(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