Ebook Surgical tips and skills (1st edition): Part 2

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(BQ) Part 2 book Surgical tips and skills presents the following contents: Closure of dorsal hand defect, head and neck – parotid defect – posterior nuchal KPIF, sacral pressure area – closure with a gluteus maximus KPIF; tendon repair – modified Kessler technique – case series, trophic ulceration – olecranon (elbow) – case series,... ADVANCED 1/3 Closure of dorsal hand defect (KPIF) – case series no INTRAOPERATIVE Introduction The problem of a skin tumour on the dorsum of the hand can usually be solved with multiple local or locoregional flaps when grafting is inappropriate (e.g over exposed tendons) The keystone island flap is designed on the side of the lesion where the ‘pinch test’ indicates maximum tissue laxity (see Figure 2) Such flaps are based on ad hoc metacarpal perforators from the distal palmar arch and tensional closure allows ready apposition Problem Figure 1: SCC on the dorsum of the (L) hand Mark-out of the KPIF along the embryological C7 dermatome Notes _ _ _ _ _ _ _ _ Solution SURGICAL TIPS AND SKILLS Figure 2: The pinch test for skin laxity The keystone is best designed along the ulnar side of the defect Placement on the radial side entails enlargement into the cleft over the first dorsal interosseous muscle, which becomes too tight Notes _ _ _ _ _ 142 _ ADVANCED Closure of dorsal hand defect (KPIF) – case series no Notes _ _ _ INTRAOPERATIVE Figure 3: The flap is raised, supported by what appears to be only diaphanous neurovascular structures Such thinness is not a contraindication for its use at this site 2/3 _ _ _ Figure 4: Closure with V–Y apposition with drainage The mark-out shows the course of the radial cutaneous nerve, which has been preserved Notes _ _ _ _ _ _ _ Figure 5: Release of the tourniquet showing the paradoxical hyperaemia (PH) Notes _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS _ _ _ 143 ADVANCED 3/3 Closure of dorsal hand defect (KPIF) – case series no INTRAOPERATIVE Outcome Figure 6: Appearance at week Notes _ _ _ _ _ _ _ _ _ Figure 7: Appearance at months – an acceptable aesthetic outcome, which has been pain-free throughout The patient is back to playing golf and regards his hand as totally normal Notes _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS 144 ADVANCED Delayed facial nerve neuropraxia following SCC excision – McLaughlin tarsorrhaphy – case series no Introduction In head and neck reconstruction, KPIF closure of large defects of the cheek in which the facial nerve has been sacrificed to achieve oncological clearance, the tightness of the closure obviates the need for immediate facial nerve reconstruction with or without static or dynamic repair, including tarsorrhaphy Problem Figure 1: Prior wide excision (8 × cm) of a (R) parotid SCC with node clearance (II, III and IV) The periosteal strip of the (R) mandible completed the procedure and the defect was closed by a KPIF followed by XRT Some months later the patient re-presented in need of a (R) tarsorraphy Incidentally, another keratinising lesion developed on the upper lip in the interval INTRAOPERATIVE Duet procedure done in association with Professor Andrew Sizeland 1/3 Notes _ _ Solution Figure 2: McLaughlin tarsorrhaphy technique: the triangulate de-epithelialisation of the lower eyelid is matched with de-mucosalising of the upper eyelid in a matching triangulate fashion Notes _ _ _ _ _ _ SURGICAL TIPS AND SKILLS _ 145 ADVANCED 2/3 Delayed facial nerve neuropraxia following SCC excision – McLaughlin tarsorrhaphy – case series no INTRAOPERATIVE Figure 3: The angles at the apices of the symmetrical triangle design are sutured with 4-0 nylon with tubing protection and left in situ for weeks Notes _ _ _ _ _ _ _ Figure 4: The appearance on completion Notes _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS 146 _ _ _ ADVANCED Delayed facial nerve neuropraxia following SCC excision – McLaughlin tarsorrhaphy – case series no Figure 5: Postoperative image showing the closure protecting the exposed pupil Notes _ _ _ _ _ INTRAOPERATIVE Outcome 3/3 _ _ _ _ _ Approximately 35-minute procedure Return of total comfort without complication SURGICAL TIPS AND SKILLS 147 ADVANCED 1/4 DRAPE procedure as salvage for recurrent disease – case series no 10 INTRAOPERATIVE Closure with a cervico-submental KPIF Duet procedure in association with Dr Sorway Chan (surgical oncologist) Introduction reconstruction becomes incorporated into the oncological clearance Problem The DRAPE procedure – delayed reconstruction after pathology evaluation – is standard practice in oncological centres where radiotherapy is delayed until histological clearance has been verified It is axiomatic that any associated flap Recurrent squamous cell carcinoma (SCC) of the left cheek following incomplete removal and flap cover, wrongly sent for radiation therapy Solution DRAPE procedure Figure 1: DRAPE procedure – the resultant defect following five procedures to achieve oncological clearance Notes _ _ _ _ _ _ _ _ _ _ _ _ Figure 2: The × 5-cm defect prior to closure SURGICAL TIPS AND SKILLS Notes _ _ _ _ _ _ _ _ 148 _ ADVANCED DRAPE procedure as salvage for recurrent disease – case series no 10 INTRAOPERATIVE Figure 3: The cervicosubmental (CSM) keystone island flap raised across the midline with the usual skin fat platysma fascia (SFPF) as part of a keystone principle of the C2–C3 embryological dermatome design The flap is rotated on the middle third of the anterior border of sternomastoid The emerging neurovascular structures (cerivcal plexus and external carotid perforators including superior thyroid artery) provide neurovascular support Note the PH Notes _ 2/4 Figure 4: The staged insertion of the CSM flap, with the hypervascular changes, evidence of reactive hyperaemia Notes _ _ _ _ _ _ Notes _ _ _ _ SURGICAL TIPS AND SKILLS Figure 5: Appearance on completion Note the flap is angled upwards past the outer canthus to reduce potential ectropion complications, with the neck wound closed directly _ _ 149 ADVANCED 3/4 DRAPE procedure as salvage for recurrent disease – case series no 10 INTRAOPERATIVE Figure 6: Day post-op Notes _ _ _ _ _ _ _ _ _ _ _ _ _ Outcome Figure 7: Appearance 12 months after XRT Notes _ _ _ _ _ _ _ _ _ SURGICAL TIPS AND SKILLS 150 _ _ _ _ ADVANCED DRAPE procedure as salvage for recurrent disease – case series no 10 Notes _ _ _ _ _ _ _ INTRAOPERATIVE Figure 8: 14 months post-op 4/4 _ _ _ _ _ _ 75 minutes for this DRAPE procedure The patient was happy to resume work in the public domain Complications of a submental small, hypertrophic, reactive thickened scar that required a Z-plasty because of neck pull and body habitus Bibliography Behan, F.C., Rozen, W.M., Kwee, M.M., Kapila, S., Fairbank, S., Findlay, M.W., 2012 Oncologic clearance with preservation of reconstructive options: Literature review and the ‘delayed reconstruction after pathology evaluation (DRAPE)’ technique ANZ J Surg 82 (11), 780–785 Behan, F.C., Rozen, W.M., Wilson, J., Kapila, S., Sizeland, A., Findlay, M.W., 2013 The cervico-submental keystone island flap for loco-regional head and neck reconstruction J Plast Reconstr Aesthet Surg 66, 23–28 SURGICAL TIPS AND SKILLS 151 ADVANCED 2/3 Variation of locking mattress suture – case series no 62 INTRAOPERATIVE Figure 3: V–Y apposition around the rhomboid flap and closure of the Bruner’s incision Notes _ _ _ _ _ _ _ _ _ A B Figure 4: A, B The oblique vertical mattress suture (OVMS) locked into epidermal eversion Notes _ SURGICAL TIPS AND SKILLS 312 _ _ _ _ _ _ ADVANCED Variation of locking mattress suture – case series no 62 _ _ _ INTRAOPERATIVE Figure 5: The hyperaemic vascularity of the rhomboid flap of the KPIF rhomboid design based on ad hoc perforators from the hypothenar complex Notes _ 3/3 _ _ _ _ Outcome Satisfactory wound healing, without delay caused by granulation tissue or slow healing grafts, to expedite hand therapy and optimise recovery No complications to date Bibliography Gault, D.T., Brain, A., Sommerlad, B.C., Ferguson, D.J., 1987 Loop mattress suture Br J Surg 74, 820–821 Hanasono, M.M., Hotchkiss, R.N., 2005 Locking horizontal mattress suture Dermatol Surg 31 (5), 572–573 SURGICAL TIPS AND SKILLS 313 Index Page numbers followed by ‘f’ indicate figures A 314 abdominal wall KPIF for  55 necrosis of  7f, 9f abdominal wall defect abdominal binder for  123f case series no 1  116–119 case series no 2  120–123 drain tubes  118f healing  122f HEMMING suture for  118f KPIF for  116 negative pressure-assisted drainage closure of  89f operative sequence for  116–119 secondary  122f abdominal wall harvest for skin graft  89–90 dressing changing  90f accessory nerve  225f aesthetic closure  10–12, 38 for melanoma  128–130 excision in  128f healed appearance of  130f KPIF creation in  129f PH in  129f of neck defect  124–127 healing of  127f mattress sutures in  125f postoperative appearance  127f alar, large composite graft to  263–266 dissolving sutures in  265f postoperative appearance  266f alar naris  99f alar rim reconstruction  263 amputation, index finger  195f anaesthetics  23f angular vein  239f ankle joint double KPIF  131–134 mesh grafting in  132f post-op appearance  133f–134f presenting defect  131f tourniquet release  132f anterior superior iliac spine KPIF  288–289 anticoagulants  307f aromas, unpleasant  7–9 eucalyptus for  8, 8f oxygen for  8f artery clip  26f arthroplasty, CMC  204–207 arthrotomy  205f appearance before  75f atypical fibroxanthoma KPIF  208–210 PH and  210f postoperative appearance  210f auriculectomy  235f axillary seroma  81–82 drainage system for  81f seroma bag  82f B Bacillus pyocyaneus  68f basal cell carcinoma (BCC)  15f forehead  178–180 post-op appearance  180f morphoeic completed reconstruction  269f DRAPE procedure  268f nasolabial fold  267–269 RDS in  269f recurrent  267–269 preauricular  181–183 excision of  181f HEMMING suture  183f basic saline solution (BSS)  185f BCC See basal cell carcinoma BEST see boutonnière elastoplast splint technique Betadine  Bezier island flap  167f biopsy excisional technique  39–42 aesthetic outcome  42f appearance on completion  41f mattress sutures in  40f blood staining  20 blue tattoo  65f–66f bony defects, knee joint completed  137f debridement in  136f KPIF  135–138 VAC of  135f boutonnière elastoplast splint technique (BEST) distal limits in  112f for mallet deformity  110–113 weekly review of  112f Braithwaite blade  53 debridement technique  189f in fenestration  91f Bruner’s incision  195f, 312f BSS see basic saline solution buccal fat pad  139f buttock, KPIF  290–293 closure of  293f cutting diathermy in  292f C canal of Guyon  45f carcinoma ductal  278 of larynx  232f see also basal cell carcinoma; squamous cell carcinoma carpal tunnel release for recurrence completion  48f compression in  49f exposure in  45f horseshoe pillow elevation in  49f open method  45–52 Penrose drain in  47f proximal extent release in  50f splint technique in  48f tourniquet in  49f transverse carpal ligament repair in  51f venous flow in  51f wound dressing technique  49–50 carpal tunnel syndrome (CTS)  45 recurrent  50f carpal tunnel technique, open method  43–44 cat’s paw  295f cephalic vein necrotic tissue  300f cerebrovascular accident (CVA)  282 cervical submental flap  227f scalp staples in  80f cervicosubmental (CSM) KPIF  149f, 155f–156f, 184, 235f closure  236f periparotid defect  227–230 closure  230f post-op radiation appearance  231f PH in  227–230 cheek, KPIF from  211–213 cheek melanoma  139–141 aesthetic outcome  141f DRAPE procedure for  155–158 paradoxical hyperaemia and  156f histological clearances of  155f KPIF  214–217 PH in  214f post-op appearance  215f wound closure  140f cheese slicing effect  217f Chloromycetin  186f for nail bed injury  104f chronic lymphatic leukemia  71 chronic ulcer on dorsum of diabetic foot  68–70 grafting debridement in  53 on lower limb  53–54 ulcer slough in  53f healing  108f lateral malleolar  244f lower limb  108–109 dressing technique  108–109 grafting technique  53–54 peroneal compartment  60 circumferential KPIF  198–200 tourniquet release  200f circumferential steri-strips  104f Clark L IV melanoma  128f Cleland’s ligaments  195f CMC arthroplasty  204–207 collateral bands  111f columella  79f compression  49f compressional advancement  34f conchal cartilage harvesting  204–207 posterior approach  205f conchal fossa  204f SCC of  235f crepe bandage  177f crescentic excision  257–259 315 CSM KPIF see cervicosubmental KPIF CTS see carpal tunnel syndrome cubital fossa  3f cut-out drape  above cubital fossa  3f cutting diathermy for abdominal wall defect  117f in buttock KPIF  292f illustration of  56f KPIF and  55–57 procedure time  57f CVA see cerebrovascular accident cyanotic discolouration  124f D 316 DeBakey forceps  285f–286f debridement of abdominal wall necrosis  9f in bony defects around knee joint  136f Braithwaite blade  189f in chronic ulcer grafting  53 dermatome in  68f, 98 even plane production  98f manual use of  98f in donor site re-grafting technique  61f in gouty tophi of thumb  201f in nail bed injury  103f of necrotising fasciitis of groin  270f olecranon ulceration  297f palmar defect, KPIF closure  273f palmar trauma, KPIF closure  276f delayed facial nerve neuropraxia  145–147 delayed McLaughlin tarsorrhaphy  184–186 dermal apposition  72f dermatome  53 in debridement  68f, 98 even plane production  98f manual use of  98f for skin graft harvest  85–88 blade thickness in  85–87 depth adjuster  86f, 88f first run  86f lignocaine gel in  85f meshing guide in  87f saline moist cover after  87f Zimmer  58 diabetic foot  68–70 diaphanous neurovascular structures  143f diamond keystone perforator island flap  106 DIP joint  195f dissolving sutures  103f haemostatic  78f in large composite graft to alar  265f dog-ear revision  11f clinical application of  14f close-up view of  14f diagram of  13f sutures in  13–14 in wound closure  13–14 donor site dressing  58–59 lignocaine gel for  58f outcome  59 harvest, full thickness skin graft  192–194 HEMMING suture in  193f rhomboidal design of  192f re-grafting technique  60–62 debridement in  61f full thickness skin graft in  60, 61f healing site in  62f dorsal hand defect KPIF for  142–144 PH in  143f pinch test in  142 post-op appearance  144f tourniquet release  143f dorsal interosseous  142f dorsiflexion  242f dorsum of diabetic foot, chronic ulcer on  68–70 dorsum of hand surgical closure technique  63–64 HEMMING suture in  63f–64f mattress suture in  63f skin eversion on  63f drain tube fixation  17–18 half hitch knot in  18f nylon in  17f reef knot seal in  17f–18f drain tube identification  19 DRAPE procedure  28f in fenestrated full thickness graft  15f for major melanoma  152–154 postoperative appearance  153f–154f melanoma of cheek  155–158 paradoxical hyperaemia and  156f melanoma of forehead  159–161 postoperative appearance  161f melanoma of temple  162–164 postoperative appearance  163f–164f morphoeic BCC of nasolabial fold  268f for recurrent disease  148–151 appearance on completion  149f postoperative appearance  150f–151f temple morphoeic BCC  165–169 macroscopic mark-out in  166f draping technique cut-out  2, 3f for hand surgery operating table  2–3 towel clips in  2f dressing abdominal wall harvest  90f in carpal tunnel release for recurrence  49–50 donor site  58–59 lignocaine gel for  58f outcome  59 external auditory canal, SCC of  237f fenestration  93f gluteus maximus KPIF  284f hand splintage  23f Kaltostat  58, 69f, 108 in nasal fracture  79f removal of  58f lower limb chronic ulcer  108–109 Mefix  58f, 69f nail bed injury  104f negative pressure, support  94–95 debridement in  94f lower limb  94f vacuum dressing  95f in preauricular sinus procedure  171f scalp staple wounds  80f VAC  9f vacuum fenestration skin graft technique  93f negative pressure dressing support  95f ductal carcinoma  278 duet procedure  124, 135, 139, 145, 148, 155, 208, 211, 214, 218, 221, 223, 227, 232, 235, 278 Dupuytren’s dissection  Dupuytren’s fasciectomy defect  311f Dupuytren’s surgery  106f Penrose drain in  106–107 post-op appearance  107f E ear surgery dressing technique  174–177 stabilisation  174f tulle gras cut in  174f preauricular sinus procedure  170–171 dressing in  171f HEMMING suture  171f scaphoid fossa reconstruction using postauricular KPIF  172–173 ectropion pull  156f epidermal-dermal division  96f eponychium  102f eucalyptus  excisional defects  39f exsanguination problems excess venous filling  4f–5f in hand surgery  4–5 tourniquet and  4f, exsanguinator, Rhys-Davies  4f, external auditory canal, SCC of  235–237 dressing  237f F facial mitotic lesions  178–183 facial nerve  139f, 256f neuropraxia  145–147 palsy  184–186 facial SCC post radiotherapy  187–188 PH in  188f fast catgut sutures  103f FCB assessment of hand function  32 clinical examination tip  32 fenestrated full thickness graft (FFTG)  15–16, 191f, 196f blade for  16f donor site harvest of, in fingertip injury HEMMING suture in  193f rhomboidal design of  192f DRAPE procedure in  15f insert  16f multiple fenestrations in  193f from preauricular groove  15–16 pre-fenestrating  193f wrist  301f fenestrated split skin graft  54f fenestrated Wolfe graft  302f fenestration  91–93 Braithwaite blade in  91f in large composite graft to alar  264f lower limb  91f 317 fenestration (cont’d) stabilising  92f vacuum dressing  93f FEPS see figure-of-8 pulley sutures FETS  129f FFTG see fenestrated full thickness graft fibroxanthoma, atypical KPIF  208–210 PH and  210f postoperative appearance  210f figure-of-8 locking suture  46f figure-of-8 pulley sutures (FEPS)  280f olecranon ulceration  298f in yin-yang KPIF  121f–122f fine needle aspiration (FNA) biopsy  251f fingertip injuries  189–191 donor site harvest of full thickness skin grafts  192–194 HEMMING suture in  193f rhomboidal design of  192f NVIF for  190f, 192f, 195–197 post-op appearance  191f firebreak principle  106 FNA see fine needle aspiration biopsy foot, diabetic  68–70 forearm melanoma  198–200 forehead BCC  178–180 post-op appearance  180f forehead melanoma DRAPE procedure for  159–161 postoperative appearance  161f PH in  160f staged excision  159f foreign body giant cell granuloma  65–67 fenestration hole in  67f lazy S incision for  65f plane of dissection in  66f removal  67f Fournier’s gangrene  270 fractured tibial plateau  135f full thickness skin graft donor site harvest of, in fingertip injury  192–194 in donor site re-grafting  60, 61f G 318 gastrocnemius  138f giant cell granuloma, foreign body  65–67 fenestration hole in  67f lazy S incision for  65f plane of dissection in  66f removal  67f gluteus maximus KPIF  282–284, 291f appearance on completion  284f dressing  284f gouty tophi of thumb  201–203 debridement in  201f post-op appearance  203f granuloma, foreign body giant cell  65–67 fenestration hole in  67f lazy S incision for  65f plane of dissection in  66f removal  67f Grayson’s ligaments  195f greater trochanteric area KPIF  294–296 tension suture closing  295f groin, necrotising fasciitis of  270–272 debridement of  270f KPIF  272f presentation of  270f VAC of  271f groin seroma  83–84 drainage  83f final connection  84f fluid collection  83f Redivac installation  84f H haematoma  119 haemostasis  221f HEMMING suture for  52f in KPIF  55 haemostatic dissolvable sutures  78f half hitch knot  18f hand defect, dorsal KPIF for  142–144 pinch test in  142 hand function, FCB assessment of  32 clinical examination tip  32 hand splintage anaesthetic injection in  23f blood staining and  20 dressing  23f finished product  24f graft sites  22f plaster ribbing  23f postoperative  20 repeat mark-out  22f technique 1  21 technique 2  22–24 tubing  21f typical plaster  21f hand surgery exsanguination problems in  4–5 horseshoe pillow elevation  25 operating table, draping technique for  2–3 head and neck reconstruction, KPIF for  38 HEMMING closure  41f HEMMING suture  38, 71–73 for abdominal wall defect  118f in donor site harvest of full thickness skin graft  193f in dorsum of hand surgical closure technique  63f–64f for haemostasis  52f in malar eminence mitotic lesion  258f outcome  73 palmar defect, KPIF closure  274f with Penrose drain  52f postoperative appearance  73f preauricular BCC  183f preauricular sinus procedure  171f wound healing  72f for wrist  301f HMF see superficial spreading melanoma Horizontal Everting Mattress Method of suturING see HEMMING suture horseshoe pillow elevation  25 in carpal tunnel release  49f in nail bed injury  105f Howarth elevator  43f, 45f Hueston full thickness graft firebreak principle  311f hyperaemia paradoxical  124 reactive  149f NVIF and  197f hypervascularity  125f hypochlorite solution  108 hypothenar keystone  311f I IDPF see island deltopectoral flap index finger amputation  195f infraorbital nerve  160f infraorbital region, V-Y closures of  153f inguinal ligament  120f inner canthal KPIF  238–240 V-Y closure  240f inner canthal mitotic development  238f intercostal KPIF  233f, 279f internal oblique  121f interphalangeal joint  201f intrinsic plus position  105f island deltopectoral flap (IDPF)  211–213 postoperative appearance  212f–213f J joint exposure technique  74–75 in hand  74f pincer grip for  74f K Kaltostat dressing  58, 69f, 108 in nasal fracture  79f removal of  58f Kessler technique, modified  285–287 keystone improvisation technique (KIT)  290 keystone perforator island flap (KPIF) for abdominal wall defects  55, 116 in aesthetic closure of melanoma  129f alignment of  139f ankle joint double  131–134 mesh grafting in  132f post-op appearance  133f presenting defect  131f tourniquet release  132f anterior superior iliac spine  288–289 atypical fibroxanthoma  208–210 bony defects around knee joint  135–138 buttock  290–293 closure of  293f cutting diathermy in  292f from cheek  211–213 cheek melanoma  214–217 circumferential  198–200 tourniquet release  200f closure of  202f CSM  149f, 155f–156f, 184, 235f closure  230f, 236f periparotid defect  227–230, 229f post-op radiation appearance  231f cutting diathermy technique and  55–57 dimensions of  121f 319 320 keystone perforator island flap (KPIF) (cont’d) for dorsal hand defect  142–144 double  120–123 fascial lined base raising  117f gluteus maximus  282–284, 291f appearance on completion  284f dressing  284f greater trochanteric area  294–296 tension suture closing  295f haemostasis in  55 head and neck reconstruction using  38 illustration of  56f inner canthal  238–240 V-Y closure  240f insertion of  140f intercostal  233f, 279f lateral malleolar defect  241f closure  242f postoperative appearance  243f in lateral malleolus metal exposure post ORIF  248f–249f in major melanoma  152f mark-out  131f necrotising fasciitis of groin  272f omega variant  56f, 89, 117f, 153f, 163f, 203f, 289f, 291f, 304f dog-ear trimming  246f lateral malleolar orthopaedic defect closure with  244–247 outline of  120f palmar defect  273–274 debridement  273f HEMMING suture  274f postoperative appearance  274f palmar trauma  275–277 closure of  276f debridement  276f recovery  277f post mastectomy reconstruction  278–281 chest wall raising  279f post-op appearance  281f postauricular scaphoid fossa reconstruction using  172–173 sutures in  172f–173f posterior nuchal for parotid defect  223–226 postoperative appearance  226f procedure time  57f of SMAS  72, 221–222 postoperative appearance  222f supraclavicular  124 supraorbital closure  261f nasal bridge defect and  260f transversus facial lined  121f yin-yang double  120–123, 132f FEPS in  121f–122f second stage of  122f KIT see keystone improvisation technique Kleid, Steve  139 knee joint, bony defects around completed  137f debridement in  136f KPIF  135–138 VAC of  135f KPIF see keystone perforator island flap K-wire  110, 206f L Langer’s line  99 large composite graft to alar  263–266 dissolving sutures in  265f fenestration in  264f postoperative appearance  266f larynx, carcinoma of  232f lateral malleolar chronic ulcer  244f lateral malleolar defect  241–243 KPIF formation  241f closure  242f postoperative appearance  243f lateral malleolar orthopaedic defect, KPIF omega variant closure  244–247 dog-ear trimming  246f lateral malleolus  132f metal exposure post ORIF  248–249 appearance before reconstruction  248f KPIF in  248f–249f lazy S incision  65f leukemia, chronic lymphatic  71 lignocaine gel  58, 69f for donor site dressing  58f in skin graft harvest, dermatome  85f lip defect angle of mouth in  252f completion  253f NVIF in  252f SCC  250–254 staged reconstruction  253f LLSS see Luer-lock suction system locking mattress suture  309–313 lower limb chronic ulcer dressing technique  108–109 grafting technique  53–54 peroneal compartment ulcer  60 Luer-lock suction system (LLSS)  188f, 301f Lumbar perforators  56f M major melanoma DRAPE procedure for  152–154 post-op appearance  153f–154f KPIF  152f major parotid defect  71 major wound drainage technique  26–27 malar and zygomatic arch complex  255–256 malar eminence mitotic lesion crescentic excision for  257–259 HEMMING suture in  258f incisional line around  257f malignant spindle cell melanoma  303f malleable aluminium splint stabiliser  78f mallet deformity  110–113 Marcain  111f mastectomy, reconstruction after  278–281 chest wall raising  279f post-op appearance  281f mattress sutures in aesthetic closure of neck defect  125f in biopsy excisional technique  40f in dorsum of hand surgical closure technique  63f HEMMING closure following  41f locking  309–313 oblique vertical  312f in ODEL  11f preparation for  40f strategic  179f locking  258f tension  72f Mayo scissors  176f McCash open granulating wound method  311f McLaughlin tarsorrhaphy  145–147 appearance on completion  146f delayed  184–186 postoperative appearance  147f sutures in  146f technique  145f MCP see metacarpophalangeal joints medial malleolus  133f median nerve  45f Mefix dressing  58f, 69f melanoma aesthetic closure for  128–130 excision in  128f healed appearance of  130f KPIF creation in  129f PH in  129f cheek  139–141 aesthetic outcome  141f DRAPE procedure  155–158 histological clearances of  155f KPIF  214–217 paradoxical hyperaemia and  156f PH in  214f post-op appearance  215f wound closure  140f Clark L IV  128f forearm  198–200 of forehead DRAPE procedure for  159–161, 161f PH in  160f staged excision  159f major DRAPE procedure for  152–154 KPIF  152f post-op appearance  153f–154f malignant spindle cell  303f preoperative appearance  159f superficial spreading  159 of temple DRAPE procedure  162–164 postoperative appearance  163f–164f metacarpophalangeal (MCP) joints  311f methylene blue  292f microstomia  254f mitotic lesion  172f facial  178–183 malar eminence  257–259 HEMMING suture in  258f incisional line around  257f modified Kessler technique  285–287 morphoeic BCC nasolabial fold  267–269 completed reconstruction  269f 321 morphoeic BCC (cont’d) DRAPE procedure  268f RDS in  269f recurrent  267–269 of temple Bezier island flap in  167f DRAPE procedure  165–169, 166f postoperative appearance  168f–169f multifocal SCC  255–256 N 322 nail bed injury  102–105 Chloromycetin for  104f circumferential steri-strips for  104f debridement in  103f dressing  104f germinal matrix repair  103f horseshoe pillow elevation in  105f nail removal in  102f soaking in  103f nasal defect bridge  260–262 large composite graft to alar  266f postoperative appearance  262f supraorbital KPIF and  260f large composite graft to alar  263–266 dissolving sutures in  265f fenestration in  264f nasal fracture  76–79 bone displacement in  75f delayed diagnosis  76f Kaltostat dressing in  79f nasolabial fold morphoeic BCC  267–269 completed reconstruction  269f DRAPE procedure  268f RDS in  269f nasolabial region  261f neck defect aesthetic closure of  124–127 healing of  127f mattress sutures in  125f postoperative appearance  127f clearance levels  124f in irradiated field  218–220 postoperative appearance  220f necrosis, abdominal wall  7f, 9f necrotic fat  292f necrotising fasciitis of groin  270–272 debridement of  270f KPIF  272f presentation of  270f VAC of  271f negative pressure dressing support  94–95 debridement in  94f lower limb  94f vacuum dressing  95f negative pressure-assisted drainage closure  89f Netscher principle  44f for transverse carpal ligament repair  51f neuropraxia, delayed facial nerve  145–147 neurovascular bundle  190f neurovascular island flap (NVIF) distal part of  196f for fingertip injuries  190f, 192f, 195–197 lip defect  252f reactive hyperaemia and  197f for thumb tip injury  96 NVIF see neurovascular island flap nylon in drain tube fixation  17f sutures  47f, 185f O oblique vertical mattress suture (OVMS)  312f ocular design with extended limbs (ODEL)  10–12, 39–42 biopsy in  10f completed  12f mattress sutures in  11f pathology in  10f ODEL see ocular design with extended limbs olecranon ulceration  297–299 debridement  297f FEPS  298f post-op appearance  299f Redivac in  298f open reduction with internal fixation (ORIF)  135f lateral malleolus metal exposure following  248–249 appearance before reconstruction  248f KPIF in  248f–249f operating table, hand surgery  2–3 ophthalmic probe  170f ORIF see open reduction with internal fixation osteophytes  205f osteotomy  75f, 76 haemostatic dissolvable sutures in  78f reversal of  75f OVMS see oblique vertical mattress suture oxygen  8f P palmar defect, KPIF closure  273–274 debridement  273f HEMMING suture  274f postoperative appearance  274f palmar fascia  44f palmar trauma, KPIF closure  275–277 closure of  276f debridement  276f recovery  277f palmaris brevis muscle  43f paradoxical hyperaemia (PH)  124, 223 in aesthetic closure of melanoma  129f atypical fibroxanthoma and  210f in cheek melanoma  214f in dorsal hand defect  143f facial SCC post radiotherapy  188f in forehead melanoma  160f paratenon sutures  287f parotid defect facial SMAS KPIF  221–222 posterior nuchal KPIF  223–226 parotidectomy  71f patient evaluation measurement (PEM)  32 pectoralis major island flap  218–220 post-op appearance  234f for radionecrotic neck ulcer  234f vascular supply for  233f PEM see patient evaluation measurement Penrose drain  44f in carpal tunnel release  47f Dupuytren’s surgery  106–107 HEMMING sutures with  52f successful  52f sutures with  52f periosteal stripping  126f periosteum  283f periparotid defect, CSM KPIF  227–230 closure  230f PH in  229f post-op radiation appearance  231f peroneal compartment ulcer, lower limb  60 peroneus longus tendon  245f PH see paradoxical hyperaemia pillar pain  44f pincer grip  74f pinch test  142 PIP joint  111f, 195f ring removal and  35f plaster splintage  21 pneumatic band  4f POP bandage  48f post mastectomy reconstruction, KPIF  278–281 chest wall raising  279f post-op appearance  281f postauricular groove  172f postauricular KPIF  172–173 sutures in  172f–173f posterior nuchal KPIF for parotid defect  223–226 postoperative appearance  226f postoperative hand splintage  20 preauricular BCC  181–183 excision of  181f HEMMING suture  183f preauricular groove, fenestrated full thickness graft from  15–16 preauricular sinus procedure  170–171 dressing in  171f HEMMING suture  171f prefenestrated split skin graft  69f pre-wash technique  Prontosan  108 proximal double silk strands  34f proximal extent release  50f Pseudomonas aeruginosa  68f Q quadrilateral cheek flap  162f R radionecrotic neck ulcer  232–234 pectoralis major island flap for  233f radiotherapy, facial SCC after  187–188 PH in  188f RDS see red dot sign reactive hyperaemia  149f NVIF and  197f recurrent median nerve  43f red dot sign (RDS)  125f–126f, 129f, 140f, 223, 225f in nasolabial fold morphoeic BCC  269f Redivacs  19, 28, 82 in olecranon ulceration  298f in seroma of groin  84f in upper limb laceration  307f–308f 323 reef knot seal, in drain tube fixation  17f–18f rhinoplasty  263 Rhys-Davies exsanguinator  4f, ring removal  33–35 PIP joint in  35f S 324 sacral pressure area, de-epithelialisation in  283f saline moist cover  87f Savlon  6, 68f scalp staples in cervical submental flap  80f in hair-bearing tissue  80 wound dressing technique and  80f scaphoid fossa reconstruction using postauricular KPIF  172–173 sutures in  172f–173f Scarpa’s fascia  288f SCC see squamous cell carcinoma septorhinoplasty  76 seroma of axilla  81–82 drainage system for  81f seroma bag  82f seroma of groin  83–84 drainage  83f final connection  84f fluid collection  83f Redivac installation  84f SFPF see skin fat platysma fascia silk strands  33–35 compressional advancement with  34f proximal double  34f zero silk  33f skin eversion  63f skin fat platysma fascia (SFPF)  149f skin graft harvest, dermatome  85–88 blade thickness in  85–87 depth adjuster  86f, 88f first run  86f lignocaine gel in  85f meshing guide in  87f saline moist cover after  87f skin graft technique for abdominal wall harvest  89–90 dressing changing  90f fenestration  91–93 Braithwaite blade in  91f lower limb  91f stabilising  92f vacuum dressing  93f negative pressure dressing support  94–95 debridement in  94f lower limb  94f vacuum dressing  95f SLMS see strategic locking mattress sutures SMAS see superficial musculoaponeurotic system SMS see strategic mattress suturing splint technique  48f See also hand splintage split skin graft, prefenestrated  69f squamous cell carcinoma (SCC)  211 biopsy proven  250f of conchal fossa  235f excision  145–147 of external auditory canal  235–237 dressing  237f facial, post radiotherapy  187–188 PH in  188f lip defects after  250–254 multifocal  255–256 recurrent  148–151, 218f sterilisation  6f strategic locking mattress sutures (SLMS)  258f strategic mattress suturing (SMS)  179f stretch technique  196f subchondral margin  120f, 122f subdermal plexus  44f, 75f submandibular node  251f superficial musculoaponeurotic system (SMAS)  187f, 211f KPIF of  72, 221–222 postoperative appearance  222f superficial spreading melanoma (HMF)  159 supraclavicular KPIF  124 suprafascial perforator vascular perfusion  198f supraorbital KPIF closure  261f nasal bridge defect and  260f supraorbital neural complex  178f sural nerve  245f sural neurovascular axis  244f sutures dissolving  103f in large composite graft to alar  265f in dog-ear revision  13–14 fast catgut  103f figure-of-8 locking  46f figure-of-8 pulley  280f olecranon ulceration  298f in yin-yang KPIF  121f–122f haemostatic dissolvable  78f HEMMING  38, 71–73 for abdominal wall defect  118f in donor site harvest of full thickness skin graft  193f in dorsum of hand surgical closure technique  63f–64f for haemostasis  52f in malar eminence mitotic lesion  258f outcome  73 palmar defect, KPIF closure  274f with Penrose drain  52f postoperative appearance  73f preauricular BCC  183f preauricular sinus procedure  171f wound healing  72f for wrist  301f mattress  11f in aesthetic closure of neck defect  125f in biopsy excisional technique  40f in dorsum of hand surgical closure technique  63f HEMMING closure following  41f locking  309–313 oblique vertical  312f in ODEL  11f preparation for  40f strategic  179f strategic locking  258f tension  72f in McLaughlin tarsorrhaphy  146f nylon  47f, 185f paratenon  287f in scaphoid fossa reconstruction using postauricular KPIF  172f–173f tension  295f 3-point  101f vicryl  103f swollen digit, ring removal from  33–35 syringe suction system  28–31 T tarsorrhaphy  216f McLaughlin  145–147 appearance on completion  146f delayed  184–186 postoperative appearance  147f sutures in  146f technique  145f teasing under tension (TUT)  256f temple melanoma, DRAPE procedure  162–164 postoperative appearance  163f–164f temple morphoeic BCC Bezier island flap in  167f DRAPE procedure  165–169 macroscopic mark-out in  166f postoperative appearance  168f–169f temporal region, V-Y closures of  153f tendon repair  285–287 tension mattress sutures  72f tension sutures  295f theatre  7–9 3-point closure refinement  99–101 3-point suture  101f thumb, gouty tophi of  201–203 debridement in  201f post-op appearance  203f thumb tip injury  96–97 closure  97f completed  97f NVIF for  96 tibial plateau, fractured  135f tibial tuberosity  136f tissue mobilisation  40f tourniquet in ankle joint double KPIF  132f in carpal tunnel release  49f circumferential KPIF  200f in dorsal hand defect  143f exsanguination problems and  4f, towel clips  2f transverse alignment  100f transverse carpal ligament repair  46f in carpal tunnel release  51f Netscher principle for  51f transverse fascial lined KPIF  121f transverse palmar ligament  43f transverse triangulate ligament reconstruction  44f transversus abdominis fascia  117f triangulate flap closure  99–101 repositioning in  100f stabilising  100f trophic ulceration  288–296 buttock  290–293 greater trochanteric area  294–296 325 trophic ulceration (cont’d) olecranon  297–299 wrist  300–302 trunk defect  303–306 outcome  305f recovery  306f TUT see teasing under tension U ulceration olecranon  297–299 debridement  297f FEPS  298f post-op appearance  299f Redivac in  298f trophic  288–296 buttock  290–293 greater trochanteric area  294–296 olecranon  297–299 wrist  300–302 ulnar nerve  45f umbilicus  280f unpleasant aromas  7–9 eucalyptus for  8, 8f oxygen for  8f upper limb laceration  307–308 closure  308f post-op appearance  308f Redivacs in  307f–308f V VAC see vacuum-assisted closure vacuum dressing fenestration skin graft technique  93f negative pressure dressing support  95f vacuum-assisted closure (VAC) of abdominal wall defect  89f bony defect around knee joint  135f dressing  9f of necrotising fasciitis of groin  271f Velband  48f venous filling, excess  4f–5f 326 venous flow in carpal tunnel release  51f vicryl sutures  103f V-Y apposition  143f, 182f, 209f, 312f V-Y closures of infraorbital region  153f inner canthal KPIF  239f of temporal region  153f V-Y tension points  80f W Wolfe graft, fenestrated  302f wound closure, dog-ear revision in  13–14 wound drainage equipment  28f major  26–27 set-up components  26f sites  29f syringe suction system  28–31 tube cutting  29f tube insertion  30f wound preparation  pre-wash technique  sterilisation in  6f wrist  300–302 FFTG  301f HEMMING suture  301f X X-ray, mallet deformity  110f Xylocaine  58 Y Y-connector  26f yin-yang double KPIF  120–123, 132f FEPS in  121f–122f second stage of  122f Z Z-flap mark-out  99f Zimmer dermatome  58 Z-plasty  99–101 ... 20 13 The cervico-submental keystone island flap for loco-regional head and neck reconstruction J Plast Reconstr Aesthet Surg 66, 23 28 SURGICAL TIPS AND SKILLS 151 ADVANCED 1/3 DRAPE procedure... infraorbital neurovascular supply, a part of the V2 embryological dermatome The flap is undermined superiorly and rotated inferiorly Notes _ SURGICAL TIPS AND SKILLS 1 52 _ ... _ SURGICAL TIPS AND SKILLS _ _ _ 157 ADVANCED 4/4 INTRAOPERATIVE SURGICAL TIPS AND SKILLS 158 DRAPE procedure
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Xem thêm: Ebook Surgical tips and skills (1st edition): Part 2, Ebook Surgical tips and skills (1st edition): Part 2, Closure of dorsal hand defect (KPIF) – case series no. 8, Delayed facial nerve neuropraxia following SCC excision – McLaughlin tarsorrhaphy – case series no. 9, DRAPE procedure as salvage for recurrent disease – case series no. 10, DRAPE procedure – malar melanoma – case series no. 11, DRAPE procedure – melanoma of the cheek – case series no. 12, DRAPE procedure – melanoma of the forehead – case series no. 13, DRAPE procedure – melanoma of the temple – case series no. 14, DRAPE procedure – morphoeic BCC of (R) and (L) temples – clinical series no. 15, Ear surgery – simple ear dressing technique – case series no. 18, Facial mitotic lesions – BCC on the forehead – case series no. 19, Facial mitotic lesions – preauricular BCC – case series no. 20, Facial nerve palsy – McLaughlin tarsorrhaphy as a delayed procedure – case series no. 21, Fingertip injuries – reconstruction of multiple digits – case series no. 23, Fingertip injury – donor site harvest of full thickness skin graft – case series no. 24, Fingertip injury – neurovascular island flap-on-flap reconstruction – case series no. 25, Forearm melanoma – circumferential KPIF – case series no. 26, Gouty tophi of the thumb – case series no. 27, Harvesting conchal cartilage for CMC arthroplasty – case series no. 28, Head and neck – atypical fibroxanthoma on the scalp – KPIF (AFX) – case series no. 29, Head and neck – closure of a large head and neck defect with an island deltopectoral flap (IDPF) and KPIF from the cheek – case series no. 30, Head and neck – large melanoma defect (8 × 6 cm) of the (L) cheek repaired with KPIF – case series no. 31, Head and neck – neck defect in an irradiated field – pectoralis major island flap – case series no. 32, Head and neck – parotid defect – posterior nuchal KPIF – case series no. 34, Head and neck – periparotid defect – cervicosubmental (CSM) KPIF – case series no. 35, Head and neck – radionecrotic (R) neck ulcer – case series no. 36, Head and neck – SCC of the external auditory canal – case series no. 37, Inner canthal KPIF – case series no. 38, Lateral malleolar defect (tattoo removal) – case series no. 39, Lateral malleolar orthopaedic defect – closure with KPIF Ω variant – case series no. 40, Lip defect – closure after SCC excision – case series no. 42, Malar eminence mitotic lesion treated with crescentic excision – case series no. 44, Nasal bridge defect – case series no. 45, Nasal defect – large composite graft to alar – case series no. 46, Nasolabial fold – recurrent morphoeic BCC – case series no. 47, Necrotising fasciitis of the groin – case series no. 48, Palmar trauma – KPIF closure – case series no. 50, Post mastectomy reconstruction using a KPIF – case series no. 51, Sacral pressure area – closure with a gluteus maximus KPIF – case series no. 52, Tendon repair – modified Kessler technique – case series no. 53, Trophic ulceration – buttock treated with a KPIF – case series no. 55, Trophic ulceration – greater trochanteric area – case series no. 56, Trophic ulceration – olecranon (elbow) – case series no. 57, Trophic ulceration – wrist – case series no. 58, Trunk defect – case series no. 59, Variation of locking mattress suture – case series no. 62

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