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

(BQ) Part 1 book Surgical tips and skills presents the following contents: Exsanguination problems in hand surgery, darpal tunnel open technique, fenestrated full thickness graft, drain tube identification with site specificity, cutting diathermy technique, dorsum of hand surgical closure technique,...

‘The reward of a thing well done is to have done it.’

RALPH WALDO EMERSON

‘Today's heresy is tomorrow's orthodoxy.’

HELEN KELLER

This image shows the 20 triangulate faces of this polyhedron which are a reflection of the versatility of this design concept, more variations of which are illustrated in this text, which is really a second volume of the KPIF principle

surgical

tips and

skills

Felix C Behan FRCS, FRACS

Associate Professor of Surgery

University of Melbourne

Plastic and Reconstructive Surgeon

Department of Surgical Oncology

Peter MacCallum Cancer Centre

Melbourne, & Western Health

Sydney Edinburgh London New York Philadelphia St Louis Toronto

is an imprint of Elsevier

Elsevier Australia ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 This edition © 2014 Elsevier Australia

This publication is copyright Except as expressly provided in the Copyright Act 1968 and the Copyright

Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher.

Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible The publisher apologises for any accidental infringement and would welcome any information to redress the situation.

This publication has been carefully reviewed and checked to ensure that the content is as accurate and current

as possible at time of publication We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication.

National Library of Australia Cataloguing-in-Publication entry

_

Author: Behan, Felix C., author.

Title: Surgical tips and skills / Felix Behan.

Content Strategist: Larissa Norrie

Senior Content Development Specialist: Neli Bryant

Project Managers: Karthikeyan Murthy and Rochelle Deighton

Edited by Linda Littlemore

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The skills of a plastic surgeon are acquired

in many ways Most surgeons learn their

craft from an experienced surgeon and then

modify their practice in the light of their

own experiences It is not surprising that

changes in operative technique usually

occur slowly, only changing rapidly when

a new technology is introduced This has

been most obvious in plastic surgery in the

emergence of microsurgery, which has

provided a method for the reconstruction of

many major defects Unfortunately, simpler,

more traditional classical methods of tissue

transfer involving less operating time and

hospitalisation are sometimes forgotten

Almost 100 years ago, a Melbourne plastic

surgeon, Jerry Moore, wrote a seminal book

entitled Plastic Surgery based purely on his

own personal experience and innovation It

is pleasing to be asked to write a foreword

to an equally important book, Surgical Tips

and Skills by Felix Behan, which may also

change the face of plastic surgery Like

Moore, Professor Behan is an original

thinker, and some 40 years ago he realised

it is possible to raise composite flaps using

embryological dermatomes, as these include

skin, neurovascular tissue, lymphatics and

fascia He gradually developed his own

ideas of local tissue rearrangement based

on this principle, enabling him to close

defects that were previously irreparable My

late brother Robert Marshall, surgeon and

anatomist, grasped this principle of the

vertical orientation of the circulation of the

skin and underlying tissue, and was

sufficiently impressed to include it in his

book, Living Anatomy, Structure as a Mirror

of Function, in 2001 Mr Marshall observed

to the author that the improved vascularity

in these island flaps may be a local

sympathectomy effect

Professor Behan has continued his

innovative approach for more than 40

reconstructions using local fascio-cutaneous keystone flaps together with many relatively simple but neat surgical tips to improve surgical outcomes This book is divided into three sections, Basic, Intermediate and Advanced, and there is something in it for aspiring surgeons as well as for the most experienced The Basic and Intermediate sections contain many surgical tips, including suturing techniques, harvesting

of skin grafts and their applications, simple means of immobilisation and innovative methods of establishing drainage to improve the results of many plastic surgery procedures The Advanced section has beautifully illustrated examples of keystone fascio-cutaneous flap reconstructions, which many experienced surgeons would be pleased to claim as their own

Plastic surgery has changed over the past

50 years, becoming dominated by cosmetic surgery and microsurgery with a decline

in the art of local tissue repair, which is the fundamental basis of plastic surgery It is

to be hoped this book may stimulate a resurgence of the more classical aspects of the specialty With the passage of time and tightening of resources, there will inevitably

be more scrutiny by health administrators of the cost of plastic surgery procedures It will become increasingly difficult to justify operations that require expensive resources, multiple surgeons and prolonged operating times, when there are simple, less expensive alternatives readily available that produce results often superior in terms of function and appearance Professor Behan has shown the way – plastic surgeons need to sit up, take notice and embrace local fascio-cutaneous island reconstruction as

an alternative to microsurgery or risk losing

a large part of our specialty

Foreword

All surgeons enjoy discussing and

evaluating surgical techniques Innovative

means of practising their craft are a

constant stimulus They also value the

visual and even graphical demonstration

of surgical procedures, as comprehensively

illustrated in this text

This surgical interest ranges from the

simple to the complex A simple procedure

done well that produces a functional

outcome is as important as a major

reconstruction after resection of a cancer

Felix Behan has vast experience in

both simple and complex reconstructive

techniques, honed by many years of

practice at the Peter MacCallum Cancer

Institute and the Western Hospital in

Footscray, Melbourne His work has

encompassed both community trauma,

including orthopaedics, and melanoma

and other malignancies

He worked as a senior plastic and

reconstructive surgeon at both these places

for almost 40 years, but his contribution has

been much more than the conventional

His techniques were noted to be original,

and were carried out expeditiously with

wonderful outcomes, as comprehensively

illustrated throughout the text in the

Basic, Intermediate and Advanced sections

His work was initially regarded as

idiosyncratic and was attributed to his

innate skill in dealing with and repairing

tissue with the keystone techniques

However, it is an accepted truism that a

surgical technique that cannot be taught

will have minimal impact on surgical

science without publication in the

international literature

I take some pride in having encouraged

Felix to document his work scientifically, to

classify it in a way that allows independent

evaluation and, thus, to publish it for wider

scrutiny of the keystone reconstructive

principle

The rest, as they say, is history, and now surgeons all over the world have learnt the simple but precise principles

of reconstruction as developed by Felix Behan The photographic details in each section of this book will make the learning process even simpler

His work has been published in the surgical literature and in previous textbooks, and he has presented his work around the world at multiple clinical meetings

I am pleased to write the Foreword to

this new volume, entitled Surgical Tips and Skills, which adds extra detail to these

surgical techniques that have now been accepted internationally Understanding the principles behind the effective reconstruction of a skin defect is critical for a good outcome This textbook is filled with handy hints and clever surgical techniques to enable both the surgical tyro and the experienced surgeon to develop and amplify their reconstructive skills

Few surgeons can claim a real advance

in surgical technique This volume indicates that here is one surgeon who has made a real contribution Through his photographs, drawings and notes, this conclusion is made clear I commend Felix Behan for his

innovative work The many patients who have benefited from his innate skill and techniques will be forever grateful for his ability, intelligence and endeavours, as will those in the future as other surgeons

embrace these principles Surgical Tips and Skills is really a summary of his work

as a reconstructive surgeon in this second volume focusing on the keystone perforator island flap concept

Robert J S Thomas Distinguished Fellow in Surgical Oncology

Peter MacCallum Cancer Centre

Melbourne

Foreword

regions of the body, has created a ‘How To Do’ guide on some reconstructive facets that others find difficult It is interesting that

the Annals of the Royal College of Surgeons

of England is now in the 10th year of

‘Technical Tips’ – meaning people like to read pearls of wisdom The science of the keystone has many elements, with recent publications looking at the evidence – the flaps are closed under tension and the vascular dynamics characteristically displayed contradict established principles of plastic surgery, requiring further elucidation The anatomical construction of skin, fat and fascia, a prerequisite to any successful keystone flap, is indispensable and the mark-outs within the dermatomes echo the embryological development of the human

Speaking in Paris recently, a senior plastic surgeon, Dr Arnoldo Fournier, said to me:

‘Felix, you have captured the art of reconstruction by these principles’ He was referring to the fact that every keystone aligned along the dermatomes has both somatic and autonomic support to supplement the arterial and venous connections while not negating any lymphatic and humeral input Microsurgery

is based on an artery, a vein and possibly

a nerve and thus has a different structural arrangement Historically I must publicly recognise the contribution of Professor Gordon Clunie in relation to the publication

of scientific material as editor of the ANZ Journal of Surgery He told me that with any new scientific principle “launch it locally, and you will get full recognition” His other famous recommendation was “if you have anything to say in print, find the time to publish” Professor Bob Thomas also gave

me sound advice in 2003, when the first article on the keystone was submitted to the

ANZ Journal of Surgery with multiple

authors He said, “This is a good idea It’s

Surgical Tips and Skills is a compilation

covering aspects of surgical development

with ongoing refinements in surgical

technique based on experience The fact

that one keeps seeking higher standards of

surgical outcome leads one to question

one’s own ability Eventually, the

accumulation of this experience bears fruit

One has only to compare the techniques

and achievements of one’s earlier years to

see the advantage of this maturation

process

This text is essentially a summary of 40

years of experience practising surgery in

both the public and the private domains

The advent of digital photography

supersedes reams of text, which are

sometimes hard to comprehend The

alphabetical sequence, common to modern

surgical textbooks for ready reference,

is an attempt to cover the gamut of

reconstructive cases that present in any

surgical domain, based on one central

tenet: the simplest way is usually the best

With the advantage of external reviewers,

the levels of expertise were factored in to

create three sections of the book covering

Basic, Intermediate and Advanced stages

of this technical development The text also

includes a comprehensive index

As a consequence, the principles of

evidence-based medicine – initiatives to

improve health management and health

outcomes while reducing health costs – are

reflected in all these cases, with Level 5

(expert evidence and opinions) and Level 4

(retrospective case series) All the singular

cases illustrated are just examples of the

many that have been compiled and have

either been presented internationally at

meetings or are in the process of separate

publication, or both

This compilation, drawn from

approximately 3000 keystone flap

a means of illustrating how to employ these

techniques I hope this straightforward,

comprehensively illustrated presentation will

encourage many more of my colleagues,

at whatever stage of their careers, to

in conjunction with microsurgical expertise

This Surgical tips and skills is a

companion volume to the first publication:

Keystone perforator island flap concept.

Surgical Tips & Skills is really a companion

textbook to our first publication, The

Keystone Perforator Island Flap Concept

Some have even called it ‘Volume II’ in view

of its extensive range of cases featuring this

KPIF principle

I must acknowledge first and foremost

all the patients and the referrals from

my oncologist and surgical colleagues,

Professor Andrew Sizeland, Associate

Professor Steve Kleid and Dr Sorway Chan

at Peter MacCallum, together with Professor

Steve Chan and Associate Professor Trevor

Jones, and the members of the orthopaedic

team, including Associate Professor Ray

Crowe and Associate Professor Chris Harris

at the Western Hospital The patients have

repeatedly said they are grateful for the

work we have all achieved, and without

reservation they gave me permission to

compile and use a photographic record of

these cases to detail these reconstructive

manoeuvres and ‘help anyone else like us’

Next I must publicly acknowledge the

staff at both these institutions, from the

wards, from theatre and the clinics, at both

the surgical and the nursing levels Without

their input, of course, the clinical success

could not have been assured

I am grateful for the invaluable help

offered by the library staff at the Western

Hospital for researching almost every aspect

of every reference used in the text

It was my French colleague, Dr T Boukris, who originally suggested the term

‘omega variant’ for the horseshoe-shaped design used throughout

I am also grateful for the technical expertise and assistance of the following:

• Kevin Tan, for his IT expertise, who compiled the initial submission of the text, constructing the alphabetical sequence of cases

• Ashwini Supperamohan as an Editorial Assistant who in the intermediate phase composed the initial quartet arrangement

of the clinical images from my extensive photographic records to make the text

as clear as has been achieved in this format

• Andrew Sanderson, also as an Editorial Assistant, who contributed to the penultimate stages of preparation including drawings

• Margaret Clancy, who refined the final text with me to produce the end result as

a readable, logical and easily accessible format

I am also indebted to all the confidential reviewers for their constructive suggestions, which resulted in the progression of cases spread over three tiers of competency This may help explain the format

Lastly I must acknowledge the tolerance

of my wife, Mariette, for my hours and days

of absence during this compilation period

Acknowledgments

Reviewers

Peter F Burke MBBS (Melb) FRCS (Eng) FRACS FACEM DHMSA

Senior Consultant Surgeon, Latrobe Regional Hospital, Traralgon, VIC, Australia

Steven Chan MBBS PhD (Lond) FRACS

Professor of Surgery, The University of Melbourne, NorthWest Academic Centre, VIC, Australia

Tim Francis BSc MBBS FRACGP

General Practitioner, Nambucca Heads, NSW, Australia

Sarah-Jane McEwan BMed DCH FRACGP FARGP AdvDRANCOG FACRRM CertClinEdDistrict Medical Officer, Hedland Health Campus, Port Hedland, WA, Australia

Julian Peters BMedSci (Hons) MBBS, FRACS (Plast)

Senior Consultant Plastic Surgeon, The Royal Melbourne Hospital, Parkville, VIC, Australia

AFX atypical fibroxanthoma

DRAPE delayed reconstruction after pathology evaluation

FFTG fenestrated full thickness graft

HEMMING horizontal everting mattress method of suturing

KPIF keystone perforator island flap

ODEL ocular design with extended limbs

SFPF skin/fat/platysma/fascia – the basis of the CSM

SMAS superficial muscular aponeurotic system (facial tissue)

SMLS strategic mattress locking sutures

Acronyms used throughout the text – key words

The biggest problem with hand surgical

tables is the underlying sterile, waterproof

sheeting, which allows sliding of the

multilayered drape coverings

Problem

The green drapes on a hand table are

unstable because of the plastic

waterproofing in the deep layer

Solution

Staff at the vascular unit of the Western

Hospital place towel clips below the level

Draping technique for hand surgery operating table

of the soft rubber mattress to create a drum effect at the four corners, providing a comfortable, stable operating surface

The ‘cut-off’ green drape at the advancing side of the table, above the wheels, is driven into the side of the operating table with the patient’s arm elevated, and this is closed around the region just above the cubital fossa The long drapes between the drip poles, from the pillow to the foot, separate the anaesthetic area from the operating area

Figures 1, 2: The use of towel clips at each corner eliminates

sliding of the drapes and creates an even surface for

photography

Notes _

Draping technique for hand surgery operating table 2/2

Figure 3: The cut-off drape closed just above the cubital fossa and the normal instrument set-up

Notes _ _

Outcome

A better operating field

Bibliography

Green, D.P., 2005 Chapter 1: ‘General principles’ In: Green, D.P., Hotchkiss, R.N., Pederson, W.C.,

Wolfe, S.W (Eds.), Green’s operative hand surgery, fifth ed Elsevier Churchill Livingstone, Philadelphia,

pp 3–24

As a preamble to hand surgery, a firm

but not excessively tight tourniquet is

applied, before exsanguination, over the

Exsanguination problems in hand surgery

biceps region to prevent any venous dilatory impedance

Problem

Figure 1: Application of a tight pneumatic band before exsanguination produces venous filling and presumably stasis This negates the effectiveness of the Rhys-Davies exsanguinator Excess venous filling may prevent a completely exsanguinated field being achieved

Notes _ _

Figure 2: The presence of excess venous filling because the tourniquet in situ has been applied too tightly before exsanguination The firm tourniquet must slide up and down the biceps

Notes _

Start again Release the tourniquet,

minimise any filling and reuse the

Rhys-Davies exsanguinator to produce

a bloodless field If the tourniquet is too

loose before pressure application, leak invariably occurs during the procedure

There’s nothing like having to reapply the tourniquet because of an oozing field in

a difficult Dupuytren’s dissection

Outcome

Failure to perform this manoeuvre often

results in tourniquet leak

Figure 3: Release the tourniquet at the Velcro®

fitting sufficiently so that it is still firm but loose enough to slide up and down the biceps segment of the upper limb

Notes _

Figure 4: Excess venous filling minimised

Notes _ _

Bibliography

Green, D.P., 2005 Chapter 1: ‘General principles’ In: Green, D.P., Hotchkiss, R.N., Pederson, W.C.,

Wolfe, S.W (Eds.), Green’s operative hand surgery, fifth ed Elsevier Churchill Livingstone, Philadelphia,

pp 3–24

Every surgical wound, dirty or otherwise,

is prepared with a pre-wash using Savlon,

Betadine® or alcoholic solutions before

commencing the procedure

This is applicable to any surgical site,

particularly the head and neck, hands and

Macroscopic removal is best done to eliminate any nidus of potential infection harboured in the contaminants using soft cotton towelling (not paper)

Figure 1: The cleaned hand, now ready to be sterilised

Notes _

If you start with iodine, stick with iodine; if

you start with Savlon, stick with Savlon Do

not interchange cleaning solutions as they

may cross-react and become ineffective

Outcome

A lower rate of postoperative infective wound infection complications

A general surgical referral with tissue

necrosis of the integument occur

periodically The aroma in theatre can be

overwhelming to theatre staff, sometimes

numerous staff, even though any likelihood

of sensitivity to the aroma amongst the staff

Unpleasant aromas in theatre

has been excluded Application of a deodorant for the surgeon’s comfort does not extend to the other theatre staff

Problem

How to deal with the odour

Figure 1: The ‘aromatic’

surgical problem of necrosis of the abdominal wall

Notes _ _

Add 100 mL of eucalyptus oil to a bucket

of warm tap water (approximately 60°) This

oil becomes aromatic at 49° However, to

increase diffusion throughout the operating

theatre suite, an oxygen source can be directed from the anaesthetic machine into the eucalyptus oil solution to increase permeation and social relief

Figure 2: The anaesthetic machine delivering 8 L of oxygen per minute

Notes _

Figure 3: Tubing connecting the anaesthetic machine to the eucalyptus solution bucket increases the aeration and deodorising effect

Notes _ _

Figure 4: Completion of the debridement of the abdominal wall necrosis

Notes _

Figure 5: Resultant defect awaiting VAC dressing and reconstruction with skin grafting

Notes _ _

Outcome

Approximately 5 minutes to set up, resulting

in a tolerably acceptable theatre

environment

Besides punch biopsies, the definitive biopsy

excision provides a solution to the problem

when there is clinical suspicion of a mitotic

lesion

Problem

Closing the wound without dog ears

Aesthetic closure – ocular design with extended

limbs (ODEL)

Solution

The ocular design with extended limbs (ODEL) accommodates the tightness of the redundant tissue at the extremes of the

‘ellipse’

Figure 1: BCC (L) jawline

Notes _ _

Figure 2: Design of the biopsy ODEL, as above

Notes _ _

Aesthetic closure – ocular design with extended limbs (ODEL) 2/3

Figure 3: A single layer everting mattress suture closing the ocular defect and eliminating dog ears

Figure 4: Two additional mattress sutures before the Horizontal Everting Mattress Method of suturING

(HEMMING) suture create sound eversions as a haemostatic closure

Notes _ _

Removal of the dog ear in a refined way

minimises extensive back cutting Dog-ear

removal is an ever-recurring surgical

problem and, if performed without

adequate expertise, can ‘chase itself’,

increasing the length of the scar This

method of creating a pyramid, which is

converted to a triangle, limits any gross

extension of the surgical incision

Dog-ear revision in wound closure

(b) creating a triangle by dividing along the base in the crease line; (c) overlapping the isosceles triangle to match the incision is the guide on how much tissue to removeTwo mirror image

triangles are created with tension by the skin hook Cut along the base of one side.

Removal of the ovelap tissue eliminates the dog ear

Use a skin hook to lift this redundancy to

create a pyramid with two mirror image

triangles Cut along the base of one side

(Figure 1b)

The unfolded, elevated tissue can then

be laid across the incision at the end of the

covers the surgical incision The redundant triangle is excised by joining the extremes of the wound underneath using a pre-incisional blue line as a guide

This single manoeuvre, performed in this manner, minimises the problem of chasing

Figure 2: A clinical application

of this technique on the face

On other parts of the body, the same principles apply

Notes _ _

Figure 3: A close-up view of the back cut after removal of the redundant flap The size does not warrant suturing in this case

Notes _ _

Summary: Convert the pyramid to a triangle

and cut along the base and excise the

Recurrent tumours of the inner canthal

region are a difficult problem The principle

of the DRAPE procedure is ever so useful

for guaranteeing clearance before the

Fenestrated full thickness graft

operation In this case, the defect was repaired by a fenestrated full thickness graft

_

_ _

Solution

Fenestrated full thickness graft (Wolfe) from

the preauricular groove

Figure 2: Delayed reconstruction after pathology evaluation (DRAPE) procedure performed on clearance of the pathology

Notes _

_

_ _ _ _

_ _

Figure 4: The insert, like a watch glass and a pocket watch, as described by Wolfe

in 1872 and published in the Glasgow Medical Journal in

1883 It needs a superficial tulle gras dry gauze dressing

Notes _ _ _

Outcome

Approximately 45 minutes for the

subsequent procedure with eventual full

recovery A basisquamous SCC developed

in 12 months at the inferior margin of the wound, indicating a multifocal mitotic state

Wolfe, J.R., 1883 Glasgow Medical Journal 5, 200–211

Wolfe, J.R., 1884 Clinical demonstrations on ophthalmic subjects J & A Churchill, London

Stabilisation of a drain tube traditionally has

been achieved by using 3-0 silk However,

the intrinsic property of the silk, as a

braided material, means that it is always a

potential source of contamination, possibly

leading eventually to some wound infections

in the vicinity

Problem

Complications of the use of braided 3-0 silk

and the potential for infection

Drain tube fixation without silk

Solution

Monofilament 3-0 nylon is a simple solution, but must encircle the drain tube according to a certain knotting sequence

The nylon must: a) attach the tube firmly

to the integument avoiding any tissue necrosis with too much pressure; b) be looped around the tube and sealed on the original knot and secured by a reef knot closure

Figure 1: The nylon is used to firmly attach the tube to the epidermal surface, without undue pressure and sealing it with a reef knot to prevent slide

Figure 2: A reef knot seal

Notes _

Figure 4: The loose strands are firmly tied before sealing the reef knot (left and right, then up and down the tubing)

A tug on the tube, so the loops diverge into the shape of

a ‘V’, guarantees security and ensures the drain tube is locked in Another tug on the tube tests the security of the system

Notes _ _

Outcome

Decreased infection rates associated with

drain tubes

When Redivacs are used in separate regions

on the body, invariably one site drains more

than the other We have all experienced

such problems When a certain drain site

has been stipulated for removal and the

wrong tube has been removed, it creates a

Never confusing drain tubes again

Figure 1: Tie a loose knot to indicate a particular

designation, or label the tube;

however, the knot is a simple solution

Notes _

_

_

_ _

_

_ _

In the early postoperative phase if there is

a need for ongoing hand splintage when

blood staining may have occurred, it is

appropriate to reuse the splint that is

perfectly moulded to the patient’s

anatomical state

Problem

Visible staining over the moulded splint It is

technically difficult to remake a close fitting

Hand splint – ongoing use postoperatively when blood staining may have occurred

splint in the postoperative wound dressing phase

Notes _ _

Outcome

When wound dressings are completed, the

orthoplast splint from the hand therapy

department completes the management

Plaster splintage following hand surgery is a

standard requirement in almost all surgical

procedures Immobilisation after tendon

surgery and any grafting procedure is a

prerequisite for a successful outcome

because it creates an environment that

optimises healing

Problem

Any movement detracts from successful

grafting, flap reconstruction or tendon repair

Hand splintage – technique 1 – single roll plaster

splintage

Solution

Single roll plaster splintage is cost effective because the use of a single roll of plaster offers the advantages, when folded over a piece of plastic tubing (from the plaster roll), of being lightweight and structurally strong and halving the cost of plastering

Sometimes, double plasters are used for strength, but the folding technique makes this unnecessary

Figure 1: A typical plaster with tubing inserted under the folded splint

Figure 2: The plaster folded over tubing

_ _

Outcome of the plaster, allowing its stability to be

The full thickness skin graft harvest for

repairing depulped fingertips is best taken

from the crease lines of the wrist ulnar side

in the rhomboid architectural manner This

rhomboid defect is easily closed by

opposing the medial and lateral sides of the

isosceles triangle The mid-point tension

suture, which is left in for 2–3 weeks,

Figure 2: The rhomboidal design is marked out to indicate the size and shape of the harvested tissue

Notes _

Hand splintage – technique 2 – grafted finger tips 2/3

Figure 3: The dressing

A 5-cm crepe is started proximally over the wrist wound before advancing distally

Figure 4: The anaesthetic injection Plain Marcaine is used and both digits are wrapped as a single unit to provide more stability

Figure 5: Ribbing of the plaster into a folded unit to double the strength without increasing the weight In the elderly, a double plaster creates rotator cuff problems

This simple postoperative manoeuvre for

drainage and oedema management

(without using a drip pole) has been my

habit for over 30 years at the Western

The horseshoe-shaped pillow support

is applied postoperatively and can be reapplied on discharge for the patient’s comfort

Figure 1: The horseshoe-shaped pillow support elevates the hand in hospital and also in the home environment

Green, D.P., 2005 Chapter 1: ‘General principles’ In: Green, D.P., Hotchkiss, R.N., Pederson, W.C.,

Wolfe, S.W (Eds.), Green’s operative hand surgery, fifth ed Elsevier Churchill Livingstone, Philadelphia,

pp 3–24

Drainage in large areas of the body cavity,

using an 18-gauge dimension, is standard

practice The application of suction

Major wound drainage technique

drainage during the procedure minimises clot accumulation, which impedes future suction

Figure 1: Drainage set-up components The sleeve protecting the Redivac cannula fits remarkably snugly into the drainage tube system once the white cap has been removed

Notes _

Problem

Achieving adequate suction for the

remainder of the procedure once the large

drain tubes are in situ

Figure 2: Artery clip clamping

of the tubing is an unsatisfactory technique

An airtight seal is necessary

to prevent loss of suction The same Redivac cannula protector can be divided into two and that fits remarkably well into a ‘Y’ connector for

a double drainage system

Notes _

An accurate plumbing seal is easily

achieved by using a Y-connector attached

to the main suction drainage 10-gauge

(drain tube) tubing fits remarkably tightly into the small piece of plastic tubing used

to protect the sharp, pointed metal inserter

Figure 3: Attachment of 10-gauge tubing to the connector For a larger ‘Y’

connector (3/8") the white connector may be retained

Notes _

_

_

_ _

_

_ _

18-gauge tubing usually fits snugly into the

arms of the Y-connector directly

Outcome

An airtight suction drainage connection is

achieved and maintained throughout and

after the procedure This eliminates

haematoma in the depths of the wound during the procedure and maintains this status once the wound is closed

Additionally, any air leak can be gauged and reinforced with more suturing at any

‘hissing point’ before applying the final dressing with suction

Negative suction drainage through a large

Redivac is not appropriate for small wounds

in the head and neck or other regions of

the upper and lower limbs

Wound drainage – mini suction system using a Luer-lock syringe

Problem

Arranging a negative suction drainage system for a small site

Figure 1: Delayed reconstruction after pathology evaluation Note the ‘red-dot’ sign in this V–Y island flap, also characteristic of the KPIF

Notes _

Solution

Figure 2: Equipment – 10-mL Luer-Lok™ syringe and tubing

Notes _ _

Wound drainage – mini suction system using a Luer-lock syringe 2/4

Figure 3: A small length of anaesthetic tubing is perforated with scissors to create elliptical drainage points (×4)

Figure 4: Cutting the tubing to the required length

_

_ _

Notes _

Figure 6: Attaching the syringe The protective sleeve from the 19-gauge needle is held in preparation for insertion to hold the plunger out to length, creating suction

Notes _ _