacking of cartilage grafts fornose tips

Simple little tips can improve speed, efficiency andaccuracy in cosmetic surgery. It came to myattention that surgeons performing a rhinoplastyoften stitch cartilage grafts together freehand onthe drapes over the patient, traumatising the flimsygrafts with forceps and large suturing needles. Inaddition, assistance is often needed. In my experi-ence, I have found it useful to skewer any stackedcartilage fragments with a fine hypodermic needlein the graft. I then use two small angled arteryforceps to block the migration of the grafts alongthe needle (Figs. 1 and 2). This stabilises the graft inall but rotation. The artery clips and needle providea stable platform on the drapes over the patient toallow precise fine suturing with little need forforceps trauma or extra sterile trolleys. Cartilagecan be easily trimmed and shaped to requirement.The ability to rotate the stacked graft on the skeweris extremely useful to complete the inter-cartilagi-nous suture stabilisation. Simple and effective!

James D. FrameSpringfield Hospital,

Chelmsford, Essex, UK

doi:10.1016/j.bjps.2004.01.002

Coughing to distraction

Sir,Percutaneous insertion of needles, for example

for the passage of intravenous cannulae or theinjection of local anaesthetic agents, can be anextremely uncomfortable experience for patients.A number of methods, both pharmacological andnonpharmacological, have been described in theliterature to help alleviate this discomfort. Non-pharmacological techniques include counterstimu-lation,1 pressure, hypnosis,2 and distraction. Ofthese, distraction appears to be the single mosteffective technique, with numerous reports of itsefficacy in reduction of the pain of injections anddressing changes.1,3 –5

Methods of distraction have include imagery, forexample lava lamps and cartoons in children,imagining pleasant scenes and experiences,humour, music, and cognitive tasks. Althoughthere is little doubt that distraction works, theexact mechanism has not been established. It may,however, be explained on the basis of the gatecontrol theory of pain,6,7 which showed that theperception of pain may be modulated at severallevels within the nervous system, by both extrinsicand intrinsic factors. It is possible that stimulitravelling along fast nerve fibres partially overridepainful sensations travelling along slower nerve

Fig. 1 Two nasal tip grafts stacked and stabilised withhypodermic needle and two artery clips.

Fig. 2 Same nasal tip graft rotated on the hypodermicneedle.

Short reports and correspondence 375