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

(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,...

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

Closure of dorsal hand defect (KPIF) – case series no 8

the ‘pinch test’ indicates maximum tissue

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

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 _ _

Closure of dorsal hand defect (KPIF) – case series no 8 2/3

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

Figure 4: Closure with V–Y apposition with drainage The mark-out shows the course of the radial cutaneous nerve, which has been preserved

Figure 5: Release of the tourniquet showing the paradoxical hyperaemia (PH)

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Figure 7: Appearance at 6 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

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Duet procedure done in association with

Professor Andrew Sizeland

Introduction

In head and neck reconstruction, KPIF

closure of large defects of the cheek in

which the facial nerve has been sacrificed

Delayed facial nerve neuropraxia following SCC excision

– McLaughlin tarsorrhaphy – case series no 9

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 × 6 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

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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

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3 weeks

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Figure 4: The appearance on completion

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Delayed facial nerve neuropraxia following SCC excision – McLaughlin

Outcome

Approximately 35-minute procedure Return

of total comfort without complication

Figure 5: Postoperative image showing the closure protecting the exposed pupil

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Closure with a cervico-submental KPIF.

Duet procedure in association with Dr

Sorway Chan (surgical oncologist)

Introduction

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

DRAPE procedure as salvage for recurrent disease –

case series no 10

reconstruction becomes incorporated into the oncological clearance

Problem

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 8 × 5-cm defect prior to closure

Notes _

DRAPE procedure as salvage for recurrent disease – case series no 10 2/4

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 _

Figure 4: The staged insertion

of the CSM flap, with the hypervascular changes, evidence of reactive hyperaemia

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

Figure 7: Appearance 12 months after XRT

Outcome

Notes _

DRAPE procedure as salvage for recurrent disease – case series no 10 4/4

75 minutes for this DRAPE procedure The

patient was happy to resume work in the

public domain Complications of a

Figure 8: 14 months post-op

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

KPIF for closure post resection of

melanoma over the malar eminence

Introduction

The DRAPE was employed here for

oncological clearance for an incompletely

Figure 1: Resultant defect measuring 3 × 2 cm following tumour clearance

Notes _

Solution

The DRAPE acronym stands for Delayed

Reconstruction After Pathology Evaluation

with H+E accuracy and not frozen section speculation

Figure 2: Mark-out of the KPIF based on the infraorbital neurovascular supply, a part

of the V2 embryological dermatome The flap is undermined superiorly and rotated inferiorly

Notes _ _

DRAPE procedure – malar melanoma – case series no 11 2/3

Figure 3: The omega (Ω) variant or horseshoe shape is turned into the line of the upper eyelid

Figure 4: V–Y closures of the temporal region and the infraorbital region

Figure 5: The final post-op appearance with drainage

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50 minutes for the subsequent procedure

The patient was pain free; the upper eyelid

felt tight but improved due to the resolving

oedema after the three procedures: 1) the

incomplete excision, 2) the DRAPE procedure and 3) the final KPIF reconstruction No recorded complications aside from the slowly resolving oedema

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

DRAPE is an acronym for Delayed

Reconstruction After Pathology Evaluation

It is a necessary technique in oncology

management, particularly in Hutchinson’s

melanotic freckle, where satellite lesions on

the face are a recurring problem

If a definitive reconstruction is completed

on the day (in spite of the limitations of

DRAPE procedure – melanoma of the cheek – case

an extensive reconstruction problem Thus, performing a DRAPE procedure eliminates this complication

Problem

Pathology clearance – DRAPE procedure

Figure 1: The incomplete histological clearances of melanoma of the (L) cheek (sites 1, 2, 3) DRAPE is the recommended management of melanoma

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Solution

Figure 2: The incomplete margins (1, 2, 3) have been re-excised creating a defect

~11 × 6 cm Note the out of the cervicosubmental KPIF including the

mark-supraclavicular point where the external jugular vein is demarcated and must be preserved for venous drainage purposes

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at the anterior border of the sternomastoid incorporating branches of the cervical plexus and external carotid perforators, including the superior thyroid artery These CSM flaps extend across the mid-line to reach the malar eminence on rotation

Notes _

Figure 4: Characteristic paradoxical hyperaemia (PH)

in spite of 90° rotation

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Figure 5: On completion Note other canthal angulation to minimise postoperative ectropion pull

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60 minutes for reconstruction phase She

was so pleased with her appearance the

patient thought nothing further was

necessary (thus trimming of the dog ear was declined) No recorded complications

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

Closure with a cheek rotation KPIF based

on the V2 embryological dermatome

Introduction

Superficial spreading melanoma (HMF) is

a problem, particularly in the elderly The

prognosis in the 80+ age group becomes

more ominous with the spread of the

DRAPE procedure – melanoma of the forehead – case

Figure 2: Staged excision

of the lesion to achieve clearance with a resultant triangular defect measuring

Solution

Hence, the DRAPE procedure is employed

Notes _

Figure 4: The raised island flap revealing keystone paradoxical hyperaemia (PH) signs even though the flap is quadrilateral in design

Notes _

Figure 5: The insertion and closure of the flap The timeframe for the procedure is shown (45 minutes)

Notes _

DRAPE procedure – melanoma of the forehead – case series no 13 3/3

now enjoy a normal life in the social community No complications

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

Figure 6: Early postoperative appearance

Approximately 45 minutes for the

reconstruction procedure The patient can

Outcome

Figure 7: Late postoperative appearance The alternative of free flap reconstruction in such a defect may not be aesthetically pleasing to the patient

Spindle cell variant of melanoma to the (L)

design in the upper part

Introduction

This elderly patient, suffering from

lymphoma, had a problem with a mitotic

change over the left temple (spindle

cell melanoma), reflecting the

immunosuppressant consequences of his

chemotherapy

Problem

A melanoma of the left temple with wide

excision and concern for pathological

DRAPE procedure – melanoma of the temple – case

series no 14

clearance; hence, a DRAPE procedure was followed

Solution

This 6 × 4-cm defect down to the zygomatic

closure That is, the two advancing limbs were turned on themselves in the shape of

a ‘U’

Figure 1: The defect (after the DRAPE procedure)

Notes _

Figure 2: The quadrilateral cheek flap is raised with its superior poles fashioned into

a horseshoe to facilitate closure overlying the V2 embryological axis

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DRAPE procedure – melanoma of the temple – case series no 14 2/3

Figure 3: Creation of the Ω variant at the apex

Figure 4: Post-op appearance at 6 days

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

Multifocal deposits of basal cells are the

reason why morphoeic basal cells are

commonly mismanaged as a result of

incomplete excision The value of the

stretch test, pearly margins and venular

appearance is to provide a diagnostic

DRAPE procedure – morphoeic BCC of (R) and (L)

temples – clinical series no 15

clue before the DRAPE procedure is commenced

Problem

Diagnosing the limits of a morphoeic basal cell carcinoma

Figure 1: Morphoeic BCC (R) malar temporal region

Figure 2: (L) malar/temporal region on stretch

Figure 4: Macroscopic out of the L side

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DRAPE procedure – morphoeic BCC of (R) and (L) temples – clinical series no 15 3/5

Figure 5: The Bezier (curvilinear V–Y) island flap for closure of the defect – R side

Figure 6: The Bezier (curvilinear V–Y) island flap for closure of the defect – L side

Figure 7: The immediate post-op appearance – R side

Figure 9: Early post-op appearance at ~8 weeks – R side

Notes

DRAPE procedure – morphoeic BCC of (R) and (L) temples – clinical series no 15 5/5

Approximately 30 minutes for initial

excisions 5 days later, the DRAPE

procedure was extended for ~1 hour,

saving the skin graft appearance on the

face Complicated by slight vascular impedance in the right temporal Bezier, which resolved

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 Journal of Surgery 82 (11), 780–785

Behan, F.C., Terrill, P.J., Breidahl, A., Cavallo, A., Ashton, M., Bennett, T., et al., 1995 Island fllaps

including the Bezier type in the treatment of malignant melanoma ANZ Journal of Surgery 65,

Preauricular sinus is prone to recurrent

infections and is usually operated on during

its non-inflammatory (quiescent) phase The

full limits of the rabbit warren must be

removed to obviate repeat infections

Problem

Preauricular sinus in a quiescent phase

(without evidence of active inflammation

Ear surgery – preauricular sinus procedure – case series

Notes _

A malleable ophthalmic probe may also be

used to find the limits of the fine channels

of the preauricular sinus without breaking

the integrity of the epidermal lining (which creates recurrence)

Figure 2: The defect size An ophthalmic probe can be useful for the finer limits of the embryological deformity

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Ear surgery – preauricular sinus procedure – case series no 16 2/2

Figure 3: Defect size following removal of the tattooed pathology

Figure 5: The layered dressing over the ear The segment of tulle gras cut to resemble pantaloons, with gauze of the same shape, can fit over the supra-auricular site to cover the wound, stabilised with layered elastoplast

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Figure 4: The HEMMING suture closure with mattress apposition for stability

Outcome

Approximately 15-minute procedure For the

first time in 20 years, a preauricular ooze

ceased Loops were cut at 7 days, mattress sutures out at 10 days No complications

Large defects of the scaphoid fossa of the

ear, after pathological clearance, can be

repaired by simple grafting However,

instead of a full thickness skin replacement

to cover the cartilaginous and skin

Ear surgery – scaphoid fossa reconstruction technique using a postauricular KPIF – case series no 17

pathology removal, another solution is a postauricular KPIF, which is transposed through the postauricular defect This is performed in a tertiary referral centre

Problem

Solution

Figure 1: Mitotic lesion of the scaphoid fossa creating a surgical defect, including removal of cartilage, of an area 2 × 4 cm Postauricular KPIF totally islanded and fed through the postauricular groove Note the blue line delineates the de-epithelialised segment The anterior half covers the scaphoid fossa and the posterior half is attached

to the post auricular section behind the helix

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Figure 2: The emerging flap covers the scaphoid defect

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Ear surgery – scaphoid fossa reconstruction technique using a postauricular

Figure 3: Definitive suturing

of the flap into the scaphoid defect

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Outcome

Approximately 35-minute procedure with

full anatomical continuity achieved

Potential complication of new hair growth over the scaphoid fossa may need

intermittent trimming

Figure 4: Sewing the postauricular KPIF flap (divided by a de-epithelialised lined segment) to facilitate anterior and posterior closure and restore epithelial

continuity Note the red dot sign (RDS), a significant feature of the hypervascularity (PH) of island flaps

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Ear dressings are a problem A crepe

around the head, if too tight, is socially

painful but often used, firmly applied, to

Solution

Figure 2: Tulle gras cut in the shape of pantaloons

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Ear surgery – simple ear dressing technique – case series no 18 2/4

Figure 3: Folded onto the anterior and posterior cut surfaces

Figure 4: The technique is repeated with absorbent cotton gauze

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Figure 6: Before application

to stabilise the dressing, this gesture facilitates adhesion to the gauze

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Figure 5: The elastoplast is pared using angled Mayo scissors without crinkling With the scissors at 45°, the elastoplast can be cut and supported by sticking to one blade This gesture allows the elastoplast to hang freely to

be applied appropriately The tape can be laid discreetly with one gesture and repeated if necessary

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Outcome

Approximately 10-minute procedure No

surgical recall for excessive oozing Fully

healed without complication

Mitotic skin changes of the forehead are a

common problem in the elderly There are

multiple local flaps that can provide a

solution to the problem In this case, the

Facial mitotic lesions – BCC on the forehead – case

Notes _

Solution

KPIF of the (L) forehead region above, and

otherwise a keystone below, would give

Notes _ _

Facial mitotic lesions – BCC on the forehead – case series no 19 2/3

Figure 3: Strategic mattress suturing (SMS) to align tissue planes

Figure 4: Closure with HEMMING sutures with exaggerated eversion to achieve dermal apposition

The nasal defect reflects another tumour removal closed with a (R) supraorbital keystone based on the glabellar circulation turned 90°

to reach the tip of the nose, covering the defect The nasal defect closure will be

discussed separately (see also Case series no 45)

Notes _

45-minute procedure Normal forehead

appearance Normal supraorbital sensation

with tumour clearance

Excision and direct closure on the face,

though a possible surgical manoeuvre,

creates a linear scar that is more visible

than a curvilinear design Mitotic lesions

over the angle of the mandible, when

Facial mitotic lesions – preauricular BCC – case series

no 20

excised, give a disfiguring straight scar on the facial tissues that is always visible The use of the keystone island flap provides an island flap solution, particularly in the loose tissue of the elderly, with the scars fitting into the aesthetic lines

Problem

Figure 1: Multifocal, proven BCC (L) angle of the jaw

Solution

Figure 2: Excision of the tumour beyond the delineated margin as a precaution, carving out the tumour down

to almost the parotid fascia

When such lesions are excised,

it is best done in the shape of the keel of a boat so

maximum depth behind the lesion is achieved while preserving the emerging mandibular branch of the facial nerve in the vicinity

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