Primary Surgery Vol.2 – Trauma: SKIN FLAPS

SKIN FLAPS

GENERAL METHOD

PLANNING will be easier if you make a cloth pattern first, and use it to carry out the procedure of the actual operation in the reverse order, as in Fig. 57-20.

Sterilize an ordinary ink pen, and some ordinary ink or Bonney’s blue. Draw on the patient’s skin after you have prepared it for surgery. Transfer the pattern of the defect to a piece of cloth, preferably jaconet. Make sure you cut the pattern to include the base of the flap. Make it a little larger and wider than you think will be necessary. Try the pattern again, making sure that each time you move it you hold the base in a fixed position, without moving it with the flap. The final flap must be larger than is necessary, particularly in its length. You can easily trim a flap which is too large, but you cannot lengthen one which is too small.

Undercut the flaps in the layers shown in Figure 54-6. You must leave some fat under the patient’s skin, if you undermine his skin alone, the flap will certainly break down.

CAUTION! (1) Make clean incisions with a sharp knife at right angles to the surface. (2) Handle all flaps with the greatest care, especially at the angles. Pick them up with skin hooks, or a silk stay suture. Don’t use thumb forceps. (3) Cut the angles as bluntly as you can, preferably at less than 45 $\ensuremath{^\circ }$ . (4) Use fine needles and sutures. (5) Make sure that a flap is not kinked, rotated, stressed or pressed on, and that there is no haematoma underneath it.

If bare areas remain when you have completed a flap, cover them with split skin grafts.

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Figure 57.19: A DOUBLE PEDICLE ADVANCEMENT FLAP. A, and B, show the principle of this flap. C, D, and E, show how it has been used to cover a pressure sore over the greater trochanter, part of which has been excised. Make the pedicles broad, and don’t be tempted to use this flap on the skin of the face or the lower leg. With the kind permission of James Smith.

Leave the flap open in the early stages, so that you can inspect it and test its vascularity.

POSTOPERATIVE CARE Ask the nurses to roll a flap from its edge towards its base to evacuate static venous blood from it and free blood from underneath it.