FUNDAMENTAL TECHNIQUES
OF PLASTrC SURGERY
AND THEIR SURGICAL
APPLICATIONS

This book is protected under the Berne Contention
It may not be reproduced by any means in tshole or
in part tetthout permission Application t-ith regard
to reproduction should be addressed to the puhhthtts

Copyright E & S Ljvincstosx Ltd , 1962

FUNDAMENTAL TECHNIQUES
OF

PLASTIC SURGERY

AND THEIR SURGICAL APPLICATIONS

BY

IAN A. MCGREGOR

M.B., r.R.C.S.fllng ), r.R.F.P.S.(GIas.)
Consultant Plastic Surgeon. Glasgow Royal Infirmary.
Lately Consultant Surgeon, Casualty Department,
Glasgow Royal Infirmarj-

FOREWORD BY

SIR CHARLES ILLINGWORTH

C.B.C., M.D., Ch.M., F.R.C.S (Ed.), T R.F.P.S (Glas.)
Hon. F ACS. Hon. T.R.C.S (Eng )

Regius Professor of Surgery, University of Glasgow.

SECOND EDITION

E. & S. LIVINGSTONE LTD.
EDINBURGH AND LONDON
1962

F rst Edition
Second Ed tion

PRINTED IN CREAT BRITAIN

FOREWORD

Like other surgical specialties, Plastic Surgery originated through
the efforts of a small group of enthusiasts who, by utilising a
particular refinement of technique, soon raised the standards of
surgical craftsmanship within a narrow field to a high pitch of
efficiency

Then came the war, and the techniques primarily evolved
for hiding facial blemishes and correcting \isible deformities
were applied with immense success to the treatment of wounds in
general Since then, as a natural sequel, plastic surgeons have
widened still further their range of interests, notably in casualty
work, in hand injuries and in bums In doing so, they have
implicitly ceased to regard themselves as a class apart, exclusive
authorities in a chosen field, but rather as expert adusers and
helpful collaborators in a wide range of surgery

Mr McGregor is emphatically of this latter class, trained in
the Glasgow School of Plastic Surgery, broadened in experience
by the responsibility of a busj casualty department, and with a
particular interest in the surgery of the hand His book reflects
these interests and this experience being designed not for specialists
but for all those who are concerned with the healing of wounds
Its approach is essentially practical, dealing as it does with the
choice of incisions with stitchcraft, avoidance of ugly scars,
methods of skin grafting, and similar matters, and with their
apphcation to casualty surgery, orthopaedics and general surgery
It will assuredly receive a warm welcome

Glasgow, i960

C F W Illingworth

PREFACE TO THE SECOND EDITION

Thu a second edition should be needed so quickly is a pleasant
confirmation of the hope expressed in the preface to the first edition
that it would fill a real gap in the surgical literature

The opportunity has been taken to revise the text but the absence of
significant change in plastic surgical technique over the past two years
has made radical alteration unnecessary

The most obvious difference in this new edition is the introduction
of a chapter on maxillo facial injuries and the simultaneous deletton of
the more complex eyelid instructions Maxi l!o facial injuries might be
regarded as outside the book, s original terms of reference but my
justification for including them is firstly that many reviewers regretted
their exclusion from the first edition and secondly that in this countrv
at least they do come into the province of the plastic surgeon I have
considered them from the viewpoint of the surgeon rather than the
dentist and given only enough detail of the more elaborate dental
techniques to make the underlj mg principle understandable Particular
prominence has been given to diagnosis and general management
with detailed consideration of those procedures which the surgeon is
likely to carry out himself In this chapter I have found m\s.elf forced
to use the term Gunning splint and though I realise that this eponym
is open to all the objections mentioned in the preface to the first edition
I have_been unable degmte much effort to think up a reasonablv concise
alternativ e

Tresh techniques introduced are those of exposed grafting and the
neurovascular island flap of Littler and the problem of skin loss in
association vv ith fractures has been discussed at greater length On this
last topic I have benefited in discussion from the wide experience of
Mr Peter London of the Birmingham Accident Hospital and I am most
grateful to him The suggestion was made by a reviewer that con
sideration of the applications of plastic surgery techniques might use
fully be extended to include specialities not at present covered B\
that time however this new edition was already m an advanced state
of preparation but the idea remains ven much in my mind as a potential
development in the future

The new subject matter has lent itself to the use of line drawings

PREFACE TO THE FIRST EDITION

Plastic surgical methods are being used increasing!) often by surgeons
who hate recen ed no formal training in plastic surgery and who are
looking for guidance on the basic techniques Advanced textbooks
of plastic surgery are apt to pass over those elementary but nonetheless
fundamental methods while the sections on plastic surgery m textbooks
of surgery describe its scope and results without giving enough detail
of actual technique to be of practical use This book I hope may help
to fill the gap

The first part describes the basic techniques of plastic surgery in
detail and the second considers their application to the situations which
surgeons in other specialties are likely to encounter A difficulty in
the second part has been that of deciding what material to include and
what to leave out The deciding factor generally has been to include
such topics and techniques as it was felt a surgeon m the particular
field might reasonably wish to deal with himself without necessanlv
referring the patient to a plastic surgeon

The book makes no atteitipt to describe all possible methods of
repair and reconstruction To include a multiplicity of methods in a
book of this nature would merclv confuse and I have preferred instead
to describe those methods which I hive found work best tn practice

In discussing the baste techniques I hav e tried to stress the difficulties
of each and to describe the complications how they can be avoided and
how to cope with them when they do occur I have endeavoured too
to bring out the principles of the various methods in the hope that an
understanding of these principles may weld the technical details into a
coherent, rational pattern and prevent them from being a mere jumble
of empirical instructions

A difficult decision has been whether or not to use the eponyans in
which plastic surgery abounds Eponyans arc an essential part of
everyday surgical shorthand and they recall men who have stood as
signposts along the way of an advancing specialty Rut often they lack
precise meaning and they are liable to cause confusion firstly because
they sometimes have different meanings in different countries secondly
because they are frequently used loosclv so that in some instances a
name has even come to be applied to a procedure different from that

X PREFACE TO THE FIRST EDITION

described by its owner The Thiersch graft is an example of this latter
categorj being nowadays applied to a graft of quite different thickness
from that originally described b\ Thiersch For these reasons I have
regretfully avoided eponyms altogether

References have purposely not been introduced into the text
Instead I have listed a few papers and monographs at the end of each
chapter under suitable subject headings to provide a starting point for
anyone wishing to pursue a particular subject further

I must acknowledge my debt to many who have helped me in pre
paring this book To Professor C F W Illingw orth who encouraged
me at the outset in its writing and Mr J S Tough who was responsible
for my training in Plastic Surgery and gave me free access to the photo
graphic records of the Unit I am deeply grateful I am greatly in the
debt of Mr Douglas R k Reid for his constructive criticism of the
text and for the pains he has taken to make it as lucid as possible without
sacrificing brevity in the process To Professor Roland Bames and
Dr J C J Ives who read and criticised parts of tl e text I express my
thanks

The illustrations are all important in a book largely concerned with
surgical techniques Mr Rob n Callander made all the drawings and
I find it difficult to convey fully the care and trouble he has taken to
portray visually what I wished to express Any usefulness which the
book may have is due in no small way to his illustrations The
photographs are the work of Mr T Meikle and Mr R Macgregor of
the Plastic Surgery Units at Ballochmyle Hospital and Glasgow Roval
Infirmary Mr R McLean Department of Medical Illustration
Western Infirmary Mr P Kelly Photographic Department and
Mr E Towler Department of Surgery Glasgow Royal Infirmary
For the care and trouble which each has taken I am most grateful
I am also indebted to Messrs Chas F Thackray for permission to use
dlustrations of their instruments

The typing and retyping of the manuscript was carried out with
patience and good humour by Airs A M Drummond

I should like lastly to record mv thanks to Mr Charles Macmillan
and Mr James Parker of Messrs E and S Livingstone for the advice
and help which they have given me throughout

Tan A McGregor.

Glasgow i960

CONTENTS

PART ONE

THE BASIC TFCHNIQUES

I Wound Care 3

II IheZplasta 40

III rRrt Skin Grafts

I\ Flaps Pedicles and Tubes 95

PART TWO

1 HE SURGICAL APPLICATIONS
V General Surgera

VI Orthopaedic Surcera ,8!

VII Hand Slrgera ^

VIII SuRGCRA OF THE E\ELIDS __ .

1 \ AIaxillo Facial Injuries 2 .

lNI>r ' . 279

M

PART ONE

THE BASIC TECHNIQUES

CHAPTER ONE

Wound Care

G IVEN accurate skin approximation and freedom from
infection epidermal healing occurs extremelj rapidlj but
the healing processes which go on in the dermis are much
more prolonged and as far as the ultimate appearance of the
resulting scar is concerned far more important The transition
from fibrin clot to the quiescent relatively avascular scar takes
place relativeh slowly over a period of months

Initial!) the scar is often red and the immediate surroundings
are frequentl) indurated, almostvvooden, in consistencv Gradual!)
the induration and redness diminish and disappear Ieav ing a soft
scar, paler than the surrounding skin The degree of redness and
induration is extremel) variable as is the time taken for the reaction
to subside, 3 months to almost a jear are the extremes The
appearance of a scar can be expected to improve up to a ) ear and
at least the greater part of the reaction should be allowed to subside
before secondarj rev ision is considered

This graduall) diminishing induration constitutes normal
progress to quiescence Such a sequence is b) no means invariable
and instead the'fibrous tissue of the dermis maj become grossl)
hypertrophic giving rise clintcall) to a raised, red, hypertrophic
scar or when the reaction is more florid to a keloid scar, but these
conditions are sufficiently important to merit separate consideration
During the healing phase the tensile strength of the wound
graduall) increases The sutures take what little strain there is
until the) are remov ed and if a scar is going to stretch thereafter
it does so graduall) over the next feu weeks Support of the
wound for as long as is feasible appears to have little effect
Naturall) a scar is most ltkel) to stretch badl) when skin has been
lost and there is obvious wound tension, but often stretching
occurs w’nen lucre is wo apparent xntsam xrfnet ‘Asm Yntfi ifmvnig
from the normal elasticit) of the skin
3

4 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERA

3Se\ertheless m many parts of the bod\ the direction of the
scar appears to influence the amount of stretching which takes
place and the directions which result in minimal stretching can be
systematised into lines of election for scars Langers lines
which map the direction of fibrous tissue bundles in the dermis
have been described as indicating such lines of election but

The I nes of elect on for scars n the face and neck sho n by the pattern of
wruikl ng and their relat on to the direct on of the underlj ng muscles

critical examination of the diagrams of Langer s fines shows tf at
more often than not they bear no relation to the actual line of
election and it would appear that any coincidence of the two sets
of lines is entirely fortuitous Unfortunately most surgeons use
the term Langer s line when in actual fact they mean the line of
election and the term as a result dies extreme!* hard

In the face and neck the lines of election are at right angles to
the direction of the resultant pull of the muscles of facial expression
and with the loss of elasticity that goes with ageing they become
set into a pattern of wrinkles (Hg i, i) In the ucmity of the
flexures the lines of election are parallel to the skin creases which
are clearly present in the region of the flexure

In the skin surfaces between the flexures the eudence for a

WOUND CARE

5

specific line of election is less clear-cut and in any case the placing
of an incision there is determined more often by considerations
other than the e\ entual cosmetic result of the scar

In general then a scar should be placed m a line of election
where at all possible

At the outset it must be said that there is great and uncon
trollable individual variation in healing characteristics and this
sets a limit to what can be achieved bv pure surgical technique
It is impossible to get a perfect scar alwavs but to produce the best
result in a given set of circumstances a meticulous technique is
essential and it must be emphasised that failure in a single aspect
is enough to give a poor result however careful all others may be
The factors concerned in wound care are

1 Placing the Scar 3 Stitchcraft

2 Preparing the W ound 4 Post-operatn e Care

PLACING THE SCAR

When the onus of placing the scar lies with the surgeon the
principles to be followed in selecting site and direction are

Use of natural lines

The scar should be placed in the line of a wrinkle or at least
parallel to it (Fig 1, 1) so that in course of time it will settle in to
look like another wrinkle Failing this the line of election for the
particular area should be chosen

Where there is a natural junction to distract the eye from a
scar this mav be used In approaching the parotid for example
the best scar line results from an incision along the junction of
ear and masseteric region

Placing the scar where it will not be seen

Theobwous examples are inside the hair line or in the eyebrow
and these are the only sites where an incision which is not perpen
dicular to the skin surface is permissible Instead the incision
should be made parallel to the hair follicles to avoid the hairless
scar which sectioning hair follicles would cause The eyebrow
incision is especially useful m appro iching a dermoid cyst of the
lateral canthal region and the mv tsible scar more than compensates
for the added technical difficulty of such an indirect approach

6 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCERY
Use of the Z-pIasty

The use of the Z-plast) m correcting contractures js discussed
in Chapter Two It has how ev er a a erj definite place as an adjunct
to other methods designed to minimise scars The Z-plast\ is not
recommended for use in the primary treatment of wounds resulting
from trauma unless the wound approximates m cliaracter to a
surgical incision and the circumstances are otherwise ideal It

The tension directly across a nound converted by Z-pUstics into a
shearing strain talen by the transverse limb of each Z

should rather be reserved for use in an) subsequent revision of
the scar The Z-plast) is carried out b) transposing the flaps
resulting from two side cuts made at 6o° angles on each side of the
line of excision (Fig 1,9) and it has the following attributes and uses

Redistribution of tension Frequentl) following an operative
procedure a wound has to be sutured under some tension and it
is in such circumstances that severe stretching of the resulting
scar is prone to occur Various procedures have been described
as helping to av otd such an occurrence and of these the Z-plast)
is probably the most valuable where it can be used (Fig x, 2)
Its effect is to break up a long scar with tension directly across the
wound into multiple short scars in which tension has been
redistributed in such a fashion that the greater part is taken as a
shearing strain b) each transverse limb of the Z-pfasties It

WOUND CARE

7

would appear that shearing strains cause much less stretching of
the scar than does straight tension

Equalisation of tcotind length It happens not infrequent!) that
the two sides of a wound to be sutured are unequal in length as m
excision of a “ comma shaped ” scar While the taking of unequal
bites of either side can partially
equate the lengths there is a definite
limit to this The Z-plast) can then
be used to reduce the discrepancy in
length (Tig x, 3)

Breaking the scar line In most
situations a scar tends to be notice-
able if it is long and straight
However narrow it ma) be the e>c
takes it for the scar that it is \\ ith
Z-plast) insets on the other hand the
appearance (Fig 1, 4) is of short
scars interspersed with unobtrusive
cross limbs giving at best a series of
unconnected short scars with virtu-
al!) imisible cross limbs or at worst
a zig-zag scar which tn practtce is far
less conspicuous than the original
straight scar

This “breaking of the line” is a Equalising the lengths of the two
most important factor ,n scar cam- EJSSS?

ouflage and the more accurately

the cross-limb is placed in a good line of election or actual wrinkle
the less conspicuous will it be and the better the end result \\ here
a scar crosses the nasolabial fold the cross limb of the Z should
alwi)slie in theline of the fold , likcw ise Z plasties to fit the forehead
wrinkles are often worth while to break a \erticil forehead scar
(rig 4, 30)

When it is in a line of election and particular!) in a wrinkle a
long straight scar as in th)roidectomy ma) of course be entirely
acceptable, but in the face where the problem has its real rele\ance
there must be few long straight scars which fad to cross a line of
election at some point and which would not be impro\ed b)
incorporating a 7 plistj

Ere r, 3

The use of ^-plasties in reusing a bridle scar crossing a concaut)

induce such a scar to sit into the concax it\ is to place a 7 . (r ig x, 5)
at the deepest part of the hollow (ste also I ig 5, 1 6)

The cuntus’ sear This max present a difficult problem and is
seen in its worst form when a trapdoor of skin has been lifted

‘the recurrence af trip-door tarring fallow trtg timpte exetston
and sulure

and mtrclx resutured in place Contraction of the resulting
scar causes elexation of the tissue within its concaxitx Seen later
it imx lie assumed, not unreasonablx , to be the result of bad
suturing hut excision of the scar, trimming of the flap quite flat,

\%OUND CARE

II

and resuture with the greatest of care only results in recurrence
of the original state of affairs within a matter of weeks (Fig i, 6)
The solution of the problem lies m the judicious use of the
Z plastj to break the cun e of the scar (Fig z, 7)

Where there is a tendencj 1
side of a scar it can usual I j be
corrected bj incorporating a
Z plastj when the scar is being
excised (Fig 1, 8)

Siting the Z-plasty To
place a Z-plastj in thebest line
requires sound jud^Pejit and
depends to some extent on the
purpose which it to' sen e
In general the resulting trans
^ erse limb across the lme of the
scar should lie in a line of
election or m the line of a
wrinkle where one exists
When the purpose is to sit a
scar into a hollow the trans
\erse limb should be placed to
lie at the deepest part of the
hollow

Having decided the best
line for the Z the problem
of placing the appropriate
incisions still remains

overriding of the tissues of one

Skin markinq of
intended transverse 1 mb

Triangles constructed around
intended transverse limb

Selection of
Z plasty cuts

Transposition of
Z plasty flaps

Completion of Z plasty leaving
transverse limb m intended line

If mistakes are to be pic x 9

avoided the planning of such a ^ ,*, h „ d „ r , , ng , z. pI „ ty

Z-plastj must be regarded as a

formal procedure (Fig 1, 9) to be marked out on the skin before
anj incision is made When the best trans\erse line has been
selected it should be marked on the skin with Bonney s Blue (Pig
Tmctorium B P C ) If in planning the actual Z-plastj incisions
each is made to end on this line transposition of the flaps wall
automaticall) leave the trans\erse limb ljang along the lme as
planned

With the desired trans\ erse line marked on the skin an

12 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCFRV

equilateral triangle should be draw on each side of the scar into
which the Z-pIast) is being placed so that an apex of each triangle
is on the transv erse line already marled Of the two possible pairs
of Z-plastj flaps outlined in this wj} the appropriate one can be
chosen m the knowledge that as each incision ends on the
transverse skin marking transposition of the flaps will place the
transverse scar along the line intended

This method works particularh well when the wound is
perpendicular or nearlj so to the line of election or wrinkle
for then the points are practical!} directl} opposite and the
tnangles are easy to construct As the wound direction becomes
closer to the line of election it becomes increasing^ difficult and
eventuallv impossible to get the transverse limb to lie in the lint
of election and a compromise must be reached which makes it as
near to the line as possible

It takes courage for the inexperienced surgeon to wilfully
increase the length of a wound alreid) present b\ incorporating
one or more Z plasties but it is a technique with which an)ont
dealing with facial surger) should be familiar One seldom has
cause to regret a Z plasty but rather failure to use one

PREPARATION 1 Or THE WOUND

When a wound is alread) present as a result for example of
trauma it is still important to consider how and to what extent it
transgresses the principles of placing a scar which have been
formulated and whether it can be modified better to fit those
principles When as often happens it proves impossible or
undesirable to make it conform as a primary manoeuvre because
of potential infection poor blood supply of wound margins skin
damage etc the aim then is to prepare it for the time when at a
later date it can be modified to conform

W ounds can be regarded as traumatised when the wound edges
have been apprcciabl) damaged or non traumatised when the wound
edges contain minimal damaged tissue as in surgical!} created
wounds

It is the presence or absence of damaged tissue which de
termtnes whether or not a wound should be excised Under nil
circumstances it is axiomatic that all dirt and other foreign material
must be removed bv excision if neccssar} In the face where

WOUND CAKE

the cosmetic result is of paramount importance the problem of
e\cmonal policy is more difficult than elsewhere and there are
two approaches to the problem

If damage is minimal the wound maj be excised so comerting
it to an atraumatic type in an attempt to get a final result primarily

14 fundamental techniques of plastic surgery

further surgery in the knowledge that a good scar cannot be
expected from the healing of such a wound This policy permits
the salt age of tissue which might otherwise be excised tissue w hich
may be valuable later

A conservative policy is obligator} m the care of severe facial
soft tissue trauma where it is seldom possible to achtc\e final
reconstruction at the primary operation and where the o\er
riding object must be to replace structures m their normal position
and suture them there The secret in suturing an irregular wound
is first to look for landmarks on either side to match 'WjtJj mo
points which definitely fit sutured together fresh parts of the
jig saw fall into place until enough ke} points ha\e been matched
to allow the intervening sutures to be placed readil} Time spent
fitting a jig saw of tissue accurately at the time of original suture
is never wasted since such a chance comes only once and if it is
missed the results can be disastrous Although it ma} be quite
obvious that Z plasties will be required later these should seldom
be used at the pnmar} operation

An added difficulty arises when there has been actual loss of
tissue and the principle which then go\erns practice is to replace
surviving tissues in their correct anatomical position so tli 3 t the
defect can be properl} displa}ed and assessed in terms of tissues
lost

While the experienced plastic surgeon ma} legitimately carry
out a primary definitive repair in sucli circumstances the less
experienced surgeon should be more modest and if the defect
cannot be closed by direct suture he should apply a split skin
graft in most instances A full thickness defect opening into the
mouth which cannot be closed without undue distortion calls for
suture of skin to mucosa

These temporary measures have at least the merit of allowing
rapid healing with minimal scarring and leave conditions suitable
for a definitiv e repair subsequently
The common errors in treating wounds at this stage are

1 Failure to remove all dirt from the wound feav mg an area
of tattooed scarring (Fig t, i x) which is usually difficult and
often impossible to eradicate later

2 The production of a scar with gross suture marks
(Fig i, 12) Such a wound would often do better to heal by

WOtmn CARE

15

granulation for the resulting scar however ugly can always
be excised whereas the presence of suture marks makes
excision infinitely more difficult

3 Failure to suture the various wound edges in the precise
position relative to one another which they occupied before

Fic 1 11

Examples of tattooed scarring result ng from fa lure to remo\e ingrained d rt
and grit from the wound at the time of the injury At th s late stage such
tattooing is \ irtualljr imposs ble to erad cate completely

the injury (Fig I, 13) The resulting irregularities are
especially obvious when the lip margin eyelid eyebrow or
nostril ire the structures which have been imperfectly matched
It is often important to know when a piece of traumatised
tissue can safely be con sen ed or v\ hether it must be excised and in
deciding this the important factor is vascularity Blanching on
pressure and the presence of dermal bleeding are both evidence of
an active circulation In doubtful cases the anatomy of the region
together with the size and content of the pedicle help in making a
decision (I lg x, 14) In the face and scalp where the problem

Tic i# 13

Examples of irregularities of c>eltd and mouth resulting from fa lure to suture
matching points together accurate! 5

arises most acutelj the vascular abundance is on the side of sur\ual
and flaps should not hghtlv be excised Indeed in the scalp a
flap with anv attachment at all should be consen ed

j8 FVSDAMESTAL TECHf. fQU£S OF PLASTIC SIRGERV
skin sterilisation which doe* not stain the skin or tissues Mer-
thiolate and iodine, suitable otherwise, should not be used,
satisfactory agents are cetrimide and chlorhexidinc (“Hihitane”)’
In preparing a wound for suture the wound edge should he
\ ertical if the best scar result is to be achieved and as a corollary
of this surgical incisions must also be made \ ertical Accurate
suturing is also very much easier when the faces of tissue brought
together are of the same thickness If the w ound is being sutured
without tension all that may be required to prepare the skin edge*
is to undercut each edge for inch to allow slight w ound eversion

When there is tension steps can be taken in preparing the
wound to eliminate it oral least prevent its worst consequences by *
Undercutting (Fjg j, J5) This allows a degree of advancement
of the shm In undercutting, level is important and depends on
the vascularity of the flaps and on the depth of important nerves
On the face, and it is the area where the problem most often arises
the appropriate lev el tsjust deep to the dermis, for any undercutting
must be superficial to the lev el of the branches of the facial nerve
The blood supply is excellent in the head and neck and necrosis is
unhkelv to follow undercutting at even such a superficial level
In the scalp the plane between galea aponeurotica and pericranium
is used and multiple relaxation incisions in the deep surface of the
galea aponeurotica giv e a little added advancement Flacwhere it
is wiser if undercutting has to be more than minimal to use the
plane of cleavage between superficial and deep fascia
Z-plasty The use of the Z-pfasty in this situation has alreadi
been discussed and when the method is employed it is mturallv
used m conjunction with undercutting

If it is clear that even with maximal undercutting closure will
not be achieved the usual procedure especially m the case of a
traumatic wound is to use a free skin graft On occasion a more
complicated flap procedure may be feasible but as a general rule
it is not a good method for emergenev use The free skin graft
is safer and simpler

STITCHCRAFT

W hen the surgeon is aiming to make hts scar as inconspicuous
as possible the actual suturing of the wound becomes an extrcmch
precise procedure and good results cannot be expected unless the
suture materials, the needles and the instruments are suitable

WOUND CARE

19

FACE

Level of
Undermining

Undcrmin nq Level of

with Scissors Undermining

LIMBS & TRUNK

SCALP

Fic i, is

The methods and levels of underm mng 10 the face limbs and trunk and scalp

20 FUNDAMENTAL TECHNIQUES Of I'LASTIC SLROFR)

Suture Materials

There is considerable \ anation in the properties of the difTerent
suture materials and these properties determine which particular
material is the appropriate one in a given situation The
commonl) used threads are

Braided silk. This material js eas> and pleasant to work «ith,)«
the surface is sufficient!) rough for knots to hold reisonabh well
especially with an initial double turn Itisnormall) supplied water
proofed and this is said to reduce reaction around the suture holes

One ot its defects is a rclativelj low tensile strength and if
much tension is needed, as for tie over sutures, it is apt to break
in the sizes used, namelj 3-0 and 5-c \\ hen the hebt cosmetic

result is essential the finer thread is used but with even minimal
tension such a thread breaks readilv and 3-0 maj be required The
finest thread which can be used will give the best cosmetic result
Linen Its relativelj rough surface makes the handling qualities
of linen less sattsfactorj than silk Some samples also tend to he
slightl) irregular in diameter though this has been much less
common recentl) Its tensile strength is much greater than silk
of comparable diameter and the rough surface makes its knot-
holding properties much better than those of silk Its sire is
approximate!) 3-0 and it can he used instead of 3-0 silk if preferred
For tie-ov ers its knotting properties and strength make it preferable
Stainless steel wire Stainless steel u ire 34 ind 36 S W G is
\ er> useful on occasion quite apart from its use in tendon suturing
It is inert in the bod) and has a ver) high tensile strength but
until the technique has been acquired it is awkward to use for
kinking occurs rendil) and creates a weak point in the wire
Though it can replace an\ t)pe of skin suture material it is much
less satisfactor) than silk or linen for ordinar) interrupted sutures
Its main usefulness is as a tension suture or as a continuous
tntradermal or “over and over” suture Used as 1 continuous
“over and over” suture its ngiditv prcvcnK it from “bunching”
the skin as silk and linen tend to do It is also useful when sutures
must be left in for longer than usual for its inertness reduces
reactions around the sutures to a minimum
Cat-gut To help relieve tension cat gut has been rtcommciukd
as a buried suture Its use is discussed on page 2S

WOUND CARE

21

Silk-worm gut and nylon Used for interrupted sutures silk
worm gut is unsatisfactory as it lacks the desirable quality of
pliability Its smooth surface on the other hand makes it easy to
remove when it is used as a continuous intradermal suture
Monofilament n\lon is pliable and inert but its knotting properties
are so poor that it is rarely used for interrupted skin sutures
It is useful as a continuous intradermal suture

Needles

Although m theory an atraumatic suture should do less damage
to the skin during its insertion the large number of sutures needed
would make the cost prohibitive and it is extremely unlikely that
their use would make a significant difference in practice Other
deficiencies of technique are usually present to explain failure to
get the best result Nos 3 and 5 eye curved cutting needles
are most generally useful for fine suturing and require minimal
effort in use If greater strength is required a thicker needle is
mturalh used

Instruments (Hg r, 16)

The instruments concerned are needle-holders, dissecting
forceps, skin hooks and scissors

It is preferable to use the instrumental method of suture tying
(Fig 1, 17) for the small needles and fine suture materials make
tying by hand clumsy and difficult With instrumental tying
tension can be regulated and knot placement earned out with
much greater finesse, exactitude and expedition after only a little
practice The needle holders normally used in general surgery
are quite useless Large cumbersome and ill designed for the
necessarily fine work of careful skin suturing the locking
mechanism in particular makes them impossible to use for knot
tying The Gillies or Kilner needle holders are essential and
though it takes a little time to acquire facility particularly with the
Gillies holder it is a most rewarding facility to have

The more a wound edge is traumatised the less good will be
the cosmetic result and so the implements for holding wound
margins steady for suturing must be as atraumatic as possible
The skin hook is the least traumatic instrument though its method
of use, described below, is a difficult one to use with elegance and
speed Because of this dissecting forceps are more routinely used

22 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

Kilners Needle Holder

M c lndo«s Dissect mg Forceps (non toothed)

Gillies Skm Hook

Fie. i, 16

The instruments used in skin suturing

WOUND CARE

23

individual preference will decide the choice of the toothed or
non toothed varieties but both should be used with due regard to
the trauma they are causing The Mclndoe and Gillies dissecting

Instrumental tying of a suture

forceps are of a suitable size for routine suturing but for real!} fine
work Adson forceps are much superior

Two types of scissors are usually employed straight sharp
pointed for cutting wound margins and suture removal curved
blunt pointed for undercutting wound edges Both should be
sharp so that the tissues are cut cleanly and not crushed

24 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY
Technique of Wound Suture

The aim is to produce a wound atraumaticalh but absolute!)
accurate!) co apted and technique of handling and suturing is
mere!) a means to this end First time accurate placing of the
suture is a habit to acquire, the second attempt is all too often
worse than the first and onh results in a moth eaten Mound edge
and poor scar The needle is curved and so moves most readily
in a circle The wrist must therefore be brought freel) into play

so that insertion and pull through of the needle are ahra}* in the
line of its curve (Fig i, 18)

For a definite period after a wound is sutured slight oedema of
the wound tends to develop and though it can be reduced b) a
pressure dressing, allow ance must be made for it in tying the suture
If the suture is too tight it will surel) cut in more rapidlj and make
a suture mark The correct suture tension just avoids blanching
the skin held bj the suture

Sutures maj be interrupted or continuous When the cosmetic
result is all important the interrupted suture is best but the con
tinuous is often adequate in other circumstances, eg delav of
flap or pedicle

Interrupted sutures The usual suture js the simple loop
suture (Fig i, 19) which consists of a simple loop knotted at one
or other side of the wound and it aims to bring the skin edges
together absolutel) accuratelv with no overlapping of one margin
A general tendencj towards slight “pouting” of the suture line

WOLND C\RE

helps to ensure complete dermal apposition and makes sure that
inversion of the wound edges is a\oided Inverted wound edges
alwajs heal more slouh and gne a poorer scar and it is to allow
the desired degree of eversion that a skin edge is sometimes
undermined for inch

Equal bite is the
coarse adjustment"

Piaemq the knot as a
“fine adjustment’

Insufficient deep bite
producinq inversion
and dead 6pace

Unequal bite producinq
poor apposition of the
wound edges

Tic i 19

The simple loop suture

The suture should include at least the whole dermis and if
the wound flap includes superficial fascia particular!} outside the
face this should also be taken so that the needle has an equal bite
of etch side I he taking of an equal bite might be termed the
“coarse adjustment’ of getting the wound edges level Not
tnfrcquentl} how ev er one or other edge is a shade higher than its
feffow and the tower side can 6e raised a fttrfe 6j manipulating (be
Knot in tving to that side of the wound Lver} suture has an
optimal side for its knot and its manipulation is the ‘fine
adjustment ”

B} making the suture take a slightl) greater bite of the deeper
part, dermis or fat, the whole face of wound margin is approvim ited

WOUND CARE

2 7

Vertical Mattress Suture

Buried Cat gut Suture
with knot placed deeply

FlC X, 21

Commonly used types of skin suture

28 FUNDAMENTAL TECHNIQUE* OF PLASTIC SURGERY

to lone stitch marks than anj other if the sutures are not tied too
tightl) and are remov ed earl}, and if the superficial bite is minima!
the tendenc} to imeit is corrected

When there is no tension of the wound the interrupted suture
alone is adequate When there is tension two possible additional
measures are described which are said to allow earl} removal of
skin sutures without wound disruption or stretching

Buried catgut sutures (Fig x, 21) Interrupted buried catgut
sutures with the knot placed deeph are used u nh the idea of taking
strain after early removal of skin sutures Their ability to prevent
wound stretching is rather doubtful, the result is usuallv as good
or bad as might have been expected had the} not been used
Their mam value is probabl} to eliminate dead space and prevent
haematoma

Continuous intra dermal suture (Fig 1, 21) This suture has the
mem that it can be left in for 10-12 dajs without /eaimg suture
marks Though it raaj be used b} itself it w ill be found that reall)
accurate skin edge apposition is onl} possible if additional inter
rupted skin sutures are used Its role then is to take an} tension
from the interrupted sutures and silk worm gut n}lon or stainless
steel wire can all be used

W hile these methods are used and recommended in text books
their value is ver} limited and the Z plast} used in conjunction
with extensive undercutting is more effective If these are not
practicable or cannot be cmpIo)ed to the full some degree of
stretching is probably mev itable

Continuous sutures The most useful continuous sutures are
the “ blanket stitch ” and the continuous “ over and over”
(Fig 1, 21) With silk or linen the blanket stitch has the
advantage of not bunching up the wound and can also be
locked with a knot at an} point The over and over suture
does tend to bunch the wound unless stainless steel wire is used
its ngidit} being sufficient to prevent this occurring Natunll}
such sutures cannot be placed quite as accuratcK as the interrupted
suture but where an impeccable scar is not essential the} certain! v
save time It is sometimes stated that the continuous suture
tends to strangulate the wound edge hut this is due to iindulv
tight insertion rather than anv inherent defect of the method

20

WOUND CURE

Distribution of Wound Tension

When a wound is tending to distort and it is difficult to distribute
the tension evenlj on both sides for suturing it often helps to make
the wound taut with a skin hook m each end so that a few kej
sutures can be placed accuratel} before inserting the intervening
sutures When distortion is to be expected and especial!) in a

Fic I, 22

Tattooing matching points with Bonne> $ Blue
before skin incision to facilitate subsequent
suturing

curxed incision trouble will be saved by tattooing matching points
with Bonney’s Blue (Fig r> 22) on either side of the projected
incision before any cut is made

The Three-point Suture (Fig 1, 23)

Where a triangular flap has to be inset it is often difficult to
get the tip of the flap to he m position, yet multiple sutures placed
through the full thickness of the dermis are apt to strangulate the
tissue at the tip and produce necrosis The three-point suture in
such a situation helps to avoid necrosis while holding the tip in
place As frequently described the suture tends to bunch the tip
of the flap and a minor variation is recommended which is theo-
retically sound and effective in practice in holding the tip without

28 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

to leave stitch marks than an) other if the sutures are not tied too
t>ght!} and are removed earl}, and if the superficial bite is minimal
the tendency to invert is corrected

When there is no tension of the wound the interrupted suture
alone is adequate When there is tension two possible additional
measures are described which are said to allow earl) removal of
skin sutures without wound disruption or stretching

Buried cat-gut sutures (rig I, 21) Interrupted buried cat -gut
sutures w ith the knot placed deep!) are used w ith the idea of taking
strain after earl) removal of skin sutures Their abilit) to prev ent
wound stretching is rather doubtful, the result is usuall) as good
or bad as might have been expected had the) not been used
Their main value is probabl) to eliminate dead space and prevent
haematoma

Continuous ultra dermal suture (rig 1, 21) This suture has the
merit that it can be left in for 10-12 days without leaving suture
marks Though it may be used b) itself it vv ill be found that reall)
accurate skin edge apposition is onlj possible if additional inter-
rupted skin sutures are used Its role then is to take anj tension
from the interrupted sutures and silk-worm gut, n)lon or stainless
steel w ire can all be used

W htle these methods are used and recommended in text books
their value is very limited and the Z-plast) used in conjunction
with extensive undercutting is more effective If these are not
practicable or cannot be emplo)ed to the full some degree of
stretching is probabl) inevitable

Continuous sutures The most useful continuous sutures are
the “ blanket stitch ” and the continuous “ over and over”
(Fig 1, 21) With silk or linen the “blanket stitch” has the
advantage of not “bunching up” the wound and can also be
locked with a knot at an) point The “over and over” suture
does tend to bunch the wound unless stainless steel wire is used,
its rigidit) being sufficient to prevent this occurring Natural!}
such sutures cannot be placed quite as accuratel) as the interrupted
suture but where an impeccable scar is not essential the} certainl}
save time It is sometimes stated that the continuous suture
tends to strangulate the wound edge but this is due to undul)
tight insertion rather than any inherent defect of the method

WOUND C\RE

Distribution of Wound Tension

29

\\ hen a w ound is tending to distort and it is difficult to distribute
the tension e\ en!\ on both sides for suturing it often helps to make
the 'wound taut with a skin hook in each end so that a few ke\
sutures can be placed accurately before inserting the mtenening
sutures When distortion is to be expected and especmllj m a

Tattooing matching points with Bonnei s Blue
before skin incision to facilitate subsequent
suturing

eur\ed incision trouble will be sa\ed b\ tattooing matching points
tilth Bonne} s Blue (Fig r, 22) on either side of the projected
incision before an\ cut is made

The Three-point Suture (Fig x, 23)

Where a triangular flap has to be inset it is often difficult to
get the tip of the flap to he in position, yet multiple sutures placed
through the full thickness of the dermis are apt to strangulate the
tissue at the tip and produce necrosis The three point suture in
such a situation helps to a\ oid necrosis while holding the tip in
place As frequent!} described the suture tends to bunch the tip
of the flap and a minor ' ariation is recommended w hich is theo
reticall) sound and effects e m practice in holding the tip without

30 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY
bunching The points to be noted in inserting the suture are
i To make sure that the suture leaves and enters the reception
side of the wound at the same le\el as its placement in the
X flap

Method of insertion and applications of the
three point suture

Fic i 3

The three point suture

2 To make the suture emerge well back on the reception
side of the wound

The principle of the 3 point suture can be extended for use
where two flaps are being approximated to the third side of a
wound

WOUND CARE

3 *

Length of Scar and the “ Dog-ear ”

When an oval or circular lesion is excised and the defect closed
bj direct suture the resulting scar is alwajs considerably longer
than the original lesion, a fact which it is always wise to explain
to the patient This is so for two reasons

i When the curved lines, ellipse up to circle, resulting from

Removal of a 'dogear Following excision of the lesion (a) the skin defect

is sutured (b) until the dog e-ir becomes apparent The dog-ear n
defined with a skin hook and the skin is incised (c) round the base Excess
skin is defined and removed (d) and the skin is sutured (e)

the excision arc brought together in a straight line the result
naturally is lengthening of the scar

1 When the ellipse following excision is sutured there is
almost invariably at each end of the suture line a “dog-ear”
and the correction of this lengthens the scar still further
To remove a “dog-car" (Fig i, 24) the wound should be
sutured until the elevation becomes pronounced A hook placed
in the end of the wound and raised then defines the extent of the
"dog-ear” 1 lie elevation is then excised h> incising around the
base on one or other side ending up in the line of the wound
The resulting flap is brought across the wound so tliat the excess
shin can he defined and removed 1 he resulting line has a slight
curve and its direction, which depends on the side of the dog-ear
cut initinlly , can be chosen to fit the best line cosmetically I allure
to remove the dog-ear leaves a rather unsightly swelling (rig 1,25)
and though it flattens somewiiat with the passage of time it does
tend to remain prominent enough to mar an otherwise satisfactory
result

32 FUNDAMENTAL TECHNIQUES of plastic surcera
POST OPERATIVE CARE

The aim of good post operative treatment is to prevent
haematoma, provide rest for healing and prevent suture
marks In practice this is achiev ed by the dressing care in suture
removal and later support of the wound

The pressure dressing With extensile undercutting it is
difficult despite meticulous haemostasis to prevent a haematoma

The result of failure to exc se a dog ear

unless a pressure dressing is used The pressure dressing also
provides the immobility and splinting which create the best
conditions for rapid uneventful healing and controls the oedema
which begins the cutting in process of a suture Unless there is a
good reason it should be left intact until the time comes for
suture removal In the face where there has been minimal
undermining particularly around the mouth the advantages of a
pressure dressing may be more than outweighed bv the almost
inevitable contamination with food and saliva and it is often found
that exposure of the w ound gives a better result It is then essential
to keep the suture line dry and free of blood clot until the fibrin
clot covering the line of the w ound is firm and dry

The wide mesh of a single layei of tulle gras allows the passage
of any discharge and this combined with the vaseline base make it a
particularly good dressing next the wound as it permits the dressing
to be removed with the minimum of trauma from sticking Over
the tulle gras gauze and w ool followed by a crepe bandage w ill giv e
adequate cushioned pressure and immobility Elastoplast may

WOUVD CARE

33

replace the crepe bandage in suitable circumstances and the
adhesive properties of the elastoplast can be greatly enhanced by
preliminary painting of the skin with Masttsol

Suture removal It is usual to lay down set days for the removal
of sutures in various sites and under varying circumstances but

Correct Method

Alternative Cbrrect Method

c.

Incorrect Method
Tic r, 26

Suture removal In (a) and (b) strain on the wound u
avoided by pulling the cut suture lotcardi the 1 ne of the
wound while in (c) the suture pulled an ay from the
wound increases the tension and liability to wound
dehiscence

this ts quite a w rung approach Clinical experience soon tells the
surgeon when a suture may safely be removed Naturally the
principle is to remov e at the earliest time judged safe and this
depends on so many factors, degree of tension site lmc of wound
etc that it is quite impossible to lav down rules In actualh
removing the suture (Fig i, 26) one must remember that the
c

34 fundamental techniques or plastic surgerv

tensile strength of the wound is minimal and dehiscence is liable
to occur on the slightest prov ocation \\ here most care is needed
the sutures arc usually smallest and therefore before beginning
there must be a good light fine sharp scissors ttktch cut to the point
and fine dissecting forceps tihich grip properly With these
prerequisites the actual technique of remo\al is not radically
different from ordinary suture removal except that absolute
gentleness is necessary and the cut suture being pulled out must
always be pulled out totcards the wound

Subsequent support of the wound As already stated earl)
suture removal leaves a wound dev oid of strength so that a sudden
ill judged tension strain maj cause it to open For this reason
the wound is best supported or at least protected up to a week
after stitch removal It is seldom practicable to support the
wound much beyond this and indeed attempts to prevent later
stretching of the wound by prolonged support are of little avail

KELOIDS AND HYPERTROPHIC SC^RS

When a scar, instead of becoming soft and pale in the usual
manner becomes red and thickened it is described as being either
a hy pertrophic scar or a keloid

These terms tend to be used rather indiscriminately, probably
because it is difficult to define each with certainty The typical
hypertrophic scar is raised rather red imtiallv but does not
encroach on the surrounding normal skin does not give rise to
symptoms and shows an eventual tendency to regress The
keloid tends to be a much more florid lesion it is grossly elevated
tends to spread and involve the surrounding normal skin and
gives rise to symptoms of itching a feeling of hotness and
tenderness to touch

These are the extremes and as such easilv recognised but in
realitv there is an infinite gradation from the completely quiescent
scar through the very mildly hypertrophic scar to the most severe
of keloids and the point at w hich a hypertrophic scar becomes a
keloid is a matter of opinion The name is fortunatelv of sub
sidiary importance for the treatment of both conditions is similar
Indeed the gradation rather suggests that the arbitrary division
into keloid and hypertrophic scar is artificial and that the

WOUND CARE

35

conditions are rcallj a single entity of varying se\ erit\ \ irtnallj
nothing is known of the cause

The clinical picture A precise picture is difficult to draw for
clinical generalisations do not necessarily applj to the indtwdual
case and the condition itself is extreme!} xariable and unpredict
able In the description which follows the term keloid will be
used to cov er both conditions

The tendenc} to de\elop keloids diminishes greatl} with age
but it is not possible in practice to forecast whether an} particular
patient will de\elop a keloid Nevertheless an} incision in a
known keloid former is more likely to de\elop into a keloid
than a similar incision in a random patient and recurrence following
simple excision of a keloid is high!} probable Keloids are
undoubtedl} much more common in the negro than in the white
patient The negro also exhibits the condition in its most active
form and the tumours can on occasion reach quite grotesque
proportions In the white on the other hand even the frank
keloid does e\ entuall} become less activ e and takes on the characters
and activity rather of a h)pertrophic scar (rig i, 27)

Certain areas of the body have a particular tendency to produce
keloids (Fig i, 28) the pre sternal area is probably the most
prone of all and here oddl} enough the shape of the keloid often
shows a sex difference m the male it is triangular in the female
the pull of the breasts gives it a butterfl) outline The deltoid
area is mother notorious site It is significant that a scar may
become keloid in onl} part of its length and this shows particular!}
in the neck where the vertical scar is vcr} subject to keloid cliange
while the horizontal scar is seldom affected This indeed is one
of the facts which the various theories of causation fail to explain
for if a scar of neck is excised incorporating Z plasties it is not
uncommon for the horizontal scars to be complete!} flat and soft
while the vertical limbs of the Zs show keloid or at very least
hypertrophic change In general scars in lines of election show
less tendenc} to keloid than those which cross them
Treatment ACTH and cortisone have been used but with
disappointing results The onl} treatment of real value is \ ra}
therap} either alone or in conjunction with surgeiy Extreme
care in dosage shielding etc are necessary and there should be
close co operation between surgeon and radiotherapist It is

}6 ruNDAMCNTll. TECHNIQUES OF FUSTIC SUBcEBV

usual!} found that a keloid is most sensitive to
red vascular and generally in an active state
scar responds poorlj

\ rajs when it is
The whiter older

Change f om kclo d to hypertrophic sea r ng o er a per od of 2 years The
kclo d scarr ng (A) arose as a comp? ca on of an ex «is e deglo mg injury of
Jeg The om area of kelo d s as excised and replaced u h a spl t skin graft
but in the areas left untouched (BJ the lessen ng of act vity is ob nous

The problem in practice

The problem presents in one of three wajs
The scar in a neutral ” area m the patient without a keloid
history This is the position of most patients and as a rule it is
enough to watch carefully such scars post operativeh and warn
the patient to look out for thickening of the scar so that treatment
may be started at the first sign

WOUND CARE

37

Fic. i, 28

Examples of keloitls and hypertrophic scars.

A. Mildly hypertrophic scar of deltoid region.

Q. Set ere post- bum hj pertrophic scarring of neck and chin.

C. Hypertrophic scarring following the ill-judged use of a vertical incision to
excise a thyro glossal fistula

D. Pre-stemal keloid in the male

E. Pre-stemal keloid m the female, showing butterfly outline.

F Set-era keloid of scapular region.

Marginal recurrence of kelo d after excis on and graft ng
A Pre sternal kelo d showing recurrence both marginally and n the suture
marks

B Kelo d of elbow sho ring recurrence both marginallv and ccntrallj \ here
small areas of graft had faded to take

WOUND CART

39

Surgery in a known danger area or in a known keloid former.
There are three possible approaches to this situation — to witch
the scar with extreme care and treat at the first sign to give
prophv lactic treatment immediateh healing is complete, or to
treat the operative site before operation and afterwards the scar
as soon as it has healed The selection of the appropriate method
in a particular patient \\ ill depend on an assessment of the prob ible
likelihood of keloid developing

The developed keloid In the worst sites, particularlv the pre
sternal and deltoid areas, recurrence after excision even preceded
and followed by a full course of \-rav therapv is so probable
(Fig i, 29) that surgery should be contemplated with extreme
reluctance A bigger keloid is the most likely result

ith the greatest care and the best treatment, the results still
leave a good deal to be desired The process can be damped
down rather than stopped completely and the extent to which
it can be reduced depends on its inherent activ ity At one end
of the scale mildly hv pertrophic change can be stopped completelv ,
while at the other the florrd keloid in a bad site seems often to be
barely influenced Fortunately mildly hv pertrophic change in
scars is the most common form of the condition for it is m it that
prophylaxis is most effective

BIBLIOGRAPHY

Lines of election for scars

KrAIssl,C J (iQ 3 i) Selection of appropriate lines for elective surgical
incisions Phil reconslr Surg 8, 1

Keloids and hypertrophic scars

Levitt, \V M (1951) Radiotherapy in the prev cntion and treatment of
hvpertrophic scars Bnt J plast Surg 4, 104
Mowlew R (1951) Hypertrophic scars Bnt J plan Surg 4,113

CHAPTER TWO

The Z-phsty

ALTHOUGH the place of the Z-pIasty in the treatment of
j-\ W0Uf tds and scars has been described in Chapter One its
■*“ fundamental use is m the release of contractur es Used for
this purpose it is a de\ice in ’wTuch.T)} transposing suitablj
constructed flaps skin is brought from adjacent areas u here there
is a re|ati\ e abundance, to release the contracture The theoretical
basis of the method in its simplest form will be discussed before
considering its applications and possible modifications in practice

THEORETICAL BASIS OF THE Z PLASTY
The basic manoeuvre

The flaps are constructed in the form of two interdigitated
triangles with a common limb giving the overall shape of a Z
The common limb of the tnangfes l e the central limb of the Z
lies along the line of the contracture to be released While the
angles of the Z maj vary within certain limits to be defined later
the common angle in practice is 6o° and this will be used m the
present description With such a construction the triangles
together give the shape of a parallelogram the shorter diagonal
sn the line of the contracture the longer diagonal perpendicular
to it The two diagonals can convenient^ be referred to as the
contractural diagonal and the transverse diagonal (Fig 2, i)

To carrj out the manoeuvre the triangular flaps are elevated
and the line of fibrous tissue causing the contracture divided
With the springing apart of the divided contracture the parallelo
gram changes shape causing the triangular flaps to become trans
posed the contractural diagonal to lengthen and the transverse
diagonal to shorten correspondingly (Fig 2, z)

As can be seen the length of the contractural diagonal
ajtcr completion of the transposition equals that of the
transverse diagonal before the transposition The lengthening of
40

Line of
contracture

r

X

F:c 2,2

A schema! c formalised representation of the several stages of the

42 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCER1

the contractuni diagonal is achieved at the expense of the trans
verse diagonal which has become shortened to equal the original
length of the contractural diagonal Translated into practical
terms this means in effect that skin has been brought in from the
sides, as shown by the shortening of the transverse diagonal to
achieve the lengthening of the contractural diagonal The
difference in length of the two diagonals is a measure of the actual
lengthening achieved

Construction of the 2

Since the skin flaps must fit together in their transposed position
the limbs of the Z must of necessity be equal in length The
angles of the Z are also usually made equal in size The factors in
construction which do varj are angle size and limb length and
the ways in which these variable factors affect the result provides
an explanation of vvhj a specific construction is used in a particular
set of circumstances

Angle size In any Z-plasty once the length of the limbs of the
Z has been decided the lengthening to be expected depends enureh
on the size of the angle and as the angle increases so too does the
amount of lengthening \\ ith an angle of 30° there is a 25 per cent
increase in length, with 45 0 a 50 per cent increase while with an
angle of 6o° the increase rises to 75 per cent (Fig 2, 3) It must
be stressed that at all times it is percentage increase of length which
is controlled b> size of angle

In theory angles of up to and beyond 90° could be used with
steady increase in the amount of lengthening but in practice
limiting factors emerge which determine the optimal angle

An angle of much less than 6o° would defeat the ver} object
of the Z-plast) since the smaller angle would produce less gain m
length this quite apart from the precarious blood supplj to the
tip of a narrow flap

The factors which prevent the use of angles much larger than 6o°
are

1 Increase in length is achieved at the expense of the tissue
on either side and as the angle increases the amount of tissue
brought in from the sides is corresponding!} increased As
a rule the amount of tissue available is far from unlimited
and as the angle increases beyond 6o° the tension produced in

THE Z-PLAST^

43

the surrounding tissues is so great that the flaps cannot
readilj be brought into their transposed position
2 Even if tissue was available at either side to allow an
angle larger than 6o° without tension the amount of tissue
turning required to transpose the flaps when the angle reaches
8 o-qo° would tend to produce unsightly dog-ears

Fic 2 , 3

The percentage increase of length which results from the use of
different angle sues

Limb length Just as angle size controls percentage increase of
length so limb length controls the actual increase in length since
the increase is a proportion of the original length A longer
initial limb results in a greater increase of length for a particular
size of angle Such an increase in the amount of lengthening
naturall} increases the tissue brought in from the sides

The factors which limit maximum and minimum angle size
ha\ e resulted in the compromise use of 6o° as the routine Z-plast)
angle It is length of limb which provides the major \anable m
practice and regardless of length of contracture the amount of
tissue available on either side determines the practicable limb
length — a large amount will permit a large Z a small amount will
corresponding! j limit the size of the Z

In considering the axailabilitj of tissue on either side it must be
stressed that the transverse shortening and the tension which it
creates are concentrated along the line of the transv erse diagonal

44 FBf.DAMEJ.TAI TECHNIQUES OF PLASTIC SURGERY

of the Z (Fig 2 4) This becomes important when methods of
diffusing tension bj constructing multiple small Z-plast,e s instead
of a single large Z are considered

4

4

4

Multiple
Z p/as ties —
Te/isron
diffused

The concentrat on of lateral tens on b> the single Z-pIasty n contradistmct on
to the multiple Z-plasty which spreads the lateral tens on o er the several
transverse diagonals

PRACTICE OF THE Z-PLASTi

From the theoretical discussion it follows that the Z plast) is
most effectn e where the contracture is narrow and the surrounding
tissues are lax enough to permit a reasonablj large Z to be con
structed since scarred and contracted tissue on either side can
Meld no slack to allow lengthening

Ideallj the central limb of the Z extends the full length of the
contracture but this requires a corresponding!) large quantit) of
tissue to be brought m from the sides tissue which is not alwajs
ai ailable It is in the limbsparticularh that this problem anses for
such tissue as is at ailable is not concentrated at one point but is
spread out along the length of the limb In such circumstances the
solution ma> be to construct a senes of short Zs instead of one
large Z and so bnng in from the sides small quantities of tissue
all the waj down the line of the contracture (Fig 2, 4)

TKC Z PLASTl

45

A good measure of the planning and execution of a Z-plasty
is the behaviour of the flaps v\hen the contracture is released
If the manoeuvre is indicated and well planned the flaps should
literally fall into their new transposed position indeed it should
be difficult to get them back into their old relationship

It is when the contracture is of the grossly bow string type that
the Z-plasty is most effectiv e ^ ith the contracture more diffuse
in breadth and length it is less satisfactory’ and a stage is reached
where it must be decided whether a Z plasty is an adequate pro-
cedure or whether fresh skin must be imported from elsewhere
as a free skin graft The answer is usually to be found m the
surrounding skin skin must come from somewhere if the
contracture is to be released and if it is not obviously available
at the sides (Fig 2, 3 ) the Z plasty will fad and a free skin graft is
the true answer to the problem

Planning the Z-plasty (Figs 2, 6 and 2, 8)

It may be difficult m planning the procedure to decide where
the flaps should be A good method is to draw an equilateral
triangle on each side of the contracture (see Fig i, 9) and from
the resulting parallelogram to select the more suitable of the two
sets of limbs One set may have no particular advantage in which
case either may be used Factors which might favour one set
rather than the other are

1 The flap with the better blood supply is preferable in
particular one with scarring across the base should be avoided

2 One or other flap may give a scar which will fall into a
better line cosmetically The factors which would influence
the choice in such circumstances have already been discussed
in Chapter One

3 The he of the flaps and thesurroumbng skin may permit one
set of flaps to rotate more readily into their transposed position

Skin which is scarred has lost much of its normal elasticity
and this may affect slightly the planning of the flaps A flap of
scarred skin should be made a little longer initially than its fellow
of normal skin otherw ise the scarred flap will be found to be too
short when it is sutured to the unscarred flap

It is usual though not absolutely essential to have the two angles
of equal size On occasion a line of scarring will limit the angle

TIIC Z PLASTY

47

of one Hap nnd dissimilar angles mi) then ha\e to be used
Lengthening in such a case becomes the nerage of the amount to
be expected from each anglealone Indeed if the full quadrilateral
of im Z is drawn complete with con tract oral md transverse
diagonals the transverse dtigonil will always show the actual
length to be expected when the (laps arc transposed

Parallel construction Skew construction

Fic 2 7

The e\oluton of the parallel and skew types of the continuous mull pie
Z-plasty from a series of interrupted smalt Z plasties

The multiple Z-pIastj

"W hen a large Z cannot be used for the reasons already discussed
the alternative often lies in multiple small Zs The line of con
tracture can be regarded as a senes of contracted segments and a
small 7 can be constructed for each segment Carmng such an
idea to its logical conclusion (Tig 2, 7) creates a continuous
Z-ptasty where the Zs instead of being individual form a
continuous senes gw mg the appearance of a long line along the
contracture with multiple L side limbs (fig 7, 6) The Zs can be
constructed with the side limbs either parallel or skew The

fundamental TECHNIQUES OF PLASTIC SURGERY

presence of scarring in a particular l.ne maj ln fl„ e nce the con

X ; and ma r e Ske ' V naps P refen,Me but the use of parallel
limbs allows uniform rotation of the flaps m transposing and
presents the occurrence of the broad tipped flap with rtie „a OT w
base which is undesirable from a vascular point of view and
inevitable with the skew construction

Whether a multiple Z-plastv must be used will large!) depend

The planning and execution of a mult pie Z-plasty in correcting a localised
post bum contracture of neck

on the depth of the bow string It is unwise to take the side
limbs much beyond the base of the bow string and if the making
of a large Z would encroach on the surrounding flat skm to any
extent especially if it tends to be taut then a multiple Z-plast)
(Fig 2 , 8) is safer and on the whole just as effective

Blood supply of the flaps

The most frequent complication of the Z plasty is necrosis of
the tip of a flap and it is particularly common if there has been
much scarring of the skin Precautions to avoid necrosis can be
taken at all stages of the procedure, by providing the flaps with
the maximum of vascular capacity by avoiding tension and bv
meticulous haemostasis

Provision of maximum vascular capacity This is achieved by
designing the flaps broad at the tip by avoiding scarring across

THE Z-PLAST\

49

the base and by cutting the flaps as thick as possible The flap tip
can be broadened without affecting the angle size by slightly
modifying the shape of the flap {Fig 2, 9) The thickest flap
practicable should always be cut using the levels of undermining
suggested in Chapter One

Avoidance of undue tension This can be a very difficult problem,
particularly when the contracture is a doubtful candidate for

Standard shape Shape modified to

of flap broaden flap tip

Fig 2,9

The mod Red shape of Z-plasty flap to gn e maximum
vascular capacity

Z-plasty or free skin graft The large, single Z concentrates
transterse tension while multiple small Zs diffuse the tension
making it less at each individual Z so that embarrassment of the
circulation from this cause is reduced to a minimum

While the contracture may be placed under tension during the
procedure to display its line and extent the parts should be dressed
and bandaged in a mid position to promote relaxation of tissues in
all directions

Meticulous haemostasis Haemostasis avoids the disaster of
haematoma adding to any tension and undue pressure of dressings
either or both of which can cause necrosis

BIBLIOGRAPHY

Davis J S 'v Kitlowski E A (1939) The theory and practical use of
Z mconon for relief of scar contractures Arrrt Sttrg tog, root
Limb erg A A (1946) Mathen atical principles of local plastic procedures
on the surface of the human body Leningrad Medg s Thi9
monograph contains by far the most exhaustive and authoritative
discussion of the Z plasty both its theory and practice
McGregor 1 A {1957) The theoretical basis of the Z plasty Brit J
plast Sttrg 9, 256
D

CHAPTER THRrE

Free Skin Grafts

AS a result of trauma pathological process or surgical excision
*l )e surgeon way be faced with a defect of skin w hich because
of its size cannot be closed by direct suture or which
because of its other characteristics, is unsuitable for suture He must
then consider whether alternative skin cover is possible and if it ts
possible what form it should take On most occasions the skin
cover of choice will be a free skin graft though circumstances do
arise where a free skin graft cannot be used and a flap is needed
The indications for the use of a flap wall be discussed in Chapter
Tour the present discussion is concerned primarily with the
use and practice of free skin grafting

As its name implies a free skin graft is completely detached
from the body during its transfer from donor to recipient site
It is used in circumstances which vary enormously and examples
of these are

1 Where there is loss of skin following trauma Grafting
may he earned out primarily immediately after the traumatic
episode or secondarily when granulations have developed

2 Where a residual skin defect is left following excision of a
simple or malignant tumour

3 Where an ulcer e g gravitational caused by a non
neoplastic pathological process is present

As a general rule a free skin graft will be accepted by any site
which left ungrafted would rapidly develop granulations
Although most often used to repair a skin defect such a graft
can also cover a defect of the mucosa of the accessible mucous
membrane lined cavities — mouth eye, accessory sinuses etc
50

free skin crafts

5 *

Free skin grafts (rig 3, 1) are of two kinds.

1 Whole skin graft consisting of epidermis and the full
thickness of dermis

2 Split skin graft consisting of epidermis and a \ amble
quantit} of dermis Split skm grafts are described as thin
intermediate or thick according to the amount of dermis
included

He 3 1

A trims -ersc sect on of skin sho or the th ckncss and co nponents of tl e
var oua type* of free skin graft

While the properties of the whole skm graft art reJatnel)
constant those of the split skin graft depend in some degree on the
thickness of its dermal component the thicker split skm graft
appro\imating to the whole skin graft in its characteristics

1 he whole skin graft takes less rcadih than the split skin graft
and before it can be used successful* conditions must be optim it
Hie thinner the split skin graft the better arc its chances of taking
tn difficult conditions

The stability of a graft depends on dermis and so the thicker
grift stinds late trauma better than the thin graft

The whole skin graft remains Mrtuallj at its original size the
split skin graft tends to contract if circumstances permit c g
inside the mouth or across a flexure \\ ithm broad limits the
thinner a graft the more it will contract secondarih

1 he donor site of the split skin graft heals spontaneous!*

52 FUNDAMENTAL TFCJINIQtlES OF rL\STIC SURCEJtt

while that of the whole skin graft has cither to he closed In suture
or co\ered with a split skin graft 'I his places a limit on the area
of whole thickness skin which can usefullj he cut

TAKE AND YASCUL VR 1 S \TIO\

Bj definition a free skin graft must be without blood supplj
until the \essels of graft and recipient area link up At normal
skin temperatures a skin graft without an effective blood supplj

A diagrammatic representation of graft tale
A Initial anchorage b> fibrin

IJ Commencing orginisation of fibrin clot with ingrowth of capillaries from
graft bed and graft

C Link up of blood vessels of graft and graft bed, and organisation of fibrin
into fibrous tissue attachment

has a limited survival time and so the rapid provision of such a
supplv is v ital The process of attachment to the recipient area
and vasculansation of the graft are referred to ns "take’ of the
graft

Initial!} there is a link-up between the capillaries of graft and
recipient area (rig 3, 2) This initial linkage is said to he re-
inforced bj fresh ingrowing \csscls from the graft bed so that the
vascular pattern of the graft is rc organised but the evidence for
this is not verv substantial The initial link up is usual K well
advanced hj the third daj At this time the attachment of the
graft to its bed is verj tenuous and remains so until the initial
fibrin clot anchorage has become organised into a fibrous tissue
attachment a process which takes some time The graft must he
protected during this period lest rupture of linking capillaries
occur with resulting haemorrhages under the graft

The speed and actual process of vasculansation of grafts lias

FREE SKIN GRAFTS

53

been inadequate!) studied in the human but in general thick grafts
are less rapidlj \ascularised than thin The anatomical la) out of
dermal capillaries may explain this, for the densit) of the capillar)
network of the superficial dermis is much greater than that of the
deeper dermis In a thin graft the greater densit) of cut capillary
ends will greatly increase the chances of meeting of the capillaries
of graft and graft bed with consequent rapid union and vasculansa
tion on the basis of mere random link up for there is no evidence
that chemotactic influences pla) any part in vascular link up

NO TAKE TAKE

NO GRANULATIONS GRANULATIONS

ric 3 3

Cap llary outgro vth as the common factor in the de\ elopmcnt of granulations
on \ anous surfaces and the r capacity to take free skin grafts

Factors Influencing Take

Take depends on rapid \asculansation and to achtete this
certain requirements must be met

1 A recipient site capable of producing capillar) buds

2 Accurate approximation of graft and recipient site so that
the granulation tissue zone between the two surfaces is
reduced to a minimum

3 Immobilisation during the phase of vascularisation

The recipient site Capillar) outgrowth is needed both to
produce granulation tissue and to vasculanse a graft and so the
potential recipient area incapable of producing granulations
Will not take a free skin graft (Fig 3, 3) As a corollary of this
the surface which granulates rapidl) and well takes a graft readil) ,
one which granulates poorl) takes a graft less readily

The parallel shows well when fat and deep fascia are compared
for just as deep fascia granulates better and more rapidly than fat
so it prowdes a better bed for grafting The need for capillary

Fic 3 4

Typ cal areas — si otcn in black — uh ch will not take a graft successfully
A Bare cort cal outer table of skull
B Bare tendon of extensor d gitorum

C Bare cortex of metacarpus and proximal phalanges t th art cular cart I age
and open metacarpo phalangeal jo nts

Granulations become less \ ascular and more fibrous as they
age and the sooner thej are grafted the better the chance of take
Infection tends to complicate the issue m such a situation for the
longer a granulating area remains ungrafted the greater ire its
chances of infection nh ch mil \ ltiate graft take

TRFC SKIN GRATTS 55

Accurate approximation The shorter the distance to be
travelled by the capillaries outgrowing from graft bed and graft
dermis to join each other the more rapid and effective will be the
development of a circulating sjstem in the graft This makes it
essential to have intimate contact of the graft and its bed and the
commonest cause of separation of the two surfaces is blood clot

Close Contact —
JZapid Vasculansation

Separation by Haematoma
— LajJure to \&scu/anse
—Loss of Craft

Immobile Contact —
Capillary Link up

mum

Movement of Graft — •
No Capillary Link up —
Loss of Craft

Fic 3 $

The influence of accurate appro* mat on anil mmob le confcfce on
the vasculir sat on of a graft

(Fig 3, 5) which forms a harrier through which capillaries cannot
grow in time to prevent necrosis of the graft

The need to have the two surfaces contain the maximum
possible number of capillar) ends explains the usual practice of
-removing all fat from the whole skin graft Fat is relatively
av ascular compared with dermis and would act in effect as a block
to the contact of the two vascular surfaces

Methods of ph)Sio!ogicaI fixation involving the use of
plasma and thrombm have been described but these have no
influence on the take of a graft They are effective only if the
principles here stated are followed and if these principles are

54 FUNDAMENTAL TECHNIQUES Or PLASTIC SURCERA

outgrowth from the graft bed means also that a free skin graft will
not take on tendon bared of paratenon on denuded cortical bone
ar on cartilage (Fig 3, 3 and 4)

Fie 3 4

Tvp cal areas — if orm in black — \»h ch ' II not take a graft xucrcstf II)

A Bare cort cal outer table of sLull
B Bare tendon of extensor d gitorum

C Bare cortex of metacarpal s arul proximal phalanges \ th art cular cart lap
and open metacarpo phalangeal jo nts

Granulations become less tascufar and more fibrous as thei
age and the sooner thc\ arc grafted the better the chance of take
Infection tends to complicate the issue in such a situation for the
longer a granulating area remains ungnfted the greater are its
chances of infection which will \itiatc graft take

Pure SKIN CRA FTS 5;)

Accurate approximation The shorter the distance to be
travelled bj the capillaries outgrowing from graft bed and graft
dermis to join each other the more rapid and effective will be the
development of a circulating s>stem in the graft This makes it
essential to hiv e intimate contact of the graft and its bed and the
commonest cause of separation of the two surfaces is blood clot

Close Contact —
Rapid Vascu/arisation

Separation by Hacmatoma
— /SvA/rv to \&scu/anse
— Loss of Craft

Immobile Contact —
Capillary Zink up

Movement of Graft —
Ac? Cap i //ary Link up —
Loss of Graft

He 3 5

The nfluence of accurate approxtmnt on and tmmob le contact on
tl e vasculansal on of a graft

(1 ig 3> 5) which forms a barrier through which capillaries cannot
grow in time to prev ent necrosis of the graft

The need to have the two surfaces contain the maximum
possible number of capillar) ends explains the usual practice of
removing all fat from the whole skin graft Fat is relativclv
jvascuhr compared with dermis and would act m effect as a block
to the contact of the two vascular surfaces

Methods of physiological fixation involving the use of
plasma and thrombin have been described but these have no
influence on the take of a graft The) are effectn e onl) if the
principles here stated are followed and if these principles are

56 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

adhered to they are unnecessary It is true that the early fixation
of a graft is by fibrin but both fibrinogen and the enzyme system
which converts it to fibrin are already present in ample quantities
without requiring to be supplied by the surgeon

Immobilisation During the phase of capillar) outgrowth and
link up the graft and its bed must remain completely immobile
relative to each other Shearing strains are particularl) to be
prevented (Fig 3, 5) for the best conditions for capillary link up
cationt obtain «i the presence c? such stsawwawd small movements
The immobility must in theory be continued until the anchorage
of the graft by fibrous tissue is strong enough to take such strains
without rupturing the capillaries

In practice other factors may influence the various time inten als
at least as far as the initial dressing following grafting is concerned
The whole skin graft is generally slower to vasculanse and is
usually left for 7-10 days while the split skin graft is left for 7 days
In the case of the split skin graft on a granulating area this may
have to be tempered by the problem of infection and it is usual
to dress such a graft on the fourth post operative day lestaccumula
tiori of discharge affect the graft adversely

A further dressing to provide support and immobility is
applied thereafter until the graft has consolidated clinically

The factor of pressure

As a result of the teaching of Ferns Smith it is often stated that
pressure preferably at the level of capillary pressure is necessary
to get a graft to take but this is not so provided the conditions
already outlined are fulfilled It must be recognised of course
that in most circumstances a pressure dressing is the surest way
of fulfilling them Nevertheless it is worth stressing that the
pressure is merely a means to the end of fulfilling the conditions
and has no inherent virtue of its own to justify its use A graft
may actually fail because of undue pressure which presumably
pre' ents the normal flow of blood into the graft bed It is in the
scalp face and limbs that such pressure is likely to be attained by
circumferential bandaging It is most prone to occur where bone
closely underlies a graft and a minimum of soft tissue is present
to buffer the pressure Indeed it needs pressure of an order
which would produce a sore even m intact skin

FREE SKIN GRVFTS

57

The phenomenon of bridging

A graft ma\ take over bare cortical bone, tendon or cartilage,
and even if separated from its graft bed by blood clot, provided
always that the area is small enough In such circumstances the
graft survives by bridging (Fig 3, 6), a phenomenon of particular
interest m view of the light which it throws on the process of
vascularisatjon It provides confirmatory evidence of a link-up
with the ousting vascular network of the graft since bridging
could not occur if vascularisatron took place bv capillar} invasion
from the graft bed

NECROTIC CRAFT

■ — ■ ^

FIT] CAL —

- r^- -r- ~ — j

Successful bridging Failure to bridge larger defect
of small defect

Fic 3, 6

The phenomenon of bridging

In most circumstances bridging is strictly limited in area and
beyond this necrosis will occur Certainly it cannot be relied on
to cover bone, tendon or cartilage successful!) Where a very rich
vascular network exists both in a graft and its bed, however,
bridging maj be possible over a much larger area and the composite
free graft of ear skin and cartilage for alar defects succeeds or fills
largelv on the extent to which bridging is successful

THE W HOLE SKIN GRAFT

'I he whole skm graft requires optimal conditions to take
successfully and so cannot be ipplied for example to a granulating
area A graft of relativ el) small size only can be used for its donor
site must cither be closed by suture or covered with a split-skin
graft These adverse qualities natural) limit its usefulness m
practice

Its desirable properties on the other hand make it v cry much the
graft of choice in certain circumstances It docs not contract
secondarily and this makes it suitable for skin replacement around
the mouth and evehds, and on the palmar aspect of hand and

56 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

adhered to they are unnecessary It is true that the early fixation
of a graft is by fibrin but both fibrinogen and the enzyme system
which converts it to fibrin are already present in ample quantities
without requiring to be supplied by the surgeon

Immobilisation During the phase of capillary outgrowth and
link up the graft and its bed must remain completely immobile
relative to each other Shearing strains are particularly to be
prevented (Fig 3, 5) for the best conditions for capillary link up
cannot obtain in the presence of such strains and small movements
The immobility must m theory be continued until the anchorage
of the graft by fibrous tissue is strong enough to take such strains
w ithout rupturing the capillaries

In practice other factors may influence the \anous time inter\als
at least as far as the initial dressing following grafting is concerned
The whole skin graft is generally slower to vascularise and js
usually left for 7-10 days while the split skin graft is left for 7 days
In the case of the split skin graft on a granulating area this may
have to be tempered by the problem of infection and it is usual
to dress such a graft on the fourth post operativ e day lest accumula-
tion of discharge affect the graft ad\ersely

A further dressing to provide support and immobility is
applied thereafter until the graft has consolidated clinically

The factor of pressure

As a result of the teaching of Ferns Smith it is often stated that
pressure, preferably at the level of capillary pressure, is necessary
to get a graft to take but this is not so provided the conditions
already outlined are fulfilled It must be recognised of course
that in most circumstances a pressure dressing is the surest way
of fulfilling them Nevertheless it is worth stressing that the
pressure is merely a means to the end of fulfilling the conditions
and has no inherent virtue of its own to justify its use A graft
may actually fail because of undue pressure which presumably
prevents the normal flow of blood into the graft bed It is in the
scalp, face and limbs that such pressure is fikefy to be attained by
circumferential bandaging It is most prone to occur where bone
closely underlies a graft and a minimum of soft tissue is present
to buffer the pressure Indeed it needs pressure of an order
which would produce a sore even in intact skin

TREE SKIN GRAFTS

57

The phenomenon of bridging

A graft ma) take o\er bare cortical bone tendon or cartilage
and even if separated from its graft bed by blood clot provided
always that the area is small enough In such circumstances the
graft survives by bridging (Fig 3, 6) a phenomenon of particular
interest m view of the light which it throws on the process of
vascularisation It provides confirmatory evidence of a link up
with the existing vascular network of the graft since bridging
could not occur if vascularisation took place by capillary invasion
from the graft bed

NECROTIC GRAFT

■

m

I

Hg

■

Successful bndqmq Failure to bridge larger defect
Of small defect

Fic 3 6

The phenomenon of br tlging

In most circumstances bridging is stnctlv limited in area and
beyond this necrosis will occur Certainly it cannot be relied on
to cov er bone tendon or cartilage successful Where a very rich
vascular network exists both in a graft and its bed however
bridging may be possible ov er a much larger area and the composite
free graft of ear skin and cartilage for alar defects succeeds or fads
largely on the extent to which bridging is successful

THE WHOLE SKIN GRAFT
The whole skm graft requires optimal conditions to take
successfully and so cannot be applied for example to a granulating
area A graft of relatively small size only can be used for its donor
site must either be closed by suture or covered with a split skin
graft These adverse qualities naturally limit its usefulness in
practice

Its desirable properties on the other hand make it very much the
graft of choice in certain circumstances It does not contract
secondarily and this makes it suitable for skm replacement around
the mouth and eyelids and on the palmar aspect of hand and

5§ FUNDAMENTAL TECHNIQUES Or PLASTIC SURCEB*

fingers It stands pressure well and so is useful on the sole of
the foot In the face moreover a whole skin graft from one of the
more suitable donor sites described below will give in genera] the
best colour and texture match

Donor Sites

The thickness appearance, texture and \asculanty of skin
\arj greatlj m different parts of the body and ha\e a strong
influence on the selection of the donor site appropriate to a
particular surgical situation

of closing the resultant defect

Post-auricular skin The posterior surface of the ear and the
adjoining post -auricular hairless mastoid skin (Fig 3, 7) make the
best donor site when the face is being grafted The one dis
adtantage is the limited quantity of skin available and this restricts
its use \ery matenallj It gives a most excellent skin colour and
texture match (Fig 3, 8) and when replacing ejelid skin is often
% irtuall) undetectable The vasculant) both of the graft and the
sites to which it is usually applied make it the easiest of whole
skin grafts to get to take The donor site is closed bj direct suture
The post auricular whole skin graft has its mam use m repairing
small defects of the face and the area of skin available behind the
ear alone limits the size of the defect which it can be used to co\ er
Supraclavicular skin The skin of the lower posterior triangle
of the neck (Fig 3, 9) gives a good colour and texture match used
on the face though one distinctly inferior to post auricular skin
A larger area of skin is available but the increase is too small to

FREE SKIN GRAFTS

make it more obviously useful as the donor area itself must be
grafted in most instances. This adds a cosmetic defect of its

60 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

Flexural skin. The antecubital fossa and the groin are both
possible donor sites. The dermis is thin and the shin mobile on the
deeper tissues. Applied to the face the cosmetic result is not greatly
inferior to that using supraclavicular shin. Onlj a limited quantity
is available unless a secondary graft is used to cover the donor site.

In the antecubital fossa the donor site is more often exposed
and the scarring of closure consequently more of a drawback.
Furthermore, if much tension is used in closing it by direct suture
a hj pertrophic scar or keloid may develop. In the groin the pubic
hair maj limit both the use and quantity available but the area is
valuable if a long narrow graft is needed, for closure in such
circumstances is relative!} simple.

The groin is more generally useful and for the hand it provides
a good source of shin

Thigh and abdominal skin. The texture and colour match of
thigh and abdominal shin grafted to the face is usually poor.
The shin either sta)s extreme!} pale or becomes hyperpigmented
rclatn e to the rest of the face. An added defect is a loss of the
constantl} varying fine play of normal facial expression. The
grafted area has instead a rather mash-like appearance due possibly
to its thicker dermis Although a thick split-shin graft cut from
the abdomen with the drum dermatome tends to be used rather
than a whole shin graft for replacing extensive areas of facial shin
loss it shares the defects of the whole shin graft.

Both sites provide a good source of shin for the palm of the
hand and the thick dermis gives a good pad to take the necessary
pressure used on the sole of the foot. If a graft of an} size is used
the donor site must in its turn be grafted and even when the donor
site can be directly sutured the scar usually stretches badl}.

Method of Use

The whole shin graft is accuratel} fitted to the defect
a pattern of the defect to be grafted must be made to h-
graft at normal shin tension in its new s^|^Alutnmium
jaconet, and oil silk are all useful matena>* 'faking ,

Around the evelids aluminium foil is psK
the others are more satisfactory .

The graft will be used under two
influence the method used to make »1

FREE SKIN CRAFTS

6l

Where the area and contour of the defect are accurate!}
known beforehand, eg when remo\ing a nae\us, it is best to
mark out the area of excision and make the pattern of this outline
This avoids having to make a pattern of the post-e\cisional defect

Imprint on jaconet Cuttmq the pattern

Fic 3, 10

The making of a jaconet pattern of the outline of a lesion prior to its excision

which would be too big because of wound retraction or of the
pathological specimen after removal which would be too small
foT the same reason

An outline of the shape can be made easilj , making use of the
solubilitv of Bonney’s Blue in spurt (Hg 3, 10) A sheet of jaconet
moistened on the fabric surface with spint and pressed on the
lesion outlined with the dye lifts enough colour to leave 3 good
imprint of the outline on the fabric

62 FUNDAMENT \L TECHNIQUES OF PLASTIC SUliCERl

men the area is irregular it is wise to orientate the graft before
cutting with multiple dje tattoo punctures (Fig 3 n) to fit
corresponding marks in the skin surrounding the defect to be
grafted Failure to do this can make the fitting of the graft
unnecessaril) difficult

Fig 3 11

The tattoo ng of matching po nts to fac I tate or entat on of the graft for
suturing

Where the defect is not known beforehand, eg following
excision of a malignant lesion or release of a contracture the
pattern can only be made once the defect has been surgical!)
created In those circumstances the defect should be d splajed
to the full before making the pattern This applies with particular
force to the e)elid where failure to make the pattern and subse
quently the graft of a size to fill the defect in full will result in
residual ectropion

TREE SKIN CRAFTS

6. 3

Cutting the Graft

In cutting a whole skin graft (Fig 3, 12) time and care can be
spent at the actual time of cutting so that no fat is left on the graft
or the graft may be cut without special regard to fat the fat being
subsequently removed with scissors Excision of the fat after the
graft has been cut is a tedious business but to cut the graft without
fat requires both skill and care It is probably easier for the
surgeon who seldom uses the method not to attempt rt lest the
graft be buttonholed in the process Most surgeons gradually
acquire a feel for the correct plane at the time of cutting the graft
\ useful dev ice especialh m the concavity behind the ear is to
balloon the whole area with fluid Using the pattern alreadv
made the outline is marked on the skin with Bonnev s Blue
incised and undercut It often helps to pull the skin of the graft
taut over the knife with hooks so that the knife is cutting blindlv
largch by touch Alternatively the graft can be held turned back
so that cutting is done under v lsion Oddly enough this method
is less precise and usually results in more fat being left on the
graft Any fat left on the graft must be carefullv removed with
scissors

Care of the Donor Site

Behind the ear closure by direct suture is usually feasible
Elsewhere direct suture should be used where possible In the
thigh and abdomen where the superficial fascia is relatively lived
the exposed fascia is best excised to facilitate closure In the
flexures where the skin is much more mobile this is less often
necessary V here the donor site defect is too large to suture
a split skin graft must be used to cover it

Tiir split skiin GRArr

A split skin graft may vary in thickness from what is virtuallv
a whole skin graft to one which is almost epidermal and each has
its place depending on which property of the particular thickness
is wanted It is used cither is temporary cov er to prov ide healing
eg m bums in the immediate post excision treatment of skin
malignancies in the coverage of bridge pedicle defects or as
permanent cover In general temporarv grafts are cut thinner
than permanent grafts but not infrequently a graft meant for
temporary cover proves entirely acceptable as permanent cover

&4 FUNDAMENTAL TECHNIQUES OF PLVSTIC SURGED

Making outline
of pattern

ft)-—

Ballooning |
area with fluid '

"\f Incising along
R outline

Cutting blindly
by touch ^

t Cutting under

"■ — Trimming fat
from graft

Fic 3, 12

The method of cutting a full thickness graft

FREE SktN GRAFTS f,

Donor Sites

These are selected in an\ set instance b\ such factors as the
amount of shin required whether a good colour and texture match
is needed local convenience as in grafting from forearm to hand
with need for only one dressing the necessitv of ha\ mg no hair on
the graft the cutting instrument available the desirability wl ere
possible of avoiding the leg m the aged or out patient

The usual areas are

\ irtually the whole of the reasonably plane surface of the
torso

The thigh and upper arm

The flexor aspect of forearm

When these are not available or all possible sues arc needed
skin can also be cut from

The other aspects of forearm

The lower leg

Graft-cutting Instruments
The instruments commonly used for cutting grafts arc
The Humbv knife which was developed from and ha» now
largely replaced the Blair knife
The drum dermatome
The electric dermatome

The Humby and Blair knives (Fig 3 13)

The Humby knife is similar to the Blair knife with the refine
ment of an adjustable roller which controls the thickness of the
graft cut It is the most frequently used instrument for routine
graft cutting despite the fact that both it and the Blair knife can onl\
be used on corn ex surfaces The technique of cutting with it is
readily acquired and for the surgeon who cuts only an occasional
graft it is much the better instrument of the two

The Blair knife is something of a \irtuoso instrument It is
much more difficult to use and when a large graft is being cut
comistenth correct thickness is a real achievement for most
surgeons \\ ith the ad\ ent of the Humb\ knife it is seldom used

E

66 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

Placing the donor site. The donor site most often used is the
thigh and the positioning of the leg for this purpose will be
described in detail (Fig 3, 14) but the principles outlined can be
applied to an} other donor site

The leg is placed with the appropriate group of muscles
relaxed so that by pressing the muscle group either mediallv or
laterall} the maximum of plane surface is presented to the knife

Humby Knife (Bodanham modification)

Hum by Knife ( Braithwaite pattern )

3 >

Humby Knife (Watson modification)

BlairKmfe (Bodenham modification )

Fic 3 13

The Humb> and Blair knives

For the medial side of thigh the leg is placed as in Fig 3, 14
The assistant presses from heron tilth the flat of both ha nds
pushing round the hamstrings and adductors to gne the necessary
wide flat surface for cutting a broad graft

When the lateral aspect is used (Fig 3, 14) the surface pro-
duced tihen the assistant presses laterally is less satisfactorily flat
than the me dial aspect especially in its loner part because of the
tautness of the 1I10 tibial band The depression uhich it produces
betueen the vastus lateralis and the biceps femons becomes less
noticeable proxunally

FREE SKIN GRAFTS

67

Tor the posterior aspect (Fig 3, 14) flexion of both hip and
knee are needed to get at the surface unless the subject is prone
Distally the ridges produced by the diverging hamstrings make a

Th gh — mtd al aspect Thigh — posterior aspect

(patient prone)

Th qh — poster or aspect Th gh lateral aspect

(pat ent ly ng on back)

Fic 3 14

Pos t oning the th gh for cutt ng a graft
good graft difficult to obtain but passing proximally the flat
surface broadens and a good graft can be cut readily

Because of the prominence of the femoral shaft the anterior
aspect does not give a broad plane surface and it is not used unless
all donor sites are needed

In the arm (Fig 3, 15) positioning and pressure are used in
the same way to give the broadest plane surface

FUNDAMENTAL TECHNIQUES 0F PLASTIC SURGERY

68

Prepimng the krnfe Ideally the blade when cutting mote, to
and tro smoothly over the skin surface which does not mote at all
with the knife Drag which is the result of friction between
blade and skin causes the skin to oscillate to and fro with the
knife and makes the graft more difficult to cut It cannot be

Arm lateral aspect

Arm medial aspect

Forearm — flexor surface

Fig 3 15

Positioning the arm for cutting a graft

complete!) eliminated but lubrication does help to reduce it The
usual lubricant is petroleum jelly and the surface of the blade
ne\t the skin should be smeared with it When the Humb)
knife is used the lubricant must be kept clear of the roller lest the
graft instead of gathering on the blade as it passes between blade
and roller should stick to the roller, winding itself around it
Setting the knife Setting the knife is necessary onl) with the
Humb) knife where graft thickness is controlled b) adjusting the
distance between roller and blade The advantage of the inter-

FREE SKIN CR\FTS

c 9

changeable blade which is now almost universal is that it gives a
much cleaner cut with minimal drag from bluntncss but this is
to some extent offset by the slight lack of rigidity of the blade
which is thin and only partly supported As a result the adjust-
ment markings present on the knife give a setting which tends to
vary u ith different blades and reliance on the markings alone in
setting the roller will give inconsistency of graft thickness

By holding the knife up to the light the actual clearance betw een
blade and roller can be seen and this method gives a more reliable
reading Although the surgeon learns with experience to set the
knife by eye a clearance of a little less than $ mm as a rule will
be found to give a graft of average thickness It must be empha
sised however that this must in turn be controlled by watching
both the graft as it is cut and the bed from which it is being cut
The guiding characters of thickness are described below
Cutting the graft The surgeon should worl from the more
convenient side of the patient cutting down the limb or up
according to his position

A little in front of the knife and moving smoothly at a fixed
distance from it a wooden board is held pressed hard down on the
skin (Fig 3, :6) The board serves the double purpose of
steadying and flattening the skin as the blade reaches it The edge
of the board which is pressing on the skin is lubricated with
petroleum jelly so that it moves smoothly with the knife To get
knife and board moving smoothly forward in unison takes practice
\\ ith both Blair and Humby knife the secret of good cutting
is to concentrate on an ev en to and fro motion rather than on the
forward moving of the knife as it cuts the graft

It may help to make the whole skin area as taut as possible by
having a further assistant hold the skin steady and tight with a
wooden board just behind the knife before it starts to cut The
board is kept still as the knife moves forward to cut the graft \\ here
the skm is atrophic, lax and mobile as m the aged or emaciated sub
ject this manoeuv re is useful insofar as it helps to eliminate drag
With the Bodenham modification the clearance between Toiler
and blade is apt to increase as the graft is being cut so that it
becomes steadily thicker and this must be watched for so that the
roller can be re adjusted to its original setting r I he Braithwaite
pattern is less prone to this and the roller mechanism of the recently
introduced Watson modification is virtually free of this defect

70 FUNDAMENTAL TECHNIQUES Or PLASTIC SURGERY

Assessment of thickness Although s setting of the roller has
been suggested above the surgeon must be prepared to modify it if
necessary The first J inch or so of the graft cut gives a good in
dication of the thickness and the setting can be adjusted accordingly
I he trmslucency of the graft is the main mdev of thickness

Fic 3, 16 j

Cutting a graft with the Humby knife

(Fig 3, 17) The very thin graft is translucent and not unlike
tissue paper, the grey of the knife blade shows easily through
Thicker grafts are increasingly opaque until the whole skin graft
has the colour and appearance of cadaver skin A split-skin graft
of intermediate thickness is moderately translucent

The pattern of bleeding of the donor site gives a further indica
tion of thickness (Fig 3, 18) The thin graft produces a high
densitj of tiny bleeding points, the thicker graft gives a lower
density of larger points

While these criteria are generally applicable they should ahiajs

Fjc 3 17

The translucencj of d detent th ckncsses of tpl t skin graft
A Thin B Med um C Th ck

Fic 3 18

The pattern of bleeding of the donor sites of d fferent th ckne^ses of spl t skin
graft

A Thin B Med um C Thick

72 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

be correlated with the initial appearance of the skm in the
individual patient particular!) as to the presence of clinical atrophv
\\ ith the papery skin of the aged the graft must be corresponding!)
thin and the distribution of bleeding points gives no help in such
cases

The thickness of the skin also seems to var) in various parts
of the limb in general lateral is thicker than medial and distal
thicker than proximal in the individual but individual variation is
considerable

The drum dermatome

In Great Britain the model generall) used is the Padgett Hood
or one of its modifications (Fig 3, 19) Its clumsiness and un
certaintv in use compared with the Humb) knife have prevented
it from achieving great populant) for routine purposes An
added defect is that successive drums of skin are not readil) cut
without meticulous cleansing and fresh preparation of both
dermatome and skin None of these criticisms appl) to the Reese
dermatome which is currentl) popular m the United States and
which is a much superior instrument It is unfortunatel) not
manufactured m this country The description which follows
refers onl) to the Padgett Hood instrument or its modifications
and not the Reese dermatome

Although the drum dermatome is not used routinel) there are
occasions where its use is particular!) indicated The precise
indications naturall) depend to some extent on the relative skill
of the operator with dermatome and grafting knife but in most
cases the Humb) knife is preferred unless there is a positive
reason for using the dermatome In the extensive deep bum
where all donor areas are needed the dermatome may have to be
used since at least until the advent of the electric dermatome it
alone could cut from abdomen chest and much of back On the
credit side the dermatome graft is recogmsabl) uniform in thick
ness and this gives it a cosmetic advantage over skm cut with the
Humb) knife when the face is being grafted It is in providing
extensive skin cov er for the face that the dermatome graft finds its
main use and in those circumstances a thick spl t skin graft is used
In using the dermatome the drum and donor area are painted
with an adhesive compound When the drum is pressed against
the skm the two surfaces adhere and the skin can be lifted with the

FREE SKIN GRAFTS

73

drum for cutting by the knife blade which is mcned to and fro
parallel to the axis of the drum at a preuoush adjusted freed

Fic 3 19

The drum dermatome and ts use
A Pa nt ng the drum with adhesive

R Lift ng the sk n with the drum before beg nning to cut the graft
C Cutt ng the graft
D Str pp ng the graft from the drum

clearance distance As cutting proceeds the graft is left adhering
to the drum (Fig 3, 19)

Cutting a graft With the dermatome can onl) be learned b)
demonstration and practice and it is not proposed to discuss the
technique in anj detail There are some hints however, which
ma\ help the beginner

74 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERV
Graft thickness Most instruments have a gauge which deter
mines thickness A graft of medium thickness is 12-14/1 000
inch but thicknesses from 8 or even less up to 16 or 18 can
be used according to need As with the Humby knife the gauge
reading is not always accurate and it should always be matched
against the graft actually cut It is often difficult to see the graft
well early on in the cut but almost as good an indication is the
density and size of the bleeding points of the donor area A thick
graft is technically easier to cut than a thin one When lobules of
fat appear the graft is m effect of whole skin graft thickness

Lacquering the surfaces Both drum and skin should be given
a thorough preliminary cleansing with ether to remove all grease
so that the lacquer will stick properly Smooth application of the
lacquer helps it to dry uniformly The edges of the drum take the
greatest pull when the dermatome is cutting and should be
carefully lacquered Being colder than the skin as a rule the drum
dries more slowly but patience m waiting until the surfaces are
quite dry pays dividends

Lubrication Both the surface of the knife mov ing against the
skin and the axle of the drum should be smeared with petroleum
jelly to help the knife to move smoothly to and fro Lubricant
must not get on to either of the lacquered surfaces or complete
loss of stickiness w ill result

Cutting the graft A good initial cut of the knife blade usually
means a good graft and care with the first cut is worth while
making sure especially that the skin is sticking from side to side
of the drum Just how far the drum can safely be raised to pull
up the skin for cutting depends on the laxity of the skin Raising
the drum too little allows the knife to plough deeph into the skm
beyond the side of the drum and an assistant should be ready to
depress, the shin here with a suitable instrument Raising the
drum too far increases the tension unduly and is liable to tear the
skin from the drum so that the knife cannot cut properly and this
produces a patchy incomplete drum of skm The middle course
is only acquired with experience as is the co ordinated to and fro
cutting of the knife and forward rolling of the drum

Removing the skm from the drum The lacquer remains

FREE SKIIS GRAFTS

75

largely on the graft and as it is taken from the drum its stickiness
must be removed With mosquito forceps on each corner to
elevate the margin of the graft an ether swab wall remove the
lacquer as the graft comes off the drum This method is effectiv e
but messy and a cleaner waj is to spraj the graft coming off the
drum with either penicillin or sulpha ponder The lacquer
remains on the graft but has lost its stickiness

The problem of residual lacquer on the graft has large!) been
solved recentlj bj using EVO STIR. IMPACT household
adhesive This contact adhesive can readilj be diluted to a
V iscosit) suitable for application to drum and skin bj adding an
equal volume of ether and stirring until the two liquids are well
mixed As an adhesive it is much better than an) the author has
previously used and it has the added advantage of bonding to the
drum even more strongly than to the skin so that the graft strips
off the drum completel) clean leaving the adhesive entire!) on
the drum

The electric dermatome

Although this instrument has been in use m the United States
for some time it has only recently become widely av ailable in this
countr) One of its major disadvantages is that it is at once a
complex and fragile instrument It does not stand rough handling
and if anything goes wrong it has to go back to the maker with
all the anno)ance and delay which this entails With it much of
the skill has gone from graft cutting and if the instructions are
carefully followed the surgeon can scarcel) fail to cut a graft
successful!) It has the great merit too of cutting a graft of
controlled w idth and accurately controllable thickness from almost
an) part of trunk or limbs and readil) cuts a ver) thin graft — a
thing that other instruments do less successful!) Its maximum
width is less than either the Humb) knife or drum dermatome
3nd with the more recent models available in this country the
width of graft cut can be narrowed at will a refinement already
present in the United States model

In appearance it is not unlike a large hair-cutting machine
(Fig 3 , 20 ) and the resemblance is maintained in action with the
rapid!) oscillating cutting blade which is driven either electrical!)
or by compressed air The skm is held stead) and lubricated

7 6 FUNDAMENTAL TECHNIQUES Or PLASTIC SURGERY

with liquid paraffin so that the instrument can move forward
smoothlj

It is in the grafting of the extensive deep burn that the electric
dermatome has been a very real advance Its abilitj to cut shin
from almost anj part of the bodj surface has greatly extended the
available donor areas The straight margin and uniform thickness
of the graft which it cuts mean that a limb can be complete!}

Fic 3

Cutt ng a very thin spl t skin graft \ 1 h the electr c dermatome

flajed with scarcely an} wastage of shin between adjoining graft
sites in the know ledge that the whole donor area will heal uniformlj
and rapid!) It becomes a practical possibility as a result to cut
successiv e crops of skin from the same donor site a most valuable
propertj w hen shin is at a premium

Healing of the Donor Area (rig 3, 21)

In the donor site of a split shin graft greater or lesser portions
of the pilo sebaceous follicles and sweat glands remain and from
these multiple foci epithelium spreads until the area is covered
with skin The pilo sebaceous follicles are much more active as
centres of epithelial regeneration than the sweat glands which
react more sluggisW} Anatomicallj the sweat glands extend
more deeplj than the hair follicles and this is reflected in the
different healing patterns of sites from which thin and thick

FREE SKIN CR \FTS

split skm grafts ha\e been cut I he donor site of the thin grift
on the one hand with its full complement of cut hair follicles heals
rapidl) within to da\s while the donor sue of the thick graft
on the other hand depending entirety on sweat gland remnants
heals much more slow!) taking 21 davs or more Most grafts
arc of intermediate thickness and lca\e a percentage of follicles

S 8 days JO 14 days

'Y |rj \f~\ f ",

tfs4^

71

rr

1 S 8 days JO- 14 days 16 20 days

H

Intermediate split skin graft

BW

\L ! 1 1 S 8 days IQ 14 days 16 20 days 2l(+)dsys

Thick split skin graft

Ik- 3 u

The 1 enl nR of tl e donor * te» of the various th ckncsscs of spl t si n graft

so that heihng takes to- 2 t dajs A donor area onty granulates
if no follicles or sweat gland* remain and in such circumstances
healing must take place from the margin of the area

It will be seen from this that the healing of a donor area is
analogous to that of a superficial burn

Care of the Donor Area

The m3in difficult m treating a donor site arises from the
fact that the dressing becomes e\trcmc|\ hard and sucks like glue
to the skm so that its remoaal causes bleeding and considerable
pain as the regenerating epithelium is tom off Usual practice

78 FUNDAMENTAL TECHNIQUES 07 ELASTIC SURCERT

is to leave the dressing quite alone until it separates spontaneous!}
or, failing this, to soak it off Such masterly inactivity is onl}
possible if the dressing remains dry \\ hen part of the graft has
been thicker the corresponding segment of donor area heals less
rapidly and may even granulate with resulting discharge It has
then tobetreated as a granulating vv ound If small in area it will heal
spontaneously, but if of any size it should be grafted without delay

A useful prophylactic where all or part of a donor area looks
at all doubtful from a depth point of view and particularly if fat
is showing to any extent is to cover it with a thm split skin graft
when the initial graft is cut Some surgeons practise routine
grafting of all abdominal dermatome graft donor areas Such a
practice of course buries some sweat gland and hair follicle
remnants and these do tend to form small cysts but such cysts
usually rupture at the surface without giving trouble and this
drawback is largely a theoretical one

THE RECIPIENT AREA

Free skin grafts are applied either to raw surfaces surgically
created or at least surgically clean, or to granulating wounds
The practice of grafting vanes with the two types of surface

The Surgically Clean Surface
Preparing the recipient area

Although a whole skin graft or split skin graft may be used
according to circumstance the underlying principle does not vary
A level surface is always desirable for irregularities are likely to
giv e rise to tenting of the graft across the hollow unless it is shallow
The common reason for failure of a graft where it might
reasonably be expected to take well is haematoma and a completely
dry field is essential before the graft is applied To this end
sev eral measures can be used

Infiltration of the area prior to excision Bleeding can be reduced
by injecting a vaso-constricting fluid into the tissue to be excised
The fluid usually used is local anaesthetic with adrenaline but as
some of the local anaesthetics are vaso dilators it is preferable in
the generally anaesthetised patient to use salme as the diluent
Either adrenaline or noradrenaline can be used Noradrenaline

FREE SKIN GRAFTS

79

is a weaker constrictor of cutaneous vessels than adrenaline but
it is less likely to give rise to side effects after absorption Consid
erable variation in recommended concentrations are described but
in the large \ olumes often required in plastic surgery concentrations
of i 2 parts m 200000 of sal me are safe and in practice effective
Ligature of obuous bleeding points The forceps must pick up only
the actual point so that the necrosis caused by the short fine cat gut
tie is minimal It has been taught that the graft wall not take over
cat gut but this is not so unless coarse massiv e ligatures are used
The diathermy is a possible alternative but against it the same
argument can be advanced as against cat gut In practice take is
not significantly reduced if the block of tissue killed by either
method is small enough

Local adrenaline If the tissue excised has not already been infil
trated local adrenaline or noradrenaline will reduce capillary ooze
Use of time Without doubt time is the most important single
factor in haemostasis The steps of the operation should be
planned to give the recipient area the longest possible time for the
normal haemostatic processes to become effective While waiting
for bleeding to cease the area may be left covered with gauze
soaked in saline or adrenaline or alternativ ely it may be irrigated
with adrenaline solution and then left exposed I\hat must be
avoided is constant dabbing and swabbing which only serve to
encourage oozing

Use and misuse of the sucker The sucker can play a most valuable
part during an excision in allowing the surgeon to see precisely
where he is cutting The defect once created however suction
applied to the raw area will only keep bleeding going If a
specific clot has to be sucked off the sucker nozzle should never
actually touch the tissue or the bleeder will surely begin again
W hen the graft has been sutured in position and the dressing
is ready some surgeons suck out any dots which have formed during
suturing 'While this is not ineffective the dressing must be
applied without delay for bleeding usually begins again as a
result of the trauma of the suction

Marginal bleeders For these a ligature is seldom needed W ith
appropriate placing the graft suture can be made to serve the
double purpose of haemostasis 3nd graft anchorage

So FUNDAMENTAL TECHNIQUES OF PLASTIC SURGFR\

Chip sy nnge and orange stick (Fig 3, 22) Unless the graft bed a
absolutelj dry it is wise to flush out the whole site with saline
once the graft is sutured in place using a chip syringe or a 20 ml
sjringe with blunt cannula Any small remaining clot can be
removed b) inserting an orange stick tipped with cotton wool

Removal of blood clots from under a graft with an orange stick and by
irrigation

When the stick is twirled the clot is caught b> the wool and can
be remo\ed with the stick

Plasma and thrombin Some surgeons use this to wash under the
graft as a final measure just before applying the dressing so that
the resulting clot wall anchor the graft As ahead) indicated the
procedure has no theoretical basis Its ritual use has been gcnerill)
abandoned with consequent simplification of grafting procedure
and no change in results
Applying the graft

The modes of application of a whole skin graft and a split skin
graft are similar in principle and in actual practice differ in onl) a

TREE SKIN GRAFTS Si

few particulars The sutures which fix the graft to position around
its margin are left long and tied o\er a plug of cotton wool which
acts as a combined pressure and immobilising dressing In this
role it is reinforced bj further dressings— gauze, cotton wool and
crepe bandages or elastoplast

The whole skin graft Cut to its prescribed pattern, the whole
skin graft is intended to fit the defect accurateh and so is carefullv

» wil-

l'll

ll 49

Tie 3.23

The application and suturing of a full thickness skin graft

sutured edge to edge along its margin (rig 3, 23) Fnough
sutures must be inserted to give as accurate an edge apposition as
would be demanded in the suture of an incision and just as in
wound suture, care must be taken to a\oid inversion of the edges
Onl) sufficient sutures are left long to provide a snug tic over, the
remainder arc cut short

The split-skin graft (Tig 3. 24) The tendenej of the spht skm
graft to contract subsequent!) makes it advisable to displav the
raw area to the full so that as much skin can be inserted as the
defect is capable of taking Such a graft is not usuallv spread
on tulle gras before being applied to the raw area though the
added ngiditj which the tulle gras backing provides sometimes
does make handling of the graft technical!) easier
F

8z fundamental techniques of plastic suRGrm

The graft should be cut large enough to overlap the raw area
slightly and there is no need to fit it accuratelj to the defect
It will take only to the margin of the defect in an> case and the
overlap can be trimmed off readily when the graft is dressed
If the margin is accurately sutured edge to edge it is apt to inroll

Suturing of graft in position

The appl cal on and suturing of a spl 1-sL n graft

and this gives a poor scar The overlapping suture avoids this
and also allows reduction of the number of sutures needed for as
long as the graft continues to ov erlap the defect bctu een the sutures
it will cover the raw area

At one time this technique was used onlv when a good cosmetic
result was not essential and in the face for example the graft was
carefully sutured end to end More recently the overlapping
method has been used even m the face with great simpfific-ttion of
technique and cosmetic results in no way inferior

FREE SKIN GRAFTS

83

Dressing the graft (Fig 3, 25)

A layer of tulle gras laid over the graft before the tie over
cotton wool bolus is applied tends to ease the first post operative
dressing but is by no means essential \\ hat is essential is the
careful packing of the graft area with the cotton wool and this

must be done meticulously so that the graft as a whole is subjected
to uniform pressure The plug must be bulky and extend to the
margin of the graft The most efficient shape is probably one
with a circular cross section which will spread the pressure evenly
With the wool tightly packed in position the long tie over sutures
are tied tightly over the dressing anchoring dressing and graft in
one mass

The material best suited to act as a plug is cotton wool prepared
with flavmc emulsion Alternatives are cotton wool moistened
with saline or tightly wrung out with liquid paraffin but flavine
wool * is much to be preferred because of its fluffing properties

Over further cotton wool padding to diffuse the pressure

* Preparation of flavine wool The materials used are Ihv ne emuls on
and best qua! ty cotton wool or Gamgee A sheet of cotton wool is soaked in
the emulsion previously warmed to reduce its v scos tv unt I it 1 completed
impregnated The excess of emulsion 13 then removed from the cotton wool
It is at this po nt that the usefulness of Gamf.ce becomes apparent for the covering
gauze odds to the strength of the material \\h ch can be rolled up and wrung out
by hand Th s must be done thoroughly unt 1 the cotton wool appears virtually
dry and no more emuls on can be extracted The sheet of cotton v ool s left
to dry off on a warm surface and when autoclaved is readv for use For ease
of hand I ng it can be wrapped in cellophane or packed in a tin

§4 FUNDAMENTAL TECHNIQUES of plastic slrgery

crepe bandages are applied If the site (ends itself better to
immobilisation b) elastoplast this should be used instead The
objectn e is as complete immobility as can be achie\ ed and both the
elastoplast and crepe are used to this end Plaster of Paris should
be used if it is felt that it will add significantly to the merall
immobility of the grafted area

The Granulating Area

In assessing a granulating area for grafting two factors are of
importance — clinical appearance and bacterial flora

Clinical appearance

Healthy granulations are flat, red and vascular, do not bleed
unduly readily, and are free from a surface film of sloughing
collagen Good marginal healing is presumptive evidence that
granulations will accept a graft for jt can be assumed that infection
virulent enough to destroy a graft would be mimical to marginal
epithelial growth

Unsatisfactory granulations take several forms

1 Granulations left ungrafted for any length of time become
more fibrous and less vascular so that it becomes increasingly
difficult to get a graft to take Infection tends to add to the
difficulties of grafting in those circumstances

2 When subjected to inadequate pressure, granulations tend
to become oedematous and in this state are often miscalled
exuberant Such granulations need pressure rather than
excision and copper sulphate has certainly no place in the
care of any surface nhich it is proposed to graft Its ooh
effect is to produce a coagulum which must be cast before a
graft will take

3 Haemorrhages are prone to take place into oedematous
granulations producing a very typical clinical appearance

4 The typically gelatinous, haemorrhagic granulations
harbouring Str pyogenes, which will be discussed later

5 When a slough separates naturally the granulations Jefi
often have a tenacious film of necrotic collagen which is slow
to separate and difficult to rub off

FREE SKIN GRAFTS 85

Bacterial flora

•\nj of the common organisms mav infect an area according to
site and circumstances \\ ith the exception of Str pyogenes and
Ps pyocyanea such organisms are of little consequence as a general
rule and clinical appearance is a better guide than bacterial flora
in assessing suitability for grafting

Str pyogenes The presence of this organism is in absolute
contra indication to an) grafting procedure its possible presence
necessitates routine bacteriological examination of exudate before
grafting is contemplated •''xNh) a graft should fail when it is
present is not evactlx known though interference with the normal
fibnn attachment of the graft b) the fibrinolxsin which it produces
ma) possiblx be the cause

Classics!!) granulations harbouring Str pyogenes are glared
gelatinous and bleed rcadi!) at the slightest touch the marginal
epithelium is seldom healthx and growing \\ ith the routine use
of antibiotics the classics! picture max not be seen and the granula
tions ma) look quite health) But this dcceptixel) tranquil
helm lour of Str py ogenes does not mitigate its destructix e effect on
grafts It must alwa)s be eliminated before grafting is attempted

Ps pjocyanea Infection with this organism does reduce graft
take but not to an extent comparable with Str pyogenes and its
presence is a nuisance rather tli m a disaster

Its cpidemiolog) is curious and unexplained \\ hen a large
number of burned patients are being nursed together it max be
quite absent for sexeral months Tor no apparent reason it then
appears on one burn and despite all the usual precautions rapidly
spreads to infect almost ex erx burned area in the ward No specific
steps can be taken to control the spread of infection because the
mode of spread is not preciselj know n Curious!) enough after a
period of some w ccks the infection disappears as suddenl) as it arose

The onl\ antibiotic to xxhich Ps pyocyanea is at all sensitixe is
Polxmyxm T and its use locall) has been recommended b) the
Medical Research Council Bums Research Unit But while
Ps pyocyanea max reduce graft take b) 5-10 per cent at most
grafting of the area on the other hand does tend to end the
infection Grafting regardless of Ps pyocyanea and accepting anx
small reduction in take gives excellent results

$6 FUNDAMENTAL TECHNIQUES OF FUSTIC SURCER\

In short a positive culture of Ps pyocyanea is not a contra
indication to grafting if the granulations look otherwise health)
Other pathogens The other pathogens which common!) infect
wounds are Staph aureus which in this situation is seldom more
than a commensal Bad colt and B proteus These latter two
organisms are especiall) common in the badl) handled heavih
contaminated granulating wound The\ arc associated as a rule
with a ver) t)pical profuse foul smelling discharge and often
occur as a mixed infection with Ps pyocyanea In the extensive
deep burn the) are often impossible to avoid hut all too often the\
are allowed to contaminate quite small wounds from which ordmarv
care would readd) exclude them

Preparing granulations for grafting

It is axiomatic that the granulating area is being treated not
its flora and so the role of local antibiotics is a controversial one
Antibiotics should not be used blindl) on the basis of scnsitmtv
reports Str pyogenes apart the flora is immaterial provided the
granulations look health) and the fastest wav to eliminate the
flora is to graft the area

In deciding the appropriate steps to eliminate Str pyot>mei
from a granulating area the organism cannot he considered in
isolation Penicillin is the obvious antibiotic to use when it is
the sole pathogen for no resistant strains hav e been demonstrated
When it is associated with a penicillin resistant staplnlococcus
however the penicillinase produced bv the staph) lococcus makes
penicillin much less effective and the antibiotic to which both arc
found to be sensitive is preferable Methicjlhn which is not
affected b> staph) lococcal penicillinase might be expected to be
effective against such a mixed Staph aureus and Str pyogenes flora
and a trial b) the MRC Burns Research Unit m infected bums
has been ver) encouraging Alternate eh one of the newer
antiseptic agents such as chlorhcxidme (‘ Ilibitanc ) nrn be used
The main cause of continuing infection is the presence of
slough measures to get rid of it ahva)s reduce the infection
Surgical excision is the most rapid and effective method and in
excising slough it pavs to be as radical as is feasible Excision to
fascia is preferable to excision to fat The alternative methods are
natural separation unaided or helped l v Eusol or the enrj mafic
agents for debridement

FREE SKIN GRAFTS

S7

here a slough is separating naturall) , pus is ine\ itable and is
by no means undesirable for its autolytic enzjmes plaj a valuable
part in separating living from dead tissue If there is no sign of
invasive infection the flora is to be regarded as innocuous, onlj
when the slough has gone is it possible to reduce the flora

The chemical agents for debridement, phosphoric and pyruv ic
acid which act by altering the local pH are unsatisfactory The\
are painful impossible to use in a sterile fashion and when the
main slough has separated there is left a tenacious film of sloughing
collagen which must be removed before grafting More recentl)
they have been replaced bv the enzymatic agents streptodornase-
strcptokinase and trvpsm but these have not achieved great
popularity and appear to have little to offer over the established
methods Eusol has still much to recommend it both for cleaning
up dirt) granulations and removing sloughs which are moist
diffluent and difficult to excise cleanly The Humby knife has
been used with the roller widel) open to excise both slough and
heavily infected granulations and is most effective in the role as
is also the electric dermatome

When granulations are clean and free of slough they should be
grafted without delay During such waiting as is unavoidable an
innocuous dressing which will not damage the granulations when
removed should be used and tulle gras is usual Unless Sir
pyogenes is present an antibiotic is not essential A meticulous
dressings technique adequate cover both in area and thickness of
dressing and infrequent dressings provide a better insurance
against superadded infection than a blind reliance on antibiotics
The other factor which will keep granulations as healthy as possible
for the longest time is pressure and crepe bandages are usual!)
necessar) to provide this

Applying the graft

Spreading the graft on a sheet of tulle gras (Fig 3, 26) eases
handling, tulle gras and graft can then be directi) applied to the
granulating area The graft is not usuall) sutured m place
though in a difficult situation a few tacking sutures ma) help to
prevent it sliding off the granulations while the dressing is being
applied There is no question of using the sutures for a tie over
dressing for the) would cut out verv rapidl)

'} he fixation of the graft is naturall) much less secure than that

88 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

of a tie o\ er dressing and it ls liable to slip during the first few
turns of the bandage if these are not carefully applied The outer
dressing consists of the usual gauze, cotton wool and crepe
bandage or elastoplast Bulk of dressing ma) be enough to
produce immobilit) but plaster of Pans should ahvajs be used
if need be to reinforce the dressings

Fic 3 26

The handling of a spill skin graft on tulle gras
A Laying the graft on the tulle gras which has been spread on a wooden board
B The graft spread on the tulle gras
C Cutting the graft into strips

The pros and cons of stamp grafting

It became usual during the 1939-45 War when large granulating
areas had to be grafted to cut the graft into squares of postage
stamp size and to applj these stamps rather than large strips or
sheets of skin Sex eral reasons were gn en for this

1 By spacing the stamps a small amount of skm could be
expanded to cox er a large area

2 The spaces between the stamps allowed the escape of pus
exudate, etc without lifting off the graft

3 Where fixation was difficult, as in the perineum or axilla,
stamps were less likely to be dislodged than a sheet of skin
which might become ruffled

It must be realised that methods of preparing \irtuall) sterile

FREE SKtN GRAFTS

91

pressure dressing instead of being a means to the desired end of
providing close immobile contact as it does elsewhere has become
the means of preventing that end The complete removal of the
dressing eliminates these shearing strains at a single stroke and
this is the basis of the exposure method of grafting method

relies on the natural fibnn adhesion between graft and bed —
merel) laid in position and protected from being rubbed off, the

Fig 3 28

Exposed grafting used in the treatment of the post eccis onal fefect foil / tt
radical vulvectomy for squamous carcinoma In th s instance grunuti ni «
were allowed to develop before the graft was appl cd

graft is allowed to he until vasculansation and W*

place in the usual vvaj (Fig 3, 2)

It should be appreciated that although supf *
technique is extremelj simple it imposes a discipline \
it is to be used successfully Although it is pcw k
primanl) if haemostasis is complete the fact that p"*
he used to prevent haematoma once the graft hr 1
means that haemostasis has to be most rigorous '
method is most successful!) used when ho 1 ''
are ahead) present and problems of haemo^

(Fig 3, 28) Of course to be able to watch &
an) little haematoma to be evacuated im/r*
snipping the graft

The method requires co operation fnr~
most dangerous time is during

92 FUNDAMFNTAL TECHNIQUES OF PLASTIC SURCERy

untcl full rcco\ erj from tire anaesthetic It is sometimes possible
to store the cut skin overnight in the refrigerator and apply it with
the patient conscious and co operativ e in bed

The protection need not be unduly elaborate If the area is
small an im erted stainless steel bowl or kidnej dish strapped across
is adequate (Hg 3, 29) Alternatively plaster of Pans built up
over the area so that it is protected can be used

The me of a kidney d sh to protect an exposed split skin graft
appl cd as in Tig 3 2S Note the use of the catheter to sa\e
unnecessary moxement of the pat ent and possible d slodgment
of the graft

There are many areas which can be successful!) grafted either
b) pressure or exposure methods and in most of these the pressure
method is still the one to use The exposure method should be
resen. ed for the site w here the pressure method is clearl) going to
be difficult or has alread) failed It is worth trying m the
problem of the small granulating areas between previous!) applied
stamps or sheets, those areas so troublesome and difficult to get
either to heal or accept a graft using conventional methods
As a technique its full potential is reall) still being explored
and its proper and permanent place has not )et been defined

FREE SKIN GR\rTS

03

STORAGE Or SUN

By storage at a low temperature skin cut in excess of current
requirements can be preserved viable for later use as needed
Within the temperature range 0-37 0 C the survival time of a
stored graft xs a function of its temperature and the lower the
temperature the longer the survu al time

The experimental work which shows this has been done mainly
With animal skin but enough is known of the behaviour of human
skin similarly stored to make the results clinically applicable
For long survival Ringers or Tyrodes solution should probably
be used to keep the graft moist but normal saline vv orks adequately
The graft is wrapped in gauze wet with the solution and placed
in a sterile sealed container Unless specially long survival
eg up to 2! day-s is needed the storage temperature is not of
paramount importance but it seems probable that 4 0 C is likely
to give the best results

LOCAL ANAESTIirSIA TOR GRAFT CUT! INC
Formerly the use of local anaesthesia for graft cutting was
restricted by the uneven surface which infiltration produced
coupled with the large volume of anaesthetic agent needed The
use of hy aluromdasc has removed these drawbacks and it is possible
now to cut quite large grafts readily if the enzy me is added to the
anaesthetic solution The solution diffuses so rapidly that it is
difficult to define exactly the area infiltrated and it is wise to outline
the area to be anaesthetised with Bonnev s Blue so that it can be
systematically infiltrated The exact amount of hy aluromdasc
which has to be used is not critical 1 500 international units
added to roo ml of anaesthetic solution will be found to work
satisfactorily

BIBLIOGRAPHY

Vasculansation of grafts

Calnan J &. Inms r L F (1957) Fxposcd delated primary sk n
grafts Bnt J plait S rg 10 11

Davis J S ^ Tnurr II F (1925) Ong n and development of the
blood si pply of wj ole th ckncss skin grafts At n Surg 82 871

94 fundamental techniques of plastic surgery
McLaughlin, C R (1954) Composite ear grafts and their blood supply

Brit J platt Surg 7, 274

Smith, F {1926) A rational management of skin grafts Surg Gynec
Obstet 42, 556

Healing of donor sites

Converse, J M &. Robb-Smith, A H T (1944) The healing of surface
cutaneous wounds Ann Surg 120, 873

Infection of granulations

Clarkson, P S. Lawrie, R S (1946) The management and surgical
resurfacing of senous bums Bnt J Surg 33, 311

Jackson, D M , Lowbury, E J L & Topley, E (19^1) Pseudomonas
pyocyanea in bums Lancet, 11, 137

Jackson, D M, Lowbury, E J L & Topley, E (1951) Chemotherapy
of Str pyogenes infection of bums Lancet, u, 705

Liedberc, N C , Kuhn, L R , Barnes, B A , Reiss, E & Asispacher,
W H (1954) Infection m bums Surg Gynec Obstet 98,693

Lowbury, E J L Lilly, H A , Miller, R W S , Cason, J S 1
Jackson, D M (1961) Treatment of infected bums with methi-
cillin Lancet 1, 1318

Storage of skin

Pepper, F J (1954) Studies on the viability of mammalian skin
autografts after storage at different temperatures Bnt J plait
Surg 6, 250

Buchan, A C (1958) Experimental studies on the storage of skin the
viability of human skin stored above freezing point Bnt J plait
Surg xi, 206

Local anaesthesia for graft cutting

CAMERON, J A (1951) Use of hyaluronidase to facilitate cutting of free
skin grafts under local anaesthesia Glasg vied J 32, 150

CH\PTER I OUR

Flaps, Pedicles and Tabes

T HESL types of tissue transfer are basicallj similar and the
general term flap will be used to co\ cr all three
1 he essential difference between i flap and a free shin graft
lies in the factor of blood supplj for in contra-distinction to the free
shin graft a flap retains a vascular attachment to the bod\ at all

Fic 4, i

I*he basic type* of llip transfer

times during transfer This implies in c\erj flap a functioning
enscular si stem, both arterial and \cnous, capable of maintaining
an adequate circul ition during the stages of transfer from donor
to recipient site T he presence of such a s\stcm enables a flap to
be transferred to an area whose blood supplj would be inadequate
to nouns!) a free shin graft and this \en factor is a frequent reason
for using a flap in preference to a free shm graft

There arc mam different tepcs of flaps (I ig 4, 1) Raised
from its donor surface lilt a lid or trap-door a flip ma\ he mo\ed
95

96 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

to its destination in se\ eral najs common!} by rotation, trans-
position or direct application, and the appropriate term is used
to describe the flap The greater pan or all of such a flap is
applied to the recipient site, there is little or no pedicle Wien a
flap does have a pedicle the vital element is usually its terminal
segment, the remainder forms its pedicle acts as its earner and
provides its channel of blood supply during transfer To reduce
sepsis b\ eliminating ran surfaces the flap is often made into a
tube and is then called a tube pedicle

THE PLANNING Or FL^PS
Defining the defect

Before repair by a flap is contemplated the extent of the defect
must be defined in terms of each component — shin bone and
lining In this the quality of the shin surrounding the obvious
defect must be taken into account Shin showing radiotherapy
damage or the fibrotic and atrophic changes of old scarring is not
good surgical material and is often better regarded as part of the
defect and excised in order to reach the good shin bevond it
(Fig 4, 2) In addition to its poor suture holding qualities the
avasctilanty of such shin makes it unsatisfactory for nourishing
a pedicle inset when the remainder of the pedicle is detached for
transfer A good criterion shin texture and appearance apart,
is the state of shin mobility , shin freely mobile deeply is usually
reasonably satisfactory to work with

Planning the procedure

A flap is planned in two distinct ways which while they
cannot be quite divorced in practice are best considered separately
They consist of deciding the type of flap and planning the
actual transfer

Type of flap The transfer of a flap may inv ol\ e mov ing tissue
adjoining tie defect or tissue at a distance from it

Before local tissue can be transferred it must be demonstrably
available and ways of assessing the size of the local flap required
for a particular defect will be described under the heading of
Rotation and Transposed Flaps

FLAPS PEDICLES AND TUBES gy

The transfer of tissue from a distance follows one of three
patterns

Fic 4 2

Typ cal areas su table for flap co er and the extent of excis on required
solely to elim nate sea r ng It should be apprec ated that further shin
may ha e to be excised to perm t the flap to ha e a shape su table from
a vascular % e vpo nt Thus F g 4 t8Bsho s the flap used to repi r the
defect r Stages in the repair of A a e sho n n F gs 4 3 4 6D and
4 18D and of D n Figs 4 7C and 4 11A

i The defect is brought to the donor site from \\h ch the
flap is raised and directly applied to the defect A direct flap
of this tj pe has its main use in covering defects of the arm —
distall) more often than proximallj — with the trunk as donor
site

G

96 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGED

to its destination in several «ajs commonly b\ rotation trans-
position or direct application, and the appropriate term is used
to describe the flap The greater part or all of such a flap is
applied to the recipient site there is little or no pedicle When a
flap does have a pedicle the vital element is usually its terminal
segment the remainder forms its pedicle acts as its carrier and
provides its channel of blood supply during transfer To reduce
sepsis by eliminating raw surfaces the flap is otten made into a
tube and is then called a tube pedicle

THE PLANNING OF TLAPS
Defining the defect

Before repair by a flap is contemplated the extent of the defect
must be defined in terms of each component — shin bone and
lining In this the quality of the shin surrounding the obvious
defect must be tahen into account Shin showing radiotherapy
damage or the fibrotic and atrophic changes of old scarring is not
good surgical material and is often better regarded as part of the
defect and excised in order to reach the good shin beyond it
(Hg 4, 2) In addition to its poor suture holding qualities the
avascularity of such shin mahes it unsatisfactory for nourishing
a pedicle inset when the remainder of the pedicle is detached for
transfer A good criterion shin texture and appearance apart
is the state of shin mobility , shin freely mobile deeply is usually
reasonably satisfactory to worh with

Planning the procedure

A flap is planned in two distinct ways which while they
cannot be quite div orced in practice are best considered separately
They consist of deciding the type of flap and planning the
actual transfer

Type of flap The transfer of a flap may mv olv e mov mg tissue
adjourn g tfe defect or tissue at a distance from it

Before local tissue can be transferred it must be demonstrably
available and way s of assessing the size of the local flap require
for a particular defect will be described under the heading o
Rotation and Transposed Flaps

Tic 4 a

Typ cal are: is su table for flap co\er and the extent of excis on required
solely to elim nate scarring It should be appreciated that further skin
may hate to be excised to permit the flap to have a shape su table from
a vascular vie v point Thus Fig 4 i^B shows the flip used to repa rthe
defect F Stages in the repair of A are shot -n in F gs 4 3 4 6D and
4 tSD and of D in Figs 4 7C and 4 11A

i The defect is brought to the donor site from which the
flap is raised and direct!) applied to the defect A direct flap
of this type has its mam use m cot enng defects of the arm —
distaJ]} more often than proximal!} — with the trunk as donor
site

G

9S IOMIAMCNTAL TECHNIQUES OF PLASTIC SURGERT

2 The donor site and the defect are both morcd into close
proMmitj to each other so that a flap can be transferred
d* recti} from one to the other This is the situation when a
direct flap is transferred from leg to leg— a cross-leg flip,
from forearm to opposite hand— a cross-arm flap; or from
finger to finger — a cross finger flap

3 The defect remains \irtuallj static and the bulk of the
mo\ ement involved tn the transfer is done b} the flap This
Situation is typified by the tube ptdic\t transfer

The appropriate type of flap in an} set instance tends to be
goterned b} the size and site of the defect, and the time factor
in the transfer

Size of the defect A local flap has to be much greater in area than
the defect it is planned to cover and the limbs are seldom able to
provide enough tissue to coier the size of limb defect which
commonly requires flap cot er In the trunk and face the necessarj
area of tissue is more likelj to be present and the local flap more
often a practical possibility

The area of tissue which is readily transferred as a direct flap
is considerablj smaller than that which can be transferred as a
tube pedicle and large defects generally require a tube pedicle

Site of the defect When the choice lies between a direct flap and
a tube pedicle a direct flap can only be used if the defect and donor
area are capable of read} approximation This limits the direct
flap to defects of arm and hand, and lower leg and foot

The mterpla} of size and site as it affects the local flap has been
described above

fhe time factor The actual transfer of a direct flap is completed
in 4-5 weeks, the tube pediclfe transfer often takes three times
as long The direct flap can be used as an emergency procedure,
subject to certain dimensional limiting factors, the tube pedicle
can onl} be used in an elective fashion for it has to be raised and
tubed before the transfer is begun

The local flap is virtually completed in a single stage and maj
be desirable on this score It does not invoke the patient in
maintaining a particular position for a period of time with con-
sequent liability to joint stiffness (see page 127) as do both the
direct flap and tube pedicle The need to maintain a position

FLAPS, PEDICLES AND TUBES 99

for a prolonged period with the bed rest which this may occasion
can be a contra-indication In the older 3ge group to the use of a
direct flap or tube pedicle.

Fic. 4, 3

Planning in reverse. The area (Fig. 4, aA) requiring replacement is covered
with the jaconet "flap” (A), the legs arc placed in the transfer position snd
(B and C) the “flap” « put inio the position it will take during the actual
transfer (see Fig. 4, i3D). The “ flap” u then laid out on the donor area (D)
and outlined with Bonney's Blue (E) to give the shape and position of the
actual flap (F).

Planning the transfer. With the type of flap decided, its site,
size and shape, and the stages of the transfer are planned by
the method of planning in reverse (Fig. 4 , 3). The defect is

100 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

outlined with a suitable material such as jaconet With this
representing the flap the procedure is carried from the end result
backwards through the various stages with the limbs in their
correct position until the ' flap’ ends up on the skin area from
which it is to be taken, where it is used to outline the definitive

Fic 4,4

The result unmed ately following the completion of the transfer of tube ped cles
to correct post bum neck contractures and after Z-plast es coupled with thinning
A previous stage in the transfer of (A) is shown in Fig 4 rjB and the tube
ped cle used for (B) is shown in Fig 4, 7D

flap In this way the patient is not given an impossible position
to maintain at a critical stage of the transfer and the surgeon
av olds a flap w Inch, is too small, one \\ hich will Link during transfer
or fad to reach its destination because it is too short Time spent
on the planning stage is never wasted in the long run

A flap should always be planned with a margin of reserve
Skimping making it just neat, wall certainl) create difficulties for
the surgeon m due course It is easv to tnm an excessively large
flap, but difficult to add to one, once begun

FLAPS, PEDICLES AND TUBES IOI

The exigencies of blood supplj may dictate dimensions shape
and thickness which would not be necessary otherwise, and
subsequent trimming, thinning and Z plasties have often to be
carried out after the flap has completed its transfer to give the
optimal result (Fig 4, 4)

VASCULAR ASPECTS OF FLATS

Blood supply governs all flap practice and a dear understanding
of this aspect will explain much which would otherwise be
inexplicable m the construction and transfer of indiv idual flaps

Vascular Adjustments

Flaps consist m most instances of skin and superficial fascia
If a block of such tissue in situ is considered from the viewpoint
of blood supply, it maj be assumed that its content of blood vessels
in respect of numberand calibre is the most efficient physiologically
Its free ingress of arterial blood and egress of venous blood are
quantitatn ely governed largely by its metabolic requirements
In ordinary circumstances, this flow is a mere fraction of its
potential vascular capacity, the reserve factor is considerable
A common circumstance which calls on at least part of this vascular
reserve is an acute inflammatory reaction Such a reaction is
well within the capacity of the normal circulation to sustain in
all but the most virulent infections unless the reserve is reduced
as in arteriosclerosis of the lower limb when a mild infection can
trigger off a spreading gangrene

A flap differs from the surrounding skin in that its quota of
arteries and veins is strictly limited This can be seen if one
considers the theoretical situation of a square flap with vascular
pattern distributed equally on each side and its deep surface
Raising such a flap to leave it attached by one side alone reduces
its vascular capacity to and though such a theoretical distribution
of blood vessels does not hold in practice the principle of reduction
of vascular capacity does

If, however, it were possible to cut off the other four vascular
attachments gradually it would be found that the pattern of the
flap had adjusted itself so that its capacity and reserve remained
almost normal It has also been shown experimentally that

102 FUNDAMENTAL TECHNIQUES Or PLASTIC SURGERY

following the raising of a tube pedicle the mean blood pressure
in the tube drops to 25 per cent of normal rising to 90 per cent
by the end of 4-6 weeks How do such re adjustments occur 5
It is well recognised that there is tremendous lability of \ascular
pattern with a flexible response to local requirements Little is
know n of the physics of these changes but a more efficient vascular
pattern is presumably produced The pattern changes have not
been worked out m detail but the end result seems to be an axial
reorientation of the larger blood vessels with an increase in number
and calibre The means adopted in practice to induce these
highly desirable pattern changes will be considered later

It has been stated that the vessels of a flap are sy mpathectomised
and dilated but this is not so Thev are in actual fact completely
denervated and the physiological consequences of complete
denervation are quite different from those which follow sy mpithec
tomy alone the vessels appear to develop an autonomous state
of tone Certainly the normal skin colour indicates that they are
not dilated and they are able to produce in appropriate circum
stances apparently normal reactions of reactive hyperaemia and
acute inflammation

Vascular Insufficiency

In a flap suffering from vascular insufficiency the difficulty in
most cases is not the getting of blood into the flap but getting the
blood which is in out It is circulation which is the problem
To lose a flap because of pure arterial insufficiency is a rarity
to lose part or all of it because of venous insufficiency is all too
common Flaps die in congestion and not anaemia Several
factors play a part singly or together in tending to embarrtss the
circulation

Mechanical tension When transferring a flap the tissues must not
be sutured under greater than normal tension rather should they
be under less than normal tension Undue tension tends to em
barrass both the venous and arterial flow particularly the v enous
htnktttg With arterial pressure higher than venous pressure
kinking of a flap impairs the venous drainage initially and makes
the flap congested It tends to be most serious when the flap
lacks flexibility and is always aggravated by any increase in tissue
turgor

FLAPS, PEIJICLFS \ND TUBES

x °3

Oedema WJitn oedema develops it contributes to and enhances
the ill effects of tension and kinking Skin initially lax and wrinkled
becomes shiny and swollen and particular!} in the confining
circumstances of a tube pedicle, there is obstruction of xenous
flow and still further increase of turgor

Transient oedema is common eien in the flap which is pro-
gressing faxourahly increasing oxer the first 24-36 hours It
remains for a further 2-3 daxs and the appearance of fine wrinkling
of the shinx oedematous skin is the first sign of its passing as the
circulation becomes more efficient

- Increase of
Tissue TbrqorV^

J

Kinking -•

Venous

Mechanical

Tension

Tic 4 5

■ lnflammat*on

The x iciou# circle of circulator) embarrassment in a (lip

Inflammation The xascular reserxe of a fi-ip is nexer normal and
xx h tie it ma} be adequate to cope xuth ordinary metabolic needs the
added burden of an inflammatorx reaction must alwa}s be an
embarrassment T he soil rather than the seed is the critical
factor and infection which would be of minor significance elsewhere
can produce necrosis of quite disastrous extent in a flap \\ hen an
inflammator} reaction does dexelop tension becomes an added
factor in causing the necrosis to spread

lor clant} these factors haxe been discussed separatcl} but
the} seldom act singl} in practice One factor max initiate the
xicious circle of increased tissue turgor leading to xenous con-
gestion leading in turn to increased tissue turgor but rapid!) the
others come into action to aggraxatc the c}cle schematically
indicated in I ig 4, 5

Flap Necrosis

Dex doping necrosis in a flap presents chmcalix with the skin
acutelx congested, cvnnosed, blanching momcntanlx on pressure
but xxtth x csscla rapidly filling again, the xascular bed is dilated

104 FUNDAMENTAL techniques of plastic surgery

and largely stagnant As the condition progresses, blanching
on pressure becomes less and less definite until there is dearly
no active circulation The cyanosis remains and takes on a
violaceous tint Histologically there is gross extravasation of
blood Blistering of the skin with serum, or blood filled blebs,
usually develops When the blister skin is removed the under
lying skin is moist, cy anosed and without demonstrable circulation
Although the development of such blisters indicates that some
circulation is still present it also implies that the onset of necrosis
is virtually inevitable and imminent At this point the margin
of the affected area is seldom well demarcated and the process
tends to spread for the reasons already indicated The final area
of necrosis is often more extensive than appearances at the onset
might have suggested This is so because the process will not
halt until a skin area has been reached whose vascular capacity is
able to cope not merely mfh ordinary metabolic needs, but also
with the added vascular burden of the adjacent necrosis and any
superadded infection When the process eventually does stop
spreading a good line of demarcation is present with, just proximal
to it, a zone of inflammation well sustained from a vascular
v levvpomt

This then is the picture of the untreated, florid, progressive
process of flap necrosis

Prevention of Flap Necrosis

Steps can be taken at all stages to prevent flap necrosis — in the
initial design of the flap, by enhancing its vascular efficiency and
by care during and after transfer
Initial design of the flap

This involves such factors as the length breadth ratio the
intrinsic vascular pattern of the flap its anatomical situation, etc ,
and the problems will be discussed as they relate to the planning
of each kind of flap The design should always allow for the
normal increase in tension which the phase of oedema creates
Enhancement of vascular efficiency

By cutting off the unwanted blood vessels the flap is * trained
to rely only on those vessels which are actuallv to be functioning
during the subsequent stage of the transfer This measure is

FLAPS, PEDICLES AbiD TUBES

*°5

termed a delaj and is achiev ed either bj surgicall j di\ ldmg the
unwanted vessels or bj clamping the pedicle where possible, the
so called physiological delaj

Fic 4 6

Examples of surgical delays

A Pancake flap delaj ed on to one end of an acrom o pectoral tube
pedicle used to repair radionecrotic ulcer of chin shown in Fjg 5, 6B
B Delay of cross leg flap Subsequent stages shown in E and Fig 4 18A
C Lengthening an abdom nal tube ped cle by delay
D Delay of the segment of the cross thigh flap (see Fig 4 18D) planned
in Fig 4 3 which was intended to cover the heel of the foot
E Delay of cross leg flap (see B and Tig 4 t8A) prior to detaching and
insetting the flap

The surgical delay A surgical delaj permits the use of a greater
length breadth ratio than would be possible without it \n
incision is made along the line across which the surgeon wishes
to cut off the blood supptj the blood vessels crossing the line are
divided, ligated if need be and the wound is resutured and
allowed to heal (Fig 4, 6) This onl) divides marginal vessels
and to cut off the blood supptv entering the deep surface the flap
must be elevated and the entering vessels dtv ided and ligated before

106 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCERt

returning the flap to its original position In a difficult situation
the flap can be delajed in stages Such vascular link up as mav
occur during healing of the incision is not enough to prevent the
redeplovment of blood vessels which results

How soon the delaj can be assumed to have achieved its
purpose has never been properl) worked out experimental!) and
the time is dictated b) the healing of the incision The next
stage is proceeded with when the delav has healed usuillv in
7-10 da)s

It must be recognised that the delav is a double edged weapon
capable of operating against as well as for the surgeon This is
true especial!) of the dela) involving elevation for no matter how
delicate the technique reaction of the separated surfjccs is alwavs
produced and is around its peak at the tenth da) Txcision of this
indurated surface when the flap is actuall) transferred dots not
altogether eliminate the zone of reaction and its presence un
doubtediy reduces the flexibrbtv of the flap makrng kinking both
more hkel) and more serious It is desirable to reduce reaction
to an absolute minimum b) using planes of cleangc In the
limb this is at the junction of superficial and deep fascu m the
abdomen at the junction of superficial fascia and aponeurosis
In the chest and back no real plane exists but the best substitute
is close to muscle

Haematoma too adds to the reaction and should be avoided b)
scrupulous haemostasis A carcfull) applied pressure dressing
post operativcl) will prevent the accumulation of fluid under a
flap though a balance between too little pressure which allows
fluid to gather and too much which causes ischaemic necrosis is
not always eas) to achieve

Surgeons var) greatl) tn the extent to which the) use the
delav Though a delav mav seem to waste time it docs on the
whole make flap transfer safer and on this score mi) reasonal Iv
be considered a time saver since the paramount cause of wasted
time is loss of part of a flap during its transfer

The ph) siological delay This measure ts useful mainl) m the
tube pedicle and trains it to rel) for its vascular support on one
end alone The pedicle is compressed either In an inflated
sph) gmomanometer cuff or a suitabl) padded intestinal clamp
initial! v for short periods gradual!) lengthening

FLAPS PEDICLES \ND TUBES IO7

Care during and after transfer

It is after transfer particularh that skilled and experienced
nursing can be invaluable not merelj in pre\entmg trouble
through careful positioning of the patient but in recognising the
danger signals of circulator} embarrassment earl} while the\
are still readil) res ersible and before the inexorable sequence which
leads to necrosis has begun in real earnest It is at this time too
that a goad nurse can provide the encouragement so necessarj
to a patient during the earh hour* and davs of what for him is so
often an agomstngh uncomfortable position

There are several vvavs however in which the surgeon can
anticipate and prevent the potential troubles which can arise
post operativelj

Haemostasis A developing haematoma is prone to initnte the
increase of tension which starts the c)de of events -dread)
described Haemostasis is easier to achieve if planes of cleavage
are used for the vessels crossing are large and few and are readil)
ligated A previous dela) tends to obscure these and a diffuse
007c is more common

A pressure dressing sometimes helps but as alread} stressed
there is the difficult) of getting just the correct pressure
Use of grout} Fgress of blood from the flap is the usual problem

and where possible gravit) should be used to help venous drainage
The foot of the bed can usefull) be raised on occasion and the
Bilkan frame mav be emplojed for suspending the appropriate
part of a limb

Control of sepsis Infection as a factor operates at all stages and
with the one exception of head and neck flaps all skin surfaces
are best healed before the next stage of the transfer it. contemplated
Skin preparation must be scrupulous and though asepsis is often
difficult to achieve at ever) stage of the various operations involved
in the transfer it must he realised that each break in technique
does endanger the procedure Planning at each stage to avoid
raw surfaces is important and this topic is discussed on page i°o
Methods designed to encourage actue circulation These consist
of the intermittent inflation of a sphvgmoma nometer cuff placed
strategicall) either to drive blood into or out of a tube pedicle
It is the flow out of a flap which needs encouragement as a rule

I08 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

and this is probably the more valuable use of the method The
cuff is wrapped round the pedicle inset where necrosis is most
likel) to occur and intermittent!) inflated Continuous pressure
has also been advocated with the object of forcing the blood out
into the veins b> increasing the general pressure on the flap,
in effect to provide an alternative peripheral resistance to the
atonic, dilated local capillar) bed of the flap suffering from vascular
insufficient The optimum pressure is thus just below capillar)
pressure

It is impossible to sa) after the event what might have happened
had in alternative method been used and critical assessment of
the method is difficult Similar criticisms appl) to intermittent
pressure Further it needs a real effort of will to cover up a
flap whose circulation is precarious so that its progress cannot be
seen

On the other hand the interference of gentle massage to tr)
to keep the circulation going, inspection, etc , do more harm than
good The) produce local hypcraemia in normal tissues and this
is exactly what one wishes to avoid in a flap It maj well be that
much of an) success achieved b) pressure techniques results from
the rest which the flap is allowed Neither intermittent nor
continuous pressure methods have achieved much popularity

Treatment of Flap Necrosis

There is a limit to what can be done to save a flap m danger of
necrosing but the very presence of necrotic tissue inviting
superadded infection tends to spread the process and the surgeon
maj make the bold decision to detach the flap, excise the d>mg
segment and re inset it m the hope that removal of the necrotic
focus will give the flap a fresh start His problem is then to
decide where the line of excision should be, and a good indication
of the v lability of a flap margin is the state of dermal bleeding its
colour and quantity

Such a drastic course is only possible if the flap has been planned
with a margin of safet) and failing this, a conservative policy
must be pursued, awaiting slough demarcation and separation
When the resulting surface is favourable a split skm graft mav be
applied but the disastrous effect of infection and fibrosis on the
vascular attachment must be recognised and each subsequent step

FLAPS, PEDICLES AND TUBES

I09

requires redoubled care, and the use of delays etc It is un-
fortunately true that a disaster of this sort during a flap transfer
makes subsequent similar disasters much more probable

Examples of tube pedicles
A Acromio pectoral tube
B Abdominal tube

C Double abdominal tube with connecting bridge ready for tubing to complete

the long tube pedicle

D Tube pedicle of scapular region The unusual site was chosen to correct
a post burn contracture of neck because the usual sites had sustained full
thickness skin loss burning

E Abdominal tube of unusual direction to he inset into the hand The
direction wa3 chosen to suit positioning of the hand during insetting
F Clavicular tube pedicle

THE TUBE PEDICLE

This is a bipedicled flap which when raised is turned in on
itself to form a tube (Fig 4, 7) It is usuall) raised on the torso
for transfer either to the head and neck or one of the limbs
Once raised and tubed the pedicle is left to mature for 6 weeks
during which time the axial vascular re orientation already

HO FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

described is de\ eloped To give a good start to a vial redepfo)-
ment tbe tube is placed along a line of venous orientation where
possible The vascular link across the mid-line of the trunk is
poor and it is seldom wise to construct a flap which crosses this line
I he abdominal tube pedicle usuall) uses the thoraco-epigastnc
Venous avis and the limiting length breadth ratio is generall)
assessed at 2 J 1 If more length is required two tubes of standard
length with a connecting bridge may be constructed In due
course the bridge is delajed along its margins, raised and finally
tubed to complete the ** double ” tube On the chest the acrom 10-
pectoral tube pedicle is used particular!) in the male and I)ing as
it does on a most efficient venous pathvva) 331 ratio of length
to breadth is quite safe

A tube pedicle is mov ed to its destination either bv attachment
to a carrier, usuall) the wrist, which b) virtue of its mobility can
carry the tube over a considerable distance in a single movement,
or b) waltzing the tube. This latter method graduall)

‘ transfers” the tube by moving each end altematel) and is onl)
emplo)ed when a carrier is unnecessar) or impracticable

The abdominal tube pedicle is most often carried on the wrist,
the acromiopectoral tube pedicle is reserved more for repairs of
head and neck in which case it is waltzed on its upper attachment
to its destination This attachment should be carried well out
to the shoulder tip so that shoulder as well as head movement can
be utilised to reduce tube tension A tube pedicle ma) also be
used as a carrier for a “pancake” flap or “spade” (Fig 4, 6\)
dela)ed on to one end, such a flap must be most carefully dela)ed
m stages

The alternative sites for tubes (e g Fig 4, 7D) are used much
less commonlv, mainl) when the usual sites are not available
because of scarring, etc

Raising the tube (Fig 4, 8)

Before raising the tube it is alwajs worth while to mark it out
with Bonney s Blue and. tattoo appropriate points to correspond
on each margin so that when the pedicle comes to be tubed the
points are alread) there to be matched

Although the amount of subcutaneous fat varies enormousl)
m different patients the depth of the mam skin vessels remains
constantly fairl) superficial, and this allows considerable thinning

112 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

to be earned out with impunity But no matter how much thinning
is needed the pedicle should be raised initially in the plane between
superficial fascia and muscle or aponeurosis, leav ing no fat on the
resulting raw area This is done because it is technically much
easier, gi\es an initial uniform thickness to the flap, v essels are
few and more readily picked up for ligation, and the bed which
results takes a free graft much better than would fat The hand
holding the flap should be used to judge the amount of thinning
required Touch gi\ es a much more accurate measure than \ ision
alone The flap should be ele\ated over its full length or even a
little beyond it and must be thinned uniformly until it tubes
readily without tension Trimming off the fat along each margin
eases closure of the tube and prevents little herniations of fat
between sutures when the flap is tubed Haemostasis must be
complete before tubing is begun A continuous “over and over”
suture can be employed to tube the pedicle with a few preliminary
interrupted sutures using the tattooed matching points before the
mam suture is begun The interrupted sutures have the effect
of distributing tension correctly As each end is approached the
tension increases and tubing should be discontinued as soon as
there is any suggestion of difficulty in bringing the skin edges
together

With the pedicle tubed the underlying defect if of any size is
split skin grafted The pressure dressing of the graft must be
carefully applied to get the necessary immobility and apposition
of the graft without being bulky enough to embarrass the circu
lation of the tube When the tube is small in size the underlying
defect is closed by direct suture and the junction of the two axial
suture lines is then best closed with a modified three-point suture

Dunng the ensuing 6 weeks it is desirable to get all raw surfaces
healed and the most difficult areas are at the junction of the graft
and the axial suture line of the tube where a tiny granulation
tends to persist Ingenuity may be required to keep the surfaces
apart so that they can heal but the surgeon should be reluctant
to embark on transfer of the tube until healing is complete

Transfer to the carrier (Fig 4, 9)

The usual carrier is the wrist and on it a cun ed trap-door of
skin and superficial fascia which includes the superficial veins is
elevated The raw surface which this creates is apposed to the

Transfer to the w rut earner After marking out the line of incision and
tattooing matching points (A) the end of the pedicle is raised giving a circular
raw surface (B) A semicircular trap-door is outlined (C) on the n rist and
raised (D) to give a circular raw area to which the end of the pedicle ts
sutured (£}

FLAPS PEDICLES AND TUBES 115

this The hinge along which the trap door is raised will be
perpendicular to the desired direction of the pedicle

Before detaching the tube it is wise to tattoo suitable points
e g centre and margins of the pedicle so that fixing sutures to
distribute suture line tension can be used The difficult healing
point is where the trap door meets the axial scar of the tube and
care in suturing here is adv isabie

Interval care of the pedicle In the early post operativ e period
the arm wrist and pedicle must be immobilised m an appropriate

Attachment of abdominal tube ped cles to vuist carT ers sho ving radial and
ulnar attachments

position It is usual to wa t for 3 weeks before the next stage is
begun but once healing is complete the patient must be encouraged
to move to the maximum of his capacity all tl e upper iimb joints to
massage the wnst inset and generally treat the ped cle in a moder
ately cavalier fashion Physiological delay in preparation for the
next stage of transfer can be started as soon as healing is advanced
Tests for adequacy of circulation Tube pedicle transfers are
tedious time consuming affairs and it is scarcely surprising that
various tests have been developed to arbitrarily decide when an
inset pedicle has developed an adequate vascular link up to
perm t detachment of the other end for transfer The vascular
link up across the inset can be isolated for testing by clamping
off the other attachment of the tube Tests are of two types
1 Measurement of the passage of a substance across the inset
and assessment of vascular efficiency in terms of this
Atropine injected subcutaneously into the pedicle can be timed

“4 FUNDAMENTAL TECHNIQUES of plastic surgem

corresponding raw surface left when one end of the pedicle is
detached From its earner attachment the pedicle obtains a new
blood supply for the ne\t stage of its transfer The nvv areas of
wrist and pedicle are made to correspond in shape and size so
that complete shin closure can eliminate raw surface

The best attachment provides the maximum of raw surface
contact and resulting vascular link up and m this the important
factor is the shape of the trap door The width of the raw surface
which is theoretically that of the pedicle is constant but its shape
can vary from a narrow ellipse to a circle As an ellipse approaches
the circle in shape its circumference and area both increase and as
a trap door more pointed than a semi circle creates its own
problems the semi circular trap door is probably the best shape
for the purpose

It is usually stated that in dn id ng one end of a tube pedicle
a straight transverse incision completing the rectangle of the flap
should be used but such a straight end sutured to the curved raw
area of the carrier creates distortion with tension on the central
part of the pedicle and this is something to be av oided A sounder
procedure is to make the end of the pedicle semi circular in shape
so that the raw area of the pedicle is virtually a circle for which a
correspondingly circular raw area can be created The trap door
is best made a trifle smaller than the pedicle dimensions would
indicate as this positively eliminates pedicle tension The correct
size for the trap door can be ascertained easily b\ making a
blood stained imprint with the cut end of the tube on the wnst
A haematoma would prevent the rapid vascular link up which is
aimed at and haemostasis is important

The raw area res thing from the elev ation of the end of the tube
is either closed by direct suture or more often split skin grafted

The position of the trap door According to the plan of transfer
the site will be the ulnar or radial aspect of wrist (Fig 4 10) and
it should be placed so that the turning back of the trap door leav e>
the raw area in one plane In this way the trap door lies smoothh
back when sutunng is complete and the attachment as a whole
runs cleanly off the limb

The other variable is the angle of attachment and consideration
of how arm and wrist are go ng to he at the next transfer and the
angle which arm and pedicle must make as a result should decide

FLAl « PEDICLES AND TUBES Hj

this The hinge along which the trap door is raised will be
perpendicular to the desired direction of the pedicle

Before detaching the tube it is wise to tattoo suitable points
e g centre and margins of the pedicle so that fixing sutures to
distribute suture line tension can be used The difficult healing
point is where the trap door meets the axial scar of the tube and
care in suturing here is adv isable

Interval care of the pedicle In the earl) post operative period
the arm wrist and pedicle must be immobilised in an appropriate

Attac) ment of abdom nal tube ped cles to rist carr era sho ng radial and
ulnar attachments

position It is usual to watt for 3 weeks before the next stage is
begun but once healing is complete the patient must be encouraged
to mo\eto the maximum of hiseapacit) all the upper limb joints to
massage the wrist inset and generall) treat the ped clc in a moder
atel) cavalier fashion Phjsiological dcla) in preparation for the
next stage of transfer can he started as soon as healing is advanced
Tests for adequacy of circulation Tube pedicle transfers are
tedious time consuming affairs and it is scarce!) surprising that
various tests have been developed to arbitrani) decide when an
inset pedicle has developed an adequate vascular link up to
permit detachment of the other end for transfer 7 he vascular
link up across the inset can be isolated for testing b) clamping
oil the other attachment of the tube 7 csts arc of two t)pes
1 Measurement of the passage of a substance across the inset
and assessment of vascular efFcienc) in terms of this
Atropine injected subcutaneousl) into the pedicle can be timed

Il6 FUNDAMENTAL TECHNIQUES Or PLASTIC SURGERV

for the development of its systemic efFects or the appearance
of fluorescence of a histamine wheal on the pedicle can be
timed following intravenous injection of fluorescein More
recently the disappearance of the radioactive sodium isotope
in the form of Na 24 Cl from an injection site in the tube has
also been used

2 Measurement of the clearance rate across the inset of
congestion created in a pedicle

The first set of tests in particular measure quite indirectly
and rather dubiously those factors which need to be measured,
namely the ns a tergo of the blood entering the pedicle and the
overall adequacy of the venous drainage The congestion test is a
more direct inde\ of vascular efficiency since it more nearly
imitates the state of affairs to be present when the tube is actuatly
transferred

It must be stressed that these tests constitute a single piece of
evidence only and they must be used m conjunction with a general
clinical assessment of the situation

The effect of haematoma. A rapid vascular lmh-up over the
maximum of area is desirable in any pedicle inset and the factor
most likely to prevent this is a haematoma Haemostasis must be
meticulous and a haematoma diagnosed clinically post-operativ ely
should be evacuated if possible Not merely does it prevent
vascular link-up, but it giv es rise to induration and loss of flexibility

Transfer on the carrier (Fig 4, 1 1)

This is essentially similar to the vvnst inset After severing
the remaining abdominal attachment the flap is moved on its
carrier to be inset into part or all of its destination It is not
usual to aim at final disposition of the flap on the recipient area
at this stage What is aimed at rather is attachment of the free
end of the tube to a suitable segment of the recipient area having
regard to the need to establish a vascular link-up adequate to
nourish the flap when it is later detached from the vvnst to be
completely untubed and inset It is therefore advisable to give
the flap as big an attachment as is expedient with positioning of the
wrist, etc To increase the raw area of the flap the tube is undone
as far as required excising the scar of the tubing and thinning
appropnately The raw area is measured against the selected

FL\FS PEDICLLS AND TUBTS H7

segment of the recipient site and an appropriate area of $ktn is
excised W here possible a small trap door flap can be raised
from the recipient site to close off the raw area where tubing of the
flap begins ngjin

Completing the transfer

After a further period of 3 weeks the pedicle is removed from
the wrist the scar of the tubing is excised and the flap is opened
It is found on opening the tube that an axial line of scarring has

I ic 4 II

Transfer of tube pedicles on wrist earners Note in each case the large
segment inset to preside a vascular attachment adequate for the nest transfer

developed along its centre which prevents it from untubing readil)
"With the tube partiallj opened it gives the appearance of a well
defined laver like deep fascia and onl> excision or at ver) least
deep multiple longitudinal scoring of this lajer will permit the
flap to untube complctel) and spread to its original dimensions
\\ hen the flap is spread out and thinned if ncccssarj the amount
of skin to be excised is defined and removed so that the flap can
be sutured in position It is not alwajs safe to complete the
transfer and spread the whole pedicle in a single procedure The
detached wrist inset mav then be set into its final destination
leaving the still tubed central segment of the pedicle (rig 4, 12)
to be untubed and inset 3 weeks or so later once both ends have an
efficient vascular attachment

The wrist trap door is sutured back in its original position
It is less easj to return to its original situation than one might
expect, for the trap door n ill be found to have shrunk somew hat
and the se\ cral w oun d edges ha\ e to be mobilised to achiev e closure

IlS FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

A good suture lme is often difficult to get but m this time
fortunately works wonders in most cases

Waltzing a tube

When a tube is being waltzed (Fig 4 13) the procedures \ ary
from those described for the carrier method only in the siting of

Double attachment of a tube ped de pr or to final insert ng Closure of
fistula (A) b\ acrom o pectoral tube nset into a re cep on area (B) immedia el)
anter or to the fistula The double attachment s made b in etting the other
end (C) immed ately poster or to the fistula pr or to untubing and closure of
the defect (D)

the trap door with a view to ach e\ ing the maximum of movement
in the des red direction commensurate with the minimum of
kinking and tension during both the current and the subsequent
transfer

THE DIRECT FLAP

The direct flap is raised with or without prelim narv delays
according to its dimensions and directlv sutured to the defect
The raw area left when the flap is raised is closed by direct

FLAPS, PEDICLES AND TUBES

120 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERT

suture jf small otherwise a split shin graft is applied Meticu
lous planning in rexerse is necessary to avoid the tension hinh
mg and shearing which are so disastrous and also to ensure that
the patient is given as comfortable a position to maintain as
possible

The direct flap should aim to get as much as possible of the
flap m contact with the defect at the initial transfer leaving
the minimum to be attached later and a good principle is to
make the flap so that any tendency to movement pulls the flap
on to the defect rather than away from it In limb flaps the
effect should be to wrap the flap around the limb

E\en in the direct flap there is always a pedicle though it is
frequently \eiy short compared with the remainder of the flap
The longer the pedicle the greater the range of permissible mobility
of recipient on donor site and the greater the safety factor against
tension etc On the other hand a long pedicle reduces the length
breadth ratio and in effect narrows the flap from a xascular point of
\ lew Those seeming lrreconcilables can both be met on occasion
by making the base of the pedicle broader than the segment which
is to be inset so that a broad pedicle is combined with a reasonably
long one

Avoidance of raw areas (Fig 4 14)

As already described pedicles are often tubed to eliminate
raw areas Similarly it is desirable though not always possible
to eliminate raw areas during other types of flap transfer —
excluding those of face — and this can be done either by using a
trap door or a split skin graft or a combination of the two

Use of the trap door A reception flap from the margin of the
recipient site is raised and sutured to the flap and/or skin
graft Such a trap door flap should be as short as possible as
it consists of tissue of the defect and tends to be scarred and
avascular

Use of the split skirt graft W hen a trap door is not possible the
split skin graft covering the flap donor site can be made longer
so that it lines the pedicle segment of the flap where it would
otherwise be raw

Despite the use of these devices greater or smaller raw areas
frequently persist and in difficult situations are virtually inevitable

FLAP'S, PEDICLES AND TUBES 121

Division of the flap

Whether a reception flap or split-skm graft hai e been used an
acute angle of fibrous tissue is nearl) alw a> s built up at the junction
of recipient area and flap (Fig 4, 15) so that the flap when divided

Fie 4 , 14

Methods of avoiding raw areas during the iransfcr of a
direct flip A reception flap when available may be
raised from the margin of the recipient area or the skin
grift used to cover the donor site of the flap maj lie
extended to line the pedicle segment

does not inset natural tj into the remaining part of the defect
The flap as a result has to be dissected ofF the defect and thinned
a little, at the same time excising the fibrous tissue of the "angle"
to allow it to sit nicclv into the remaining defect Such dtsscction
though minimal, does have an adverse effect on the \ ascular supplj
and marginal necrosis of the flap is apt to result Because of tins

122 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

it js often advisable to delay the flap before dividing it complete!)
though a dela) causes the usual induration which follows any
incision and a neat suture line when the flap is finally inset ma)
not be achieved initially It is fortunate!) remarkable how the
flap settles m with time and the scars improve in appearance.

A dela) used in this context does of necessit) leave the limbs

Fic 4, is

The angle of fibrous tissue usuallj built up at the junction of the flap and the
recipient area which has to be excised to allow the flap to sit into the remainder
of the defect The dissection involved in this has an adverse effect on the
blood supply of the flap margin

in their immobile position for a further week or so and this ma)
sometimes be undesirable When the pedicle has a residual raw
area too a dela) means a fresh incision in an area which cannot be
made surgically clean and one which an unavoidabl) awkward
position ma) make difficult to keep as clean post operative!) as one
would wish An alternative then is to detach the flap completel)

FLAPS, PEDICLES AND TUBES

723

without attempting an inset This has the same effect as a delaj
and while waiting to inset the remainder of the flap in 7-10 dajs
limbs, fingers, etc , can be mobilised as required

Practice of the Method in Various Sites

The upper limb. In major resurfacing of the arm and hand, the
usual donor site is the trunk and the flap must be planned so that
with the limb m a comfortable position the flap “wraps round”

the limb In the forearm the limb is most comfortable in the
neutral position , extreme pronation or supination is difficult to
maintain Because of this the base of the flap is best made
superior where the defect is radial and inferior where the defect
is ulnar so that in each case the natural tendencj of the limb to
move downwards and outwards from the trunk “wraps” the flap
round the recipient site rather than pulling it away from it

Similar considerations arise in flaps applied to the wrist and
dorsum of hand, though on occasion a direct flap from one forearm
to the other hand is used and then the broad principles described
for cross leg flaps appl> Cross-arm flaps together with the other
types of flap used jw Hand Surgery are discussed in detail in
Chapter Se\en

The lower limb. The direct flap used in the leg and foot is the
cross-leg flap where the skin of one leg is transferred as a direct
flap to co\ er a defect of the other leg, the appropriate parts of the
limbs being approximated b> suitable positioning (Fig 4, 16)

124 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY
The donor sites are limited to

1 Middle two-thirds of the length of tibia In this
segment the site must not include the shin directly over the
tibia lest failure of the split shin graft applied to the secondary
defect should leave bare tibia to complicate the transfer
Usually flaps are outlined just behind the subcutaneous surface
of tibia based in the direction found to suit best w hen the
procedure is planned

2 Lower anterior thigh To use this site successfully the
defect requiring the flap must be in the \ lcinity of the heel or
ankle (Fig 4, 18c) since in all but the acrobatic these are the
onl) areas capable of read} approximation to the donor site
on the thigh Indeed even with the ankle and heel the
position required of the patient takes a degree of agility seldom
found in the a\erage adult The site as a result has very
limited usefulness

In theory a proximally based flap should have a more normally
directed vascular flow but in the distally based flap the main
direction of the \ascular flow remains along the axis of the limb
even if reversed in direction and therefore the direction of the
base is not of great significance Disruption of normal flow is
likely to be greater m the side based flap

Unless the length breadth ratio is unusually fa\ourable it is
advisable to delay cross leg flaps and the delay can include as a
stage elevation of the flap so that perforating veins may be divided
The donor leg of the flap should be avoided as a source of the spl t
skin graft w hich cov ers the secondary defect for the dressing of
the donor site will naturally raise the venous pressure of the leg
and such a rise however small tends to increase congestion of
the flap and helps to set off the cycle of congestion oedema
kinking etc unless extreme care is exercised

IMMOBILISATION DURING FLAP TRANSFER

When a transfer is to the upper limb or head and neck
elastoplast must be relied on in conjunction with sand bags
pillows etc to keep the parts suitably positioned (Fig 4 17)
When the transfer is to the lower limb whether tube pedicle
on the wrist or cross leg flap immobilisation by plaster of Pans

FLAPS PEDICLES AND TLBES 125

is much more effective for it takes altogether from the patient
the onus of maintaining his position Plaster does nevertheless
impose its own. discipline on the surgeon and it must be used
with care

1 he plaster of Pans can be applied at the time of operation
but prefabrication has undoubted advantages These procedures

The method of fixing the arm dur ng transfer of a d rect
flap lo the upper limb

cross leg flaps especially arc among the more evading in plastic
surgery at all phases — in planning in execution and in post
operative care The position of the limbs must be maintained
from the moment of inserting the first suture joining flap and
recipient site to the final division of the pedicle 3-4 weeks later
Holding the limbs during suture and subsequent immobilisation
is an unrewarding and most fatiguing task With ample able
bodied assistance application of the entire plaster cast at the
time of operation mav be feasible and satisfactory but when

126 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

such assistance is minimal all concerned will welcome anj thing
which can speed-up the process of post operative immobilisa-
tion Speeding up is best achieved bj prefabricating the plaster
cast

The prefabricated plaster Prior to the operation, and with the
limbs in the position to be maintained post-operativelj to permit
accurate moulding of the plaster to the muscular contours, lengths

Examples of prefabricated plaster fixation during cross leg flap transfers

of encircling plaster are applied at strategic points so that, strutted
together post-operatn ely (Fig 4, 18) eg, with lengths of broom-
handle, the whole sjstem is held ngidlj immobile in its correct
position Added lengths of plaster and struts maj be used but
seldom are more than three or four needed The flap is best
left exposed while the struts are being applied so that its position
can be watched carefully , the slight contamination with plaster
has not been significant In this situation one of the transparent
plastic dressings can usefully be emplojed to protect the suture
line

With a pedicle on the wrist the arm plaster is the really
important though most difficult segment of the sjstem and a

128 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

presence indicates a need to persist with active exercises rather
than discontinue them, a need for reassurance and not rest.

ROTATION AND TRANSPOSED FLAPS

To cover a primary defect it may be possible to move the
adjoining tissue, any secondary defect being closed by direct
ROTATION FLAP

Without Back-cut

With Back-cut

TRANSPOSED FLAP

primary
Defect

Fic. 4 i >9

a era ms of rotation flaps with and without back-cut, and
transposed flap.

suture
primary
into the

When the tissue is rotated into the
•.died a rotation flap; moved laterally
transposed flap. Most flaps combine
Varees and a particular flap may be
predominates (Fig. 4, 19).

FLAPS PEDICLES AND TUBES

129

These flaps cannot adequately be described in print even with
a profusion of illustrative examples (rigs 4, 20 21 22 and 23)

Fie 4 20

Transposed /bp need Miat mg * tcs an of jadent vices n n'» ng avsrr whtr
of skull Flap outl ned after tr angulat on of defect to be left when the ulcer
(A) is \v dcl> esc sed (B) The (lap transferred (C) and the secondary defect
covered with a spl t sk n graft Fhc final result (D)

for every flap is an individual problem In the face particulirlv
judgment in selection and imagination in design come with the
I

128 rUNDAMENTAL TECIIMOUES OF PLASTIC SCRCERl

presence indicates a need to persist unh actnc unerases rather
than discontinue them, a need for reassurance and not rest

ROTATION AND TRANSPOSTD FLU'S

To CO'. er a pnmarj defect it ma\ be possible to mote the
adjoining tissue, anj seconds rj defect being closed b\ direct
ROTATION flap

Without Back cut

With Back cut

TRANSPOSED FLAP

Fie 4, 19

Diagrams of rotation flaps with and without back cut and
transposed flap

suture or free skin graft When the tissue is rotated into the
primary defect the flap is called a rotation flap, moved lateral?)
into the defect it is called a transposed flap Most flaps combine
both principles in varying degrees and a particular flap rruv he
called by the principle which predominates (fig 4, 19)

FLAPS PEDICLES AVD TUISLS

129

These flaps cannot adequately be described in print e\en with
a profusion of illustrative examples (Figs 4 20 21 22 and 23)

t30 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

experience bom in surgical apprenticeship Present discussion is
concerned to explain the principles underlying the construction of

Fig 4 2-»

Rotation flap with lack cut used follow ng excis on of rodent ulcer invoking
outer table of skull Flip outlined (B) after tnangulai ng the defect to be
left after excision of the ulcer (A) T inat result (C) with the secondary defect
split skin grafted

using such a flap should remember aheays that a major i oscular
disaster ts liable to leatc a deformity far greater than the one the
flap teas intended to re//ete

Principle of rotation (Tig 4, 24) As the flip w ill he rotated
into position it should in theory be the arc of a circle of which the
pnrran. defect is a segment, flap and defect together making a

1^2 FUN Z>A MENTAL TECHNIQUES OF PLASTIC SURGCR\

half-circle The defect is thus approximately triangular in shape
and the narrower the triangle the less does the tissue ha\e to
rotate to fill the defect With the flap rotated into the defect
and sutured in place there is a difference of tension on the two

Fic 4, 23

Combined rotation — transposed flap used following excision of a pre
malignant keratosis of cheek Flap outlined (A), raised (B C) and transferred
(D) with direct suture of the secondary defect

sides of the suture lme and ideally this difference of tension is
distributed e\ enly all along the suture lme It follows that the
larger the circle of the flap, the longer is the line along which the
tension difference can be distributed and the smaller the difference
at any particular point

Apure rotation flap has no secondary defect but often, depending

FLAP* PFDICLES AND TUBES

133

on the laxity of the tissues and the degree of rotation required the
primary defect cannot be closed pureh b\ redistributing the
tension and a further incision has to be made to allow the flap to
mo\e laterally as well as rotate into the defect W here the curve
of flap and defect makes a half circle the incision is made as a

Without back cut

With back cut

Small Flap -
/arge tension

d ffercnce

c\

Effect of flap size on differential tension.

Tic 4 24

Diagrams of rotat on flaps show ng the effect of the back cut and the
influence of the s 2e of the flap on lens on d fference

back cut along the diameter line This enables the flap to move
b\ a combination of rotation and transposition into the defect
This back cut creates a secondary defect which is closed where
possible bv direct suture failing this b} a free skin graft

Principle of transposition Even m its purest form the trans
posed flap does piv ot on an axis and so does rotate but the major
movement is lateral The primary defect is again triangular and

134 FUNDAMENTAL techniques of plastic surgery

the rectangular flap constructed along one of its sides raov es lateral!)
^hen transposed into the defect One purpose of the manoeuvre
is to avoid tension of the suture line closing the primary defect
and so the secondar) defect cannot be directly sutured since this
would recreate the very tension the flap was designed to avoid
It must therefore be closed either b) a free skin graft or by a
further plastic procedure which wall perm t closure without tension
The vascular limitations of local flaps

When a local flap is moved there tends to be a line of tension
along the base or obliquely across the flap and this if excessive
is extremel) prone to cause necrosis of the tissue beyond it
A back cut will usually eliminate the tension line and allow the
flap to move readily into the defect but it must he recognised
that the back cut also reduces the vascular area of the base and thus
the circulatory reserve

These two factors — vascular area and tension— must always be
balanced and to know just how much one maj be reduced to
eliminate the other in a particular situation is a measure of
experience Probably tension is a more potent producer of massiv e
necrosis than reduction of vascular area The enhancement of
vascular efficiency produced by a delay fends to be offset by the
fibrosis which it causes particularly if the delay includes elevation
of the flap for the flexibility of a flap ahvay s helps to reduce tension
Planning the flap (Fig 4 25)

It must be stated at the outset that the guiding principles to
be laid down apply to rotation and transposed flaps in their classical
forms and do not necessarily apply to many of the flaps used m
certain parts of the head and neck These wall be discussed
separately

The first step with either type of flap is to triangulate the
defect The defect must be capable of hemg outlined as a
tnangle with tw o sides approximately equal and this may necessitate
the sacrifice of normal tissue to make the triangle A defect w hich
for any Teason cannot be triangulated is seldom suitable for a
standard local flap As a rule the two equal sides of the tnangle
are longer than the third which forms the base and in visualising
the procedure and the flap appropnate to it the defect must be
thought of as being closed by moving one of the equal sides as
a side of the flap across to the other

136 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

square and in a difficult situation its dimensions should be even
more favourable

The classical shape then is square and in planning it must
first be recognised that the point around which the flap will pivot
m moving is not the apex of the triangle, but rather the other side
of the base of the flap From this it follows that if the flap is to
dose the defect the distance from the ptv ota! point to the far point

A

Correct Design

Incorrect Design
Fic 4 *6

The design of a transposed ftjp Compare the well designed
flap where the distance from the pivoi point to A equtls that
to B and the transfer is consequentl} « ilhout tension and the
incorrectly designed Rap where the distances ore Unequal
because the flap ts too short ond the transfer can only be
achieved with tension

of the triangle must equal the diagonal length of the flap from the
pivotal point

Before anv incision is made the pivot point must be clearlv
defined and the distance from the pivot to each point of the flap
compared with its estimated distance to the same point when
transposition is complete \\ here the distance before transposition
vs shorter there will be a line of tension along that line when the
flap is transposed The diagonal length o f the flap from the piv ot
point m the square flap is the one particuhrl) liable to be short
The distances can be equated in two wavs

t Initial design The flap can be made longer than the side
of the triangulated defect so that us actual diagonal length

FLAPS, PEDICLES AND TUBES

137

before and estimated diagonal length after transfer are equal
and the actual shape and dimensions of the flap can be stmilarl)
decided bj considering actual lengths before and estimated
lengths after

This is the best method and the one to be used in planning
the flap If, however, it should be found when the flap has
been cut that the length is inadequate and a tension line will
result, an alternative but on the whole less satisfactorj device
must be used, namely the bach cut Indeed to hate to me a
back-ad ts an admission of bad initial design
2 The back cut As the flap has been cut its length is fi\ed
and so the point of pnot must be altered to reduce the
discrepancies of length and a bach-cut achieves this Though
it does reduce tension it must be remembered that it also
reduces vascularity and so should be as small as possible
Sometimes it proves possible to reduce the tension without
significantly reducing the vascularity by cutting onl> the
actual tissue responsible for the tension leav ing at the same
time the blood vessels intact In shin w ith a good thichness
of superficial fascia section of the shin alone may give enough
relaxation, while in the scalp cutting the galea aponeurotica
maj have the same result In the face and neck such differ-
ential section is seldom feasible, but fortunately blood supply
and tissue availability are usually so good that the problem is
less hhelj to arise m an acute form
The transposed flap is especially useful w here a secondary graft
is not contra-indicated for cosmetic reasons and so it is used
mainly outside the face With it the size of the secondary defect
approximates in area to the primary defect and it is covered with a
spht-shin graft Any attempt to close the secondarj defect bj
direct suture destroys the whole point of the flap transfer for the
reason already given

The rotation flap (Fig 4, 27)

The classical rotation flap has a near-circular curse and, used
with or without a back-cut along the diameter of the semi circle,
the curve of the flap is able to rotate along the corresponding curve
of the other side of the incision outlining the flap It is sutured
in its new position with a degree of differential tension, but when
a back-cut is needed in addition, as it frequently is, a triangular

138 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

secondarj defect is opened up and the flap reallj then combines
rotation and transposition \\ ith the mov emcnt of cun e on cune
there is no defect in the region of the actual flap except at the back-
cut The larger the flap is made the less the difference of tension
at each point of the flap and most difficulties arise from planning
on too small a scale rather on too large
The point around which the flap pivots hes approximately
mid waj between the apex of the triangular defect and the end of
the back cut, and the distance from this point to each point of the

flap must equal its distance to the point to which it will be sutured
after rotation The pivot of the rotation flap cannot be pin-
pointed with the accuracy possible in the transposed flap for the
rotation flap does rely to some extent on the flexibility of the
tissues It is because of this that it general) work* best when
the skin is lax and flexible

Outside the head and neck the secondarj defect is routinelj
split skin grafted and in actual practice suturing of the flap is
stopped as soon as tension is clearly present and the graft is applied
In the head and neck the secondary defect is usuallj closed bj
direct suture with the proviso that such closure must not create
tension along the base of the flap sufficient to jeopardise its blood
supplj If direct closure is impossible a graft must be used

The problem of the secondarj defect left when the flap is
rotated can sometimes be solved in quite a different wa) (Fig 4 , 28)
which is best understood bj considering the relative wound lengths

Ft APS, PEDICLES AND TUBES

139

The length of the flap is less than that of the wound to which it
has to be sutured and the two lengths can be equated either bj
increasing the length of the flap side, which is the effect of the
bach-cut, or reducing the length of the outer line of the wound
to make it equal the length of the flap Excising a triangle of
tissue opposite where the bach cut would normal!} be has just
this effect and is feasible when there is enough tissue available to
allow excision In the event the flap is rotated without bach cut
and as suturing proceeds it becomes obvious that there is some
redundant tissue on the outer side of the suture line and eventually

Fic 4, 28

A method of avoiding a seconds?} defect which can sometimes be used when
the shin is lax and tissue available in consequence Fig 5, 19 shows the
method in practice

a dog-ear develops, excision of which leaves the two sides equal
m length It is only in the head and neck that there is spare
tissue available to allow this method to be used

The dog-ear of the triangulated defect

If the pivoting took place round the apex of the triangulated
primarj defect the resulting suture line would be quite flat but
with the pivot point elsewhere both in the rotated and transposed
flap there tends to be a dog-ear left at the apex of the triangle when
the flap is moved Though it raaj be possible to deal with this
m the usual way at the time of flap transfer, it should alwajs be
left for subsequent excision if its removal would m an} way
jeopardise the blood supply of the flap

TLAPS OF HEAD AND NECK
Although classical local flaps are often used m the head and
neck the extremelv rich vascular pattern coupled with a laxitj of
tissue greater than elsewhere in the bod} permit the planning and
execution of flaps with scant regard for the usual requirements
A common t} pe is the long narrow pedicled flap based on a known
vascular system.

X40 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

Examples are the temporal flap based on the superficial
temporal vessels (Fig 4, 29), and the Indian forehead flap based
on the supra orbital vessels (rig 4, 30)

In most of these the greater part of the flap is used as a carrier

A pedicled flap based on the superficial temporal vascular pattern The
post traumatic scarring with loss of e>eball and severe damage to ejchds (A)
is replaced by the flap (B) the forehead defect being spl t skin grafted \Y ith
the carrier segment returned to its original site the final result is shown
without (C) and with (D) the prosthesis (inset)

of the terminal segment which alone is set into the defect Three
weeks suffice for the inset segment to establish its vascular supplj
Iocallj , the flap is divided and the unused carrier segment is
returned whence it came It is fortunate that the copious viscular
pattern permits the carrier segment to be left raw on its deep
surface without fear of disastrous sepsis for the narrowness of
these flaps relative to their bulk would make tubing impossible
Where the defect left by raising the flap cannot be closed by

FLAPS, PEDICLES AND TUBES 141

direct suture a spltNsbn graft is used for temporary co\er and this
is removed in due course when the carrier segment is returned
to its original site The graft covering the donor site of the
transferred segment is usual!) left as 1 permanent

142 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCER1

and care spent on this step will prevent the disaster of the flap
which only reaches its destination with difficult} or not at all

Flap transfer

The precise thinness of tissue required m the defect can often
be duplicated m the flap with safet} so abundant is the blood
supplj but in passing from the part of the flap to be mset to the
carrier segment the flap should be broadened and thickened to
allow of maximal blood suppl} For the purposes of flap thickness
the head can be divided into the vault of the skull as far as the
margins of the galea aponeurotica where the blood suppl} is
entirely marginal and the routine plane of dissection is the loose
areolar tissue deep to the galea and the remaining skm which of
course has an additional deep blood suppl} As a result delav of a
scalp flap need never include elevation

In the forehead the terminal flap ma) safcl} be made thm
enough to leave the frontalis muscle behind and in the face and
neck it may include the minimum of fat but in both instances it
should thicken fairly rapidl} to the more usual plane of dissection
In the neck this plane is best deep to plat}sma and includes as
much of the superficial venous s}stem as possible

Returning the carrier segment

During the 3 weeks the carrier segment tends to tube itself in
two distinct wa}S b} fibrotic contraction of the raw surface and
by marginal epithehahsation When returning it to its original
site the fibrous tissue must be excised completelj to undo the
tubing and to get the best suture line the marginal epithelium
should also be removed Even so the flap tends to remain a
trifle narrower than when it was onginall} raised and when
suturing it back in position after removing the temporar} graft
the scalp ma} have to be mobilised quite widel} to bring the skin
edges readil} together This is most likelv to occur if the graft
has been applied with the scalp in the naturall} retracted position
it assumes when the flap is raised It is possible to overcome
retraction of the scalp b} suturing the temporar} graft under
slightly greater than normal tension This reduction of the
grafted area to a minimum makes the subsequent replacement
of the flap much more straightforward and free of tension

Follow ing div lsion an d return of the carrier segment the insetting

FLAPS PEDICLES AND TUBES 143

of the transferred segment of the flap is completed and as m the
direct flap a little thinning of the margin may be necessary to allow
it to sit neatly into the defect

Raps based either on the superficial temporal or supra orbital
\essels tend to be the most useful m the repair of sizeable defects
of the face above the level of the mouth — generally of the nose
cheek and lower eyelid

The first point to be considered in planning is whether the skin
cover is to be hairy or not for this will decide whether scalp or
forehead must provide the skin Thereafter the appropriate
pedicle can be selected using jaconet to give the exact outline
A supra orbital based flap works well for symmetrical nasal defects
defects of one side can be cohered with either type supra orbital
or temporal When the defect involves cheek either alone or
with part of the nose the temporal flap is usually more satisfactory
as the length of pedicle gives the flap a longer reach

While it is often necessary to provide lining as well as skin
cover the methods used to provide such lining are beyond the
scope of this book and will not be discussed further

Flaps are often required to repair the defects which follow
excision of neoplastic lesions simple premalignant and malignant
which are unsuited for repair by direct suture or free skin graft
They may also be used to replace a free skin graft used for primary
repair which is unsatisfactory cosmetically This subject will be
discussed m more detail in Chapter Five

In acute trauma as described in Chapter One flaps have a
■very limited use and should be attempted only by an experienced
plastic surgeon

BIBLIOGRAPHY

Flap planning in reverse

Gillies H D (1932) The des gn of d rect ped cie flaps But med J
2 1008

Vascular adjustments in flaps

Douglas B &. Buchholz R R (1943) The blood circulat on in ped cle
flaps An 1 Surg 117 69a

German W Finesilveh E M &Dams J S (1933) Establishment of
circulation in tubed skin flaps Arch Surg (Cl tcago) 26 27

PART 'I WO

THE SURGICAL
APPLICATIONS

CHAPTER TIVE

General Surgery

T HE need for plastic surgical methods ingeneral surgerj arises
in man} different \va} s and the onlj factor common to all is
that shin requires to be replaced Shin loss ma} ha\ e resulted
from the pathological process itself, from the surgical attach on it,
or from a combination of both Consideration of the various \va\s
in which the need for repair arises will be concerned particular!}
with the influence of the pathological condition on the surgeon’s
approach and how it dictates the t}pc of repair necessar)

A few miscellaneous conditions defy classification but most
examples of shin injur} or loss requiring replacement fall into the
broad categories of traumatic, infective and post-surgical.

TRAUMATIC SKIN LOSS

Trauma can be thermal, mechanical and radiational.
It is not proposed to discuss thermal trauma as a separate entit}
for an adequate discussion would entail consideration of aspects
outwith the scope of this booh but much of the discussion on the
granulating area and its shin co\er is direct!} applicable to the
care of a full-thichness shin loss bum

Mechanical Trauma

Mechanical injur} may denude am shin area but the parts
particular!} prone to mjun of this t}pc are the scalp, the limbs and
the scrotum.

The scalp

The usual mechanism, less common with shorter hair st}lcs
and a more widespread use of suitable hair-enclosing caps in
industry, is for the hair to be caught in machinery am Ling part
>47

I4 8 fundamental techniques of plastic sunrnn

or all of the scalp It js an injun of females The avulsed
segment maj be partiallj or complete!} avulsed

If only partly aztilsed the flap should be preserved no matter
how small its pedicle and should be sutured bach m position after
suitable toilet shaving etc The blood supplj of the scalp is so
good that much more of the flap mav survive than the size of the
pedicle might suggest Once dressed the area should he left
untouched for a week bj which time a good demarcation line will
have developed between viable flap and slough The slough can
now be excised without delaj while it is still dry and rclamcl)
sterile To await natural separation is a mistake If there is no
contra indication excision can be followed b) the application of an
immediate split skm graft Tailing that closel) set sheets of skin
can be applied 4 or 5 dajs later The mam contra indication to
the immediate graft is the inclusion of the pericranium in the
avulsed flap the treatment of this complication is described below

When the segment has been completely azulsed it should under
no circumstances be sutured back in position There is no
prospect of such a free graft taking and the optimism of the surgeon
watching and hoping will onl) delay the renun al of the inevitable
slough

Treatment depends on the plane of avulsion The usual plane
of cleavage is through the loose areolar tissue deep to the galea
aponeurotica and the pericranium which this leaves intact makes
an excellent bed for a graft It should be completelj covered
with split skin sheet grafts as a pnmarj measure (I ig 5, 1)
Probablj the crucial point of technique is to avoid too much pressure
in appljing the dressing There is no give in the skull and too
much pressure will cause ischaemic necrosis of the pericranium and
give rise to a slough which when removed leaves the umlcrljmg
bone bare When the forehead is involved the smooth iiniformlj
thick graft of the dermatome giv es the best cosmetic result 1 1 can
be applied either as a pnmarj procedure or sccondanlv after
excising the pnmarv graft (Fig 5, 2)

More rarefj the skuff is either part?} or completed denuded of
pericranium over the area of avulsion and treatment of the bare
area of skull becomes quite different more tedious and difficult
Bare outer table of skull will not take a graft and methods have to be
adopted to produce bleeding bone which will granulate
(r<g 5> 3) The fastest and surest waj of getting the bone to

r»c s, i

Immediate cover With split-skin grafts follow me scalp avulsion when the
pericranium is intact showing the raptdit) of healing
A Appearnnec two weeks after iryur>

II Seven weeks after injur} showing complete healing

Tic 5, 2

Use of a dermatome split skin graft in sccondir} replacement of forehead
skin whrn the cosmetic result of the pnmarj graft is unsatisfactorv
A Hie poor covmctic result of pinch grafts applied pnrruril)

II Hep! torment with the dermatome graft

150 FUNDAMENTAL techniques of plastic surgery

granulate is to chisel away the outer table of skull With ex-
perience an immediate split skin graft can be got to take on such
a surface but little is lost by waiting until reasonable granulations
ha\ e developed Chiselling has frequently to be repeated as small
areas fail to granulate The whole procedure is extremely tedious
for both patient and surgeon The end result, too, is much less
satisfactory as the lack of mobility and cushioning under the graft
make it susceptible to minor trauma

Fic 5,3

Healing following destruction of the pericranium In this example
destruction was by burning but the sequence of events is similar when the
skull is exposed by avulsion of the scalp
A Bare outer table of skull
B Patchy granulations four months later

C State of heal mg thirteen months after A show ing areas of instability

No hair grows from the avulsed area and this maj call for
subsequent surgery The position can sometimes be improved
by moving a flap of any remaining normal scalp to the front of the
scalp to provide an anterior hair line The hair growing back
from such a flap brushed appropriately can co\er the bald area
and though never quite natural gives a better result than most w igs
Attempts have been made to apply grafts cut from the avulsed
scalp m an attempt to get hair to grow but to date the results have
largely been negative
The limbs

Extensive loss of skin from a limb is most often the result of a
wringer or roller injury which causes degloving Although this
is becoming a much more common injury it is clear, judging from
patients referred at a later stage to plastic surgery units that the
condition is less well known than it deserves to be

CENERAL SURGER\

The usual cause is either the catching of a limb in power driven
rollers, eg the wringer of a washing machine, or the running
over of a limb by a pneumatic tyre, both of which produce a
sudden severe shearing strain (Fig 5, 4) The results differ only
in seventy Bony or joint injury may be associated, but the
characteristic feature is the flaying of the skin The word

‘Physiological’ 'Anatomical

deqlovjng deg loving

Fig 5,4

The mechanism of deglovwg (after Slack)

“flaying ” must be qualified font may be anatomical or physiological
If anatomicall) flayed the skin is actually tom off, if phjsiologi
cally, the skin surface is intact but there is complete disruption
at the level of the deep fascia with undermining At the same
time the vascular network of the skin is damaged more or less
severely bj the sudden extreme tension set up by the shearing
strain, usually sexerely enough to cause ischaemic necrosis of skin
and superficial fascia

It must be realised that initially there may be little eudence
clinically of the seventy or extent of the v ascular and skin damage —
unless it is tested for The clinical sign to be looked for in such
an injur) is failure of the skin to blanch when pressed with return
of colour when the pressure is released or, when a skin edge is
present, absence of dermal bleeding Both signs indicate absence

ij2 fundamental techniques of plastic surcert

of active skm circulation Over the u hole undermined area the
skin must be regarded as suspect and the surgeon must decide what
is viable and can be sated, or dead and to be evcised It is
positive evidence of circulation which decides viability and if
there is not positiv e ev idence of v labihtv the skin should be excised

|?vVPi5^

UL

:v m

a

Fic s,5

Deglo-wng of leg primarily resurfaced with sheet split skm grafts
A Ettent of injury
B First dressing seven days later
C Healing with full function

A clearer picture of the shin area which retains an active circulation
can sometimes be obtained by observing the distribution of the
reactive hyperaemia which develops when a sphygmomanometer
placed proximal to the injured segment is released after being left
inflated for 5 minutes— the tourniquet test

Here as in the scalp early grafting should be earned out
(Fig 5, 5) Although the general condition may ov ershadow the
local and dictate at least temporary delay a local assessment
should be made as soon as possible, the non viable shin being
excised and the resulting defect split-shin grafted after suitable

GENERAL SURGERA

r 53

debridement if necessary As much skin as possible should be
applied with priority to the flexures and areas with underlying
tendons

Damage to muscle is often present and excision of necrotic
tissue must be as radical as is consistent with the presen ation of
such vital structures as arteries and nerves Only on a healthy
base will a graft take and residual necrotic tissue mil mean gra t
failure

Associated bony or joint damage is fortunately not common
The treatment of the two injuries occurring together is discussed
on page 181 The exposure of tibia or ulna which are the bones
most liable to be bared ma\ also add to the difficulties but m such
i situation a universal solution is not practicable and consultation
between orthopaedic and plastic surgeon is desirable

The avulscd skin is often relatively undamaged and in those
circumstances it may be possible after all the subcutaneous fat has
been carcfullv excised to re apply the skin as a whole skin graft
This measure cannot be recommended for routine use It
requires experience and judgment to select the appropriate
case

Abov e all things should not be allowed to drift until the slough
separates slowly and spontaneously If the injury has not been
recognised primarily and only becomes obvious when a slough
forms the slough should be txcised as soon as demarcated and the
area grafted To wait bevond this is to wait for the infection
iness and delay of slough separation with consequent grafting
difficulties

The scrotum

The catching up of the scrotal skin with the trousers on a
horizontally rotating shaft is the usual cause of avulsion of the
scrotum In the past the denuded testicles were implanted in the
thighs or covered by a flap but it has been shown that tlicv can be
covered with a free skin graft Often the avulscd skin is available
and rclam ely undamaged and it has been successfully used as a
whole skin graft after careful excision of the dartos muscle layer
As an alternative the use of a split skin graft has been described

T hese techniques should onh be used by an expert , success
calls for experience and skill Such cases should be referred to a
plastic surgery unit m the first instance

154 fundamental techniques of plastic surcery
Radiational Trauma

The forms of radiational trauma which may call for plastic
surgical methods are radionecrosis and radiodermatitis These
conditions are late results of irradiation (Fig 5, 6) and man) of the
worst examples are seen in patients treated inexpertly for con-
ditions in which radiotherap) has either long since been abandoned
as a therapeutic measure or in which the actual method of treatment
has been radical!) modified, as for example m thyrotoxicosis,
tuberculous cervical adenitis, sycosis barbae, acne vulgans, lupus
vulgaris haemangioma and many others

W ith a greater awareness of the dangers of radiation and more
expert use of the various techniques these late complications are
less common but they still do occur ev en in the most careful hands
The area particularly prone to develop radionecrosis or radio-
dermatitis sufficiently severely to merit surgical treatment is the
oral cavity and its environs when a carcinoma has been treated by
radiotherapy The ear and the post mastectomy scar are also
sometimes involved

In both necrosis and dermatitis the constant factor is general
avasculanty of the affected area and this influences the surgical
approach in two ways

1 Unless the area is excised deeply beyond the damaged
zone, the resulting granulations tend to be poor and the
chances of take of a free skin graft either at the time of excision
or subsequently are poor

z The suture holding properties of therapy damaged slun
are bad and the tissues are slow to heal
Which tissues have borne the brunt of the damage will depend
on whether the skin or deeper structures have been the primary
target of the radiotherapy and this must be assessed before
deciding on the type of repair The mobility of the skm is a good
clinical indicator of whether the deeper structures are involved
If skm alone is damaged, excision and replacement with a split-
sfon graft or whole skin graft is usually satisfactory If, on the
other hand, an ulcer is present, it may be assumed that deeper
tissues are grossly mvoh ed In such a situation, a blood carrying
flap wall be needed and excision of the ulcer should be as radical
as is technically feasible deeply, clearing therapy -damaged skin
at the margins If bone is m\ olv ed a sequestrectomy may be done

Fie 5,6

Examples of mdionccrosis and mdiodenrutitis

A Radiodermatitis of neck following radiotherapy for thyro
toxicosis

B Bad 10 necrosis of chin floor of mouth and mandible n ith fistula,
following irradiation of squamous carcinoma of floor of mouth
The tube pedicle raised for repair of th<- ulcer is shown in
Tig 4, 6A

C Radionccrosis of chest wall resulting from radiotherapy
following radical mastectomy for carcinoma showing central
deep ulceration with exposure of ribs and surrounding radio-
dermatitis

D Radiodermatitis following radiotherapy for acne vulgaris
Rodent ulcers of right lower *\ctul and right pre auricular
region are present and since this record was made multiple
rodent ulcers have been removed as thev appeared

A further example of radiodermatitis is shown in Tig 4, “A following
radiotherapy for *j costs barbae

156 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERV

simultaneously Unfortunately where sequestrectomj is needed
the margins of necrosis are difficult to define and this is especial!)
true of the mandible which is often the bone involved

Before any ulcer is treated a biopsj must be considered to
exclude malignancy since this will naturally influence the extent
and depth of excision In this connection it is w orth remembering
that a malignant ulcer developing m therap) damaged shin is
seldom clinically typical and recurrences of shin tumours following
radiotherap) are very liable to masquerade as radionecrosis until
biopsj reveals the true state of affairs When a post irradiation
tumour recurrence is being excised the entire area of therap)
change should be regarded as suspect even although the visible
recurrence is only a small segment of this for the area of therap)
change represents the surface extent of the original tumour

INFECTIVE SKIN LOSS

With the adv ent of the antibiotics shin necrosis from fulminating
cellulitis is uncommon but it may still occur from an uncontrolled
infection b) Str py ogenes or as a result of post operative progressive
bacterial s)nergistic gangrene which gives rise to the chronic
undermining ulceration brought to surgical notice by Meleney
With either infection the problem of shin cover arises once the
infection has been controlled and in both instances two conditions
must be satisfied— the granulations must hob healthy with evidence
of marginal healing and the bacterial flora must be innocuous
Probabl) stamp grafts closel) placed are the appropriate t)pe of
repair they are certainly the safest

POST SURGICAL SKIN LOSS

A post surgical shin defect may arise as a result of excision of a
tumour of shin itself or one involving shin secondaril) as in
carcinoma of breast Shin grafting has also been used m the
treatment of certain anal conditions

Neoplasia of Skin

It is essential in treating malignant shin tumours that the
surgeon should separate in his mind at least the excision of the
tumour and the repair of the defect so that the tumour will be

GENER \L SURGFR\ 1 57

treated according to its nature and extent without regard to
possible problems of repair

The head and neck apart the policy of skin replacement
following excision of a mal gnant tumour of skin is a straight
forward one The cosmetic aspect is of minor significance as a
factor in deciding type of repair and the split skin graft applied
immediate^ after excision is the usual method emplo\ed The
free skin graft has the advantages in this field of being technically
easier and of not obscuring the field when recurrence is being
watched for

One of the few situations wh ch m ght call for the primary use
of a flap would be one where excision leaves a surface which cannot
take a free skin graft for example cortical bone or tendon The
ad\antages of flap co\er must then be weighed against the degree
of certainty of adequate excision

The pros and cons of immediate flap repair arise with greater
urgency in neoplasia of head and neck and wall be considered m
detail then but much of the argument applies to the problem
elsewhere in the bod) In practice the flap has a very minor role
m providing immediate skm cov er follow >ng excision of a malignant
skin tumour

Neoplasia of the Head and Neck
This subject is a vast one and will be discussed only as it
affects the surgical procedure As in other fields of surger)
pathologv should gov ern practice So many malignant neoplasms
of head and neck are local conditions that adequacy of excision
becomes of paramount importance and thoughts of subsequent
repair must never influence excision if this wall in any way con
travene pathological considerations The merits and dements of
pnmary definitive repair following excision thus emerge as a
matter of overall policy Considerations of age general cond tton
absolute certainty of excision etc may all influence an
individual decision discussion here is concerned with the general
problem

The defect left when a trial gnant lesion has been excised can
usually be repaired either by a free skm graft or a flap Often the
flap would gne a much better cosmetic result and soleh on those
grounds would be preferable The free skm graft on the other

> 5 S fundamental techniques of plastic sukcem
hand, uilh the cscept.on of the post auricular uholc slm graft
around eje and nose gnes a related} poor cosmetic r4.lt
Despite this its merit on pathological grounds is unassailable for
its use allows inspection of the operative field for an> recurrence
and permits carl) biops) of an) area which is remote!) suspicious
Recurrence deep to a flap would be disastrous!) large before its

Tic 5 7

Acrjlic prosthesw as permanent repair of nasal defect following rxc sion
of a rodent ulcer The ope and general condition of the patient were con
sidcred to preclude defimme repair with the patients s own tissues
I'll rt her examples of prosthetic repairs are shown in Figs 4 29 and 5, 19

presence would be sufficient) evident chnicaH) to tempt the
surgeon to interfere with his fljp

A proper polic) then is to repair evcisional defects where at all
possible with free skin grafts, including where necessar) the
wearing of prostheses When the area has been watched for
9-18 months according to the local and pathological circum
stances until any recurrence js like!) to have appeared, a re
assessment can be made and the definitive repair proceeded with
if this is felt desirable A permanent prosthesis sometimes giv es
the best result and if so ma) be considered as the definitive
‘ repair’ (Fig 5, 7)

Circumstances may on occasion necessitate departure from tins

GENERAL SURGERY 159

principle, but they must be overriding before departure becomes
justifiable Examples of such circumstances are

1 Where a gross salivary fistula will be produced by the
excision This applies especially to older patients who do
not tolerate a fistula well, m such circumstances it is wise to
aim at primary definitive repair In any case such excisions
usually involve the full thickness of cheek or lip and marginal
recurrence alone need be watched for

2 \\ here bare skull will be produced by an excision a rotation
flap is needed Fortunately deep clearance can be more
assured here than in most other situations

3 Where deep clearance is clinically definite but during
excision temporo mandibular joint or mandible is exposed
Neither is capable of taking a free skin graft and the tnsmus
produced if either is left to granulate before grafting makes a
flap necessary

4 Where it prov es impossible to achieve complete excision of
a tumour it may be worth while to rotate a flap for skin cover
so that further radiotherapy can be given

Excluding the free skin graft, and there are no special points to
distinguish graft usage m the head and neck from elsewhere
except the technical problems arising from the need of the patient
to breathe and eat, the types of repair can best be illustrated by
reference to the various parts of the head and neck involved

The lips

The type of repair depends on whether a full thickness defect
results from the excision requiring lining to be transferred with the
flap employed

Full thickness defects V-exctsion and direct closure (Fig 5, 8)
Up to one third of either lip can be excised and directly closed with-
out unduly constricting the mouth Suturing as w ith all lip repairs
1a in tv\ o lay ers Undermining of the skin for | inch or so defines
the muco-muscular lav ers which are united with vertical muco-
muscular mattress cat gut sutures These sutures take the strain
of the repair and allow the skin edges to be closed without tension
or tendency to im ert It is usual in cleft lips to incorporate a
Z-plasty of the red margin to giv e a smoother margin to the lip

<6° FUNDAMENTAL TECHNIQUES OE PLASTIC SURGERY

but in cancer surgerj it IS preferable to use straight suture for this
leaves a single line onl) to be watched for recurrence

Insertion of muco Completion of

muscular cat gut suture suturing

Fig 5 8

Squamous carcinoma of lower I p treated by V-excis on with direct closure
showing the two layer method of suture which is rout nely used in repa ring
the full thickness of the lip

Many of these patients show diffuse pre malignant change of
the exposed area of the whole length of red margin and this can
be treated bj excising the affected strip mobilising the mucosa
inside the lip and advancing it round to meet the skin — the lip
shave (Tig 5, 9) When the main lesion is regarded either as

Exeis on of red marqin and mucosal advancement — "lip shave"

Combined V excision and “lip shave"

Fig s «j

Excision of pre malignant red margin of lower lip and repair by lip shasc As
ind catcd this method of repair can be combined with a V ctcis on if necessary

red margin after the V excision has removed the area of fnnh
clinical carcinoma

The V-hp sxiitch flap This consists of the transfer of a full
thickness flap, pedided on the labial vessels, from one lip to fill
a corresponding!) shaped defect of the other lip (Fig 5, 10) The

lG° FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERA

bul m cancer surge,} ,t ,s prefemble to use slough, suture for this
leases a single line onlj to be Hutched for recurrence

Lines of excision
marked out

Insertion of muco
muscular cat-gut suture

Completion of
suturing

Fig s. 8

Squamous carcinoma of lower Up treated by V-eidsion with direct closure
showing the two layer method of suture which is routinel) used in repairing
the full thicfcness of the lip

Man) of these patients show diffuse pre-malignant change of
the exposed area of the t\hoIe length of red margin and this can
be treated by excising the affected strip, mobilising the mucosa
inside the lip and advancing it round to meet the skin — the ‘ hp-
shave” (Fig 5, 9) "When the mam lesion is regarded either as

GENERAL SURGER\

prc malignant or not jet in\asi\e the lip sha\e can replace the
V excision and it can. also be used to remo\c the prc malignant

neoplasms of the lower lip arc much more common it is the defect
of the lower lip which usual!) calls for repair

A fan-shaped flap based on the labial \essels of the normal lip
and of depth corresponding to the defect is constructed and routed
to fill the defect 1 he sccondar) defect is closed b) taking up the
slack present on the check It is fortunate that most repairs are
earned out in the older age group where adequate slack in the
cheek is usualh available

164 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCER1

The flap can be rotated until flap red margin meets lip red
margin (Fig 5, 12) but this reduces the size of the mouth consider-
ablj An alternative method which is particular! j useful in
repairs following extensive lip resections is to suture the skin
and mucosa of the flap along the line of resection and use it as the
red margin (Fig 5, 13) This often leaves a larger mouth

single fan flap rotating red margin to meet red margin showing the reduction
in the size of the mouth which results The patient refused further surgery
to enlarge the aperture of the mouth

In practice the best method is that in which the flap lies most
easilj

It maj happen that the angle of mouth has to be opened up
secondanl) if the orifice is too small This should if anything be
underdone as the opened segment tends to gape in a rather
unsightly manner

Bilateral fan flaps can be used to repair a defect of the entire
lower lip (Fig 5, 14) In such a situation skin to mucosa suture
must be used to reconstitute the red margin as the alternative
method approximating red margins would make the orifice of the
mouth impossibly small

GENERAL SORCERY

165

Skin and muscle defects. The potential source of material for
repair depends on the size of the defect When the defect is of anj

Recurrence of squamous carcinoma of loner lip following radiotherapy
excised and repaired by single fan flap with reconstruction of the red margin
by advancing mucosa

size tke main sources are the forehead and neck For the upper
lip and naso-labial region (Fig 5, 15) bridge pedicles of forehead
skm based on the temporal \essels are usual Rotation or trans-
posed flaps for the lower lip (Fig 5, 16) are usually taken from the
neck either with a secondary free skm graft to the donor site or
direct closure if the skin is sufficiently lax

rn fundamental techniques of elastic surcer\
The nose

Tor small defects particularly where there is no loss of lining
the forehead is the usual source of skin *1 o cover the upper nose
and adjoining canthil area a flap based on one set of supra orbital

Exc s on of almost the entire lo er I p for squamous care noma In ual
closure by sk n mucosal suture and subsequent repair by bda eral fan flaps

vessels can be rotated leaving a forehead defect which can usuallj
be closed by direct suture (Tigs 5> anc * 4 3°)

The reach of this flap is strictly limited and be\ ond it the i sual
complication which arises in considering repair if the defect is
of full thickness is need of lining The methods of coping with

l68 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

this problem are be>ond the scope of this book If no lining is
needed, the forehead bridge pedicle flap based either on the
temporal (Fig 4 , 29) or supra-orbital \essels (Fig 18) is most
useful though with a smaller defect a naso-labial flap may be
possible

The cheek

The most useful method of repair using local tissues is the
inferiorlj based rotation flap bj which pre auricular skin is
brought forward (Figs 5, 19 and 4 , 23) The defect posteriorh

Rodent ulcer overlying and invading the body of the mandible, excised and
repaired by transposed flap
A Extent of excision and delay of flap

B Transfer of flap with development of web across the chin and Z-plasty
outlined

C End result after Z plasty

can usuallj be closed but when a free skin graft « needed its
refatn ef) inconspicuous position gnes a good cosmetic result
The method works best where the lesion is long and narrow or is
readilj triangulated

An alternate e method with horizontal lesions of the lower
cheek is to ad\ ance neck skin in association w ith extensit e under-
mining m the neck The resulting scar tends to stretch very
badlj and the method cannot be recommended

The ear

Quite unnecessarily complicated reconstructions of ear following
limited excision are described and reasonablj good results can be

GENERAL SURGERT

l6g

Modified Glabellar Flap incorporating

Z plasty

Fie 5 17

\ ery extensive molloscum sebaceura (confirmed by b opsy) excised and
repaired by s mple glabellar flap A modificat on is also shown wh ch s
useful when there is d fficully in closing the secondary defect of forehead

Fic 5 18

Penetrat ng rodent ulcer of med al canthus and adjo n ng nose (A) excised
and repa red pr mar lv v th a spl t sk n graft (B) After a period of folio up
w thout recurrence cfefin C -e repa r by forehead br dge ped cle flap ( nset
and C) Result folio v ng return of br dge segment (D) The pat ent refused

to hate further tr mm ng etc of the flap

small enough to be excised leaving enough ear to make recon
struction worth while a simple V shaped full thickness
excision with the apex towards the meatus and the limbs of

*7 2 rUNDAAIENTAL TECHNIQUES

OF PLASTIC SURGERY

GE \ ER 41 SURGERY

m

the \ of equal length should be used gn ing adequate tumour
clearance Closure of the defect bj suturing the limbs of the
V together in the two skin layers produces some distortion
but in most cases is entirely adequate cosmeticallj (Fig 5,
20%) When good prosthetic facilities are available an alterna
tive method may be to leave the defect fully displaced bj
suturing the skin on the two sides of the ear together The
residual ear can be made the basis of a partial prosthesis
(Fig 5, 20 b)

2 The peripheral lesion can be dealt with bj adequate
clearance of the tumour followed b} an additional excision
of ^ inch of cartilage to allow the skin to be closed direct!}
ov er it

I here should be no hesitation however in excising the ear
completel) and if necessar} of removing adjoining skin etc
A free skin graft does well in this site making an appropriate
incision to correspond to the meatal stump (Fig 5, 20 n ) The ear
is one of the easiest appendages to replace efTectiv el} either w ith a
partial or total prosthesis

Carcinoma of Breast

Radical mastectomy involves removal of a large area of skin
and further skin loss ma} be caused b} suturing the wound under
tension This has led to an increasing awareness of the value of
the free skin graft following mastectom} The usual graft used
is a thick split skin graft and the essential point of technique is to
ensure dose and immobile contact of graft and chest wall The
skin flaps are liable to be mobile and it is unwise to rcl) on them
alone for anchorage Various methods are described to give
added fixation but as simple as an} is to make the graft 01 erkip the
defect so that it extends on to the flaps The usual anchoring
suture with a bite through intercostal muscle or rib periosteum
will fix both graft and flap to the chest wall

B> leaving the sutures long as usual a tie over bolus dressing
can be used to giv e the necessar} local immobiht} I he flaps can
be independent^ drained or treated b} continuous suction as
preferred the graft still remains a separate entity fixed to the
chest will

>74 fundamental techniques of plastic surgert

Anal Surgery

In the treatment of fistula in ano anal fissure and anal stenosis
it is usual practice to leave at the end of the surgical procedure a
widely open saucensed or fiat raw area to epithehalise slowly
from its margins By grafting this area considerable reduction
in healing time can be achieved Indeed the methods used to
cure the pathological condition and present its recurrence namely
the eradication of fistulous tracks the prevention of pocketing by
wide skin excision and the conversion of the wound into a single
widely open cavity are the very points one w ould stress m lay
mg down principles of successful grafting under such conditions
The natural resistance of the perineum to its normal flora would
appear to extend to skin grafts and infection is seldom a problem
given good contact between graft and recipient site and no dead
space full of haematoma or tissue fluid to provide a culture
medium As haematoma is the most likely cause of graft loss
adequacy of haemostasis becomes the deciding factor m whether
the graft can safely be applied immediate!) on concluding the
anal surgery or whether it is better applied as a secondary pro
cedure 2 days later The superficial flat surface can readily be
grafted immediately but the deeper cavity left after the treatment
of an ano rectal fistula where haemostasis is more difficult is
probably better left for secondary grafting When secondary
grafting is being used the wound can be packed for the 2 days and
then gently cleared of clot to receive the graft With either method

massive cat gut ligatures should be a\oided

The actual method of applying the graft does not differ from
elsewhere a split skm graft overlapping the margin of the raw
surface is used with the usual tie over dressing A thin split skm
graft is preferable because of its better taking properties The
secondary contraction of such a graft is of no moment and such
contraction as does occur can be turned to advantage in reducing
the depth of the grafted cavity

After the first dressing on the fourth to fifth day all dressings
are discarded and the bowel can safely be opened if the area is
gently and carefully cleaned afterwards The use of a skm graft
need not influence the administration of intestinal antibiotics as a
co\ er during surgery of the anal condition

It is a fortunate coincidence that the surgical steps essential

GPSeRAL SUfc6£ltt

>«

for good graft take should be those necessary to eliminate the
particular pathological condition for it means that partial or even
complete failure of the graft to take is not an irreparable disaster
local treatment can if necessary proceed as though a graft had
never been used

MISCELLANEOUS CONDITIONS
Varicose and gravitational ulceration

The part placed by plastic surgical methods is onl\ a very
minor facet of the treatment of this condition The provision of
skm cover does not influence the fundamental circulator} deficienc}
and unless this is coincidentally treated grafting is a complete
waste of time ulceration will inevitabl} recur Onl> the
methods of providing skm cover will be considered here

Grafting the ulcer Using the methods ahead} described the
granulations must be prepared for grafting Of these measures
pressure is probably the most important Marginal healing and
an absence of Str pyoqeues indicate the time to graft and the best
graft is a thin sheet split skm graft Once healed measures to
combat the circulator} defect must continue Grafting raa) also
be used merely as a preliminary to excision and grafting of the
whole ulcer bearing area

Excision of the ulcer bearing area This is a much more
ambitious project and failure is correspondingly more serious The
ulcer with its surrounding pigmentation and induration is e\ci«ed
en bloc to the lev el of deep fascia The fascial plane of cleavage in
the zone of the ulcer is usually poor or virtually absent and in the
vicinity of the medial malleolus this can make d ssection extremely
tedious and difficult as exposure of a tendon is something of a
disaster for over it the graft will fail A thick split skin graft is
usually applied with a tie over dressing which must be most
carefully applied o\ er the instep for graft failure here 1 ea\ cs hare
tendon and the creeping of granulations over sloughing tendon
is a depressing!} slow process Attempts to hasten matters by
excising the slough only produce fresh slough of the tendon left
Post operative immobilisation of the ankle is essential either by
bulk of dressing or more effectively by plaster of Pans

176 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

Such an excision can be carried out while the ulcer remains
unhealed but the clinical appearance and flora must be satisfactory
and it is safer to get the area healed with a split skin graft before
excising and grafting The success of radical excision and grafting
m giving permanent cure is probably due largely to the destruction
of the perforating vein blow outs which is inevitably part of the
procedure

Plantar vart (A ) exc sed and repaired by full th ckness graft (A,) Recurrence
(B) at the margin of a graft appl ed at the t me of previous excis on of a plantar
wart

Plantar warts

Fortunately the majority of plantar warts do not require ex
cision and repair and such surgery is usually regarded as a last
resort It may be required either because the wart has failed to
respond to other methods or because of complications arising from
the methods themselves in particular from over enthusiastic
radiotherapy The warts treated by excision and repair are thus
a highly selected group and a particularl) unpromising one It is
scarcely surprising therefore that surgery cures only a percentage
and it should not be lightly undertaken since a cure cannot be
guaranteed

The warts which give rise to symptoms common!) overlie the
metatarsal heads particularly the second but any of the weight
bearing sites may be involved When exc sion is considered
desirable two methods of repair are possible
Whole skin graft In most cases this is the easiest and best
met! od (Fig 5, 21) and should be used unless previous treatment

GENERAL SURGERY

*77

e g radiotherapy has caused so much scarring that a bed
sufficiently vascular to accept a graft is unlikely Skin from thigh
or abdomen has an adequate thickness of dermis to provide a good
pad

Local flap Gross scarring is the mam indication for using a
flap and such a flap must come from a non weightbearing area
The source (Fig 5 22) is usually the side of the foot when the

Fic 5 22

Examples of transposed flap repa rs after exc s on of plantar « arts.

wart is near the margin or the plantar surface distal to the weight
bearing ridge of metatarsal heads when the wart is on that site
The secondary defect has to be grafted which explains why the
flap must be tal en from a non weightbearing area

IVith both methods the common cause of failure is marginal
recurrence (Fig 5 2IB) Along the margin of the graft or
flap though not encroaching on the actual tissue transferred the
typical callosity gradually develops w ith return of sy mptoms In
adequate removal is not the cause of recurrence for even the most
radical of excisions may be followed by the gradual de\ elopment
and spread of the recurrent callosity The infective aetiology
of the lesion may explain the tendency to recurrence certainly
much remains unknow n about the natural pathology etc of the
lesion

If there is no recurrence symptoms are usually completely
relieved and even despite marginal recurrence the symptoms are
M

I?8 FUNDAMENTAL TECHNIQUES OF ELASTIC SLIiCFM

often improved Measures lo a\oid Meightbearing on the area of
recurrence maj suffice to gn e wrtualh complete relief

Tic s. 23

Chronic axillary hidradcmt s treated b> exc lion of the mtoltcd ikm areas and
replacement bj spf t skin grafts

Hidradenitts

This entitj is more common than is usual I) recognised It is
an infection of the apocrine s\\ eat glands and ma\ affect an\ of the
sites of these structures The most common site is the axilla
{Fig 5, 23) and here it presents as multiple npparenth superficial
furuncles spreading o\er the axillar) concautj ft is relatnel)

GENERAL SURGERY

m

chronic anti, despite opening of the abscesses as the) de\eIop,
sinuses form which flare up sporadical!). In se\ere cases the
draining lymphatics become imohed in the inflammation and
fibrosis

When, in spite of conscnatne treatment, the condition has
persisted long enough and is sufficientlj disabling to demand
radical measures, the entire area of shin imolvement with the
associated fibrosed subcutaneous fat and indurated ljmphatics
must be excised The condition should preferabl) be as quiescent
as possible before surger) is begun A thick, split-skin graft with
a tie-o\er dressing is used to co\er the defect and an immobilising
plaster of Paris shoulder spica ma> be added to gi\ e the necessary
stability to the dressing

BIBLIOGRAPHY

Traumatic skin loss

Balakrishnan, C (1956) Scrotal avulsion a new technique of
reconstruction b> split skin graft Bnt J plait Surg 9, 38

Brown, J B &, Trxer, M P (1957) Peno scrotal skin losses, repaired
by implantation and free skin grafting Ann Surg 145, 636

GinsON, T (1954) Traumatic avulsion of the skin of the scrotum and
penis use of the asulsed skin as a free skin graft Brit J plait
Surg 6, 283

Innis.C O (1957) Treatment of skin avulsion injuries of the extremities
Bnt J plast Surg 10, 122

Robinson, F (1953) Complete avulsion of the scalp Bnt y plan
Surg 5, 37

Slack, C C (1952) Friction injuries following road accidents
Bnt vied y it, 262

Watson, J (1956) Loss of the skin of the scrotum treatment by free
skin grafts Bnt y plait Surg 8, 333

Radiational trauma

Brown, J B , McDowell, F &- Frier, M P (i949) Surgical treatment
of radiation bums Surg G) me Obstet 88, 609

Routuedcf, R T. (1954) The surgical problem of local post- irradiation
effects Brit y plait Surg 7, 134

Anal surgery

UlcIies, E S R (1957) Treatment of ischiorectal anal fistula
Aust NZ y Surg 26, 281

l8o FUNDAMENTAL TECHNIQUES Or PLASTIC SURCFIU
Plantar warts

Monroe, C W (1956) The treatment of plantar watts Plait rcrowtr
Surg 17, 16S

Chronic hidrademtis

CoNWAt H , Stark, R B , Cumo, S Weeter J C &• Gahcia F A
(1932) The surgical treatment of chronic hidratUnitts suppuratua
Surg G\nee Ohstet 9^, 4 it

CHAPIFR SIX

Ot thopaedic Surgery

S KIN cover in orthopaedic surgery is required because of tl e
need for i stenle field during and after surgery of bone and
joint In acute bony trauma with shin deficiency skin
co\er can for practical purposes convert an open into a closed
fracture with a corresponding drop in the probability of infection
In the late treatment of trauma adequate shin cover permits an
op rative approach without fear of wound breakdown and infect on
When secondary surgery of n"rve or tendon is required good skin
cover is equally necessary for similar reasons

The care of the paraplegic has become a matter for the ortl o
paedic surgeon and the surgery of decubitus ulceration will be
considered in this context The problem of pressure sores extends
to the non paraplegic but the principles of surgical treatment
apply to both types of ulcer and they will be discussed together

SKIN COVER IN BOM TRAinLi

W hen shin loss is associated with bony damage the ty pe of skin
cover possible depends on whether a fracture is compound to the
skin defect The fractures most likely to be compound and
associated with skin loss are those of the subcutaneous long bones
particularly tibia and ulna The circumstances are often such that
much damage to surrounding tissues occurs and there may be
deglov mg anatomical or physiological of greater or lesser extent
These factors affecting as they do the blood supply of the skin
which is locally available for skin cover must be kept xn mind rn
planning closure of the wound

If the loss of skin is small primary suture may be attempted
but with larger deficiencies tension of the suture line is likely and
may lead to breakdown and infection of the wound A relaxing
incision placed in the long axis of the limb and at some distance
i8r

182 fundamental techniques of plastic SURCERl

from the wound may allow the resulting bipedicled flap to mo\c
across the limb sufficient!} to close the wound, the resulting
secondary defect is covered with split skin Hovvev er, it must be
appreciated that local tissue damage and degloving ma} hate so
disrupted the blood vessels of the skin that this manoeuvre mav
result in a large slough Such a procedure must therefore be
carefully assessed, the relaxation incision must be placed at a
considerable distance from the wound so that the flap his at least
the safety of breadth and finall}, undermining of the skin is to be
avoided as far as possible The procedure tends to work only
when the defect could almost be closed by direct suture and it
should be used rarely

The rotation or transposed flap is not recommended in acute
injury of the limbs Even under optimal conditions such flaps in
the limbs must be planned and delayed most carefully and in fict
are seldom used If the defect is large, the only possible methods
of primary closure are the split skin graft or the direct flap —
in the arm from the abdomen, in the leg from the opposite leg
In the arm a direct flap applied primarily is not likely to pose
any major technical problems other than those of achieving in
adequate length breadth ratio in the flap by the methods described
below for the cross-leg flap but in practice the need to use a
primary flap in a compound fracture of forearm must rarely arise
The muscular cover of the arm bones is normally complete except
for a single border of the ulna so that with the fracture reduced
the reconstitution of the soft tissues should almost always leave the
fracture minimally compound and a split-skin graft might
reasonably be expected to take over the entire area

In the leg the problems are much greater The tibia has
fully one third of its surface subcutaneous and a fracture is likelv
to be much more extensively compound quite apart from the
fact that associated skin damage tends to be much more wide-
spread and severe The bony injury with skin loss takes three
mam forms

i The extensive degloving injury m association with any of
the bone and joint injuries which can occur in the vicinity
of the ankle or even of the knee The occurrence together
of the two injuries is fortunately uncommon probably because
they hav e quite distinct patterns of causation

ORTHOPAEDIC SURGERX 183

2 The localised skm loss associated with a compound
fracture of tibia

3 The shin loss initially unrecognised or possibly not present
and only becoming apparent when the area is dressed This
type of shin loss may occur even when the fracture lias not
initially been compound

The limitations of the cross leg flap in such a situation are
very considerable It can only be contemplated m the otherwise
fit young patient with unimpaired circulation to the other lower
limb and joints capable of tolerating the necessary immobilisation
The presence of deglovmg with shin necrosis much beyond ihe
width of the subcutaneous border of the tibia and bevond its
length completely rules it out The more localised the shin loss
the more feasible is it likely to be Used in such circumstances
it is liable to be extremely difficult technically and is by no means
free from potential disaster Preliminary delays are not possible
and so the dimensions of the flap must pro\ ide as large a margin
of safety as possible A one to two ratio of length to breadth is
desirable and the shin defect may have to be enlarged by excising
adjoining normal skm if need be to accommodate a flap of adequate
breadth The fracture must be simultaneously stabilised either
by plating or intramedullary nailing whichever is appropriate and
such a method can only be used if the fracture is seen soon after
injury and adequate debridement can be carried out The
number of patients who are suitable candidates is extremely
small

The alternative then is the split shm graft and it has to be used
even although the surgeon is all too aware of its deficiencies m the
circumstances

The surface to be grafted with the exception of such bone as
is bare, is likely to be capable of taking a graft and m preparing
the surface all non viable tissues should be excised Such pen
osteum as is alreadv stripped can be excised but intact periosteum,
even if damaged, should not be removed Intact periosteum
leaves the possibility of graft take while periosteum removed
leaves only the certainty of graft failure

With the bone and joint injury reduced the wound is debnded
as just described In deciding the method of bony fixation
whether by plate and screws intramedullary nail, or plaster of

184 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCFRV

Paris alone the surgeon should appreciate the importance of
absolute fixation of the fracture and realise that it is failure
of adequate fixation which is more likely to lead to bony infection
in such a situation than anything else

Surface sequestration is probably inevitable from the begin
mng in those areas denuded of periosteum In view of this the
surgeon should do as little as possible to add to the area of bare
bone by his manipulations Plates should be applied on top
of the periosteum Open joints should be closed bv suture
of the capsule if at all possible to present a surface suitable for
grafting

The split skin graft is then applied to the entire area as it
would be if the injury was a simple degloving injury (sec page 150)
recognising of course that it will almost certainly fail over the
areas of bare cortical bone The graft can reasonablv be expected
to take over a joint closed as described or even slightly open and
it mav well bridge the fracture if it is well reduced and fixed
though in actual practice it is not common for the site of skin loss
to coincide with the fracture stte "N hen it does coincide however
it is the presence of bare bone rather than the fracture which will
determine take if fixation is good

At the first dressing 7-10 days later the full extent of the skin
loss can be assessed accurately and any residua! necrotic skin fat
and muscle excised The general aim then becomes to prepare
the area left uncovered to receive skin and as each part granulates
to cover it with split skin Any internal fixation of the fracture
should be left in place even if it is quite exposed until the fracture
is at least sticky ’ Where bone is bare a local surface sequestrum
will form and granulations can only be expected when it has
separated It is not advisable to excise such dead bone as soon
as it is recognised to be dead Excision at this point is likely to
damage the blood supply of the bone which is left and a fresh
sequestrum will form Spontaneous separation should generally
be awaited Sequestrectomy should be carried out reluctantly
and only when a good line of demarcation has formed Time may
actually be saved in the long run by waiting for spontaneous
separation for granulations will already be present and ready to be
grafted when the sequestrum is lifted off

"When skm loss is only recognised late the principles to be
followed in providing skm cover 3re exactly those described

OJITJtOIMEDIC StRGFHl

above from the time of the first dressing unkss the ann and other
circumstances fit the criteria laid down for the use of -1 cro s kt
flap

\ late problem of mi'ccd skm ind hon\ damage mn result from
the fact that a sccondan orthopaedic procedure c g hone grafting
cannot be carried out through a scarred or e\en fret «kin grafted
area cspccnl!) tf the bont is normallv subcutaneous and ft r tint
reason alone such scarring mav require replacement with a direct
flap or tube pedicle

Tl \!X>\ \\I) M u\r I\Jt \{\

When a nen c or tindon is injured in a-* ncnlii n with iMtr »vc
loss of shm it is ncces«an to pro\nlc a coMnng of subcut im us
tissue as well isshintoform 1 sat isf actors bed prior toamopir it i n
of the nerve or tendon itself and a flip must be used is e Mr
i he flap ma\ he transferred as a primarv pr<>cedurc m faw ur 1 le
conditions altcrnati\cl\ it ma\ be u td second ink once prm irv
healing his been achieved In a split shm graft

In the upper limb a direct abdominal flip »•. u«irl while m the
lower limb a cross leg flap mat be used for a localised shin ) s
I lie large defect of lower leg or thigh most often requires an
abdominal tube pedicle

osiio\nruns

It ts the unstable scarring of the meriting shm produced In
ibrontc osteomyelitis, especially of tibia winch umiiIIn requires
treatment Such an arei of scarring is scld< ni suitable for Iret
skin grafting is it mu be ncccssarv to treat the bone either at tl e
time of skin lcplacemcnt or subsequent!) and an abdommtl tube
pedicle or direct flap is used when scarring is cxtenstvi lie
infection must be quiescent before the transfer is ( cgun the best
results tend to be achieved when the bom infection is burned
out‘ and all that remains is the scarred unstable skm

Operations on the diseised bone can be undertaken during flap
transfers onk if the treated bone is to be covered immcdutclv
and complctch hv the flap

I$6 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

PRESSURE SORES

Pressure sores occur m bedridden and in paraplegic patients
In both the pathological processes arc essential!) similar and the
cause is pressure sufficient!) se\ere and sustained to produce
ischaemic necrosis of the skin The ulcers develop in areas where
pressure is borne and where the pad of subcutaneous tissue is
scanty

The Non-paraplegic Pressure Sore

Usual sites are the sacral area and heel, occasionall) the iluc
crest The cause of the sore, i e the factor producing the immo-
bility must alwajs be treated before considering active surger)
of the ulcer , the patient must be capable of keeping off the pressure
point

Local treatment is aimed at getting the ulcer fit for spht-skin
grafting W hen the time comes to appl) the graft the problem is
usuall) a technical one of immobilisation and the ingcnuit) of the
surgeon ma> be taxed to get immobilit) for the 4 da)s or so
necessar) for graft take Where all other methods have failed,
success has sometimes been achieved b) appl>ing closch set thin
split skin stamps without an> dressings and mercl) protected
against being rubbed off, the patient being kept on the surface
opposite the sore

If, despite local measures, the ulcer becomes static m size, more
heroic measures maj be contemplated though the local condition
has all too often to be subordinated to the general state of the
patient This is particular!) true in sores of the heel where,
in theor) , the alternative to a spht-skm graft would be a cross leg
flap an alternative quite out of the question in the aged patient
For the sacral area and ilium the alternative to the split-skin graft
is usuall) a rotation or transposed flap, the practice of which will
be discussed in relation to the paraplegic

The Paraplegic Pressure Sore

The areas particularl) liable to ulcerate lie over the pressure-
bearing bon) prominences and in the paraplegic the ulcers tend
to have much more of nn “iceberg” quaht) with extensive
undermining and osteitis of the underl)ing bone or even p)°*

ORTHOPAEDIC SURCERl 1S7

arthrosis m severe cases Treatment consists of cov erage of the
completely excised ulcer with a movable pad of health} skin and
subcutaneous tissue and simultaneous elimination of anv under
l}ing bon} prominence which could act as a focal pressure point
This latter procedure is essential as such prominences left
untouched reproduce the mechanical pressure which caused the
original ulcer

During the acute phase of the spinal injur} the common sites
are over the sacrum and femoral trochanter after recover}
prolonged sitting in a wheel chair makes the ischial area the most
frequent site Sacral ulcers tend to be large and flat with minimal
undermining ulcers of the trochanter and ischium usuall} have a
small opening leading into a large slough lined cav it} into the base
of which the bon} prominence projects

Healing of the anaesthetic tissues of the paraplegic is poor and
with the slightest provocation the wound will fad to heal following
surgerj Tension of flaps must be avoided haemostasis must be
even more meticulous than usual cavities and dead space must be
positively eliminated — failure in an} one means failure as a whole
When the state of the ulcer permits a prehminar} split skin graft
is worth using for although useless as a definitive procedure it
enables the subsequent surgery to be done in a clean surgical field
If skin loss is minimal excision and direct closure maj suffice
but in most cases a rotation or transposed flap is needed It is
seldom possible to avoid grafting the secondarv defect but the
grift need not nccessaril} be applied at the actual time of flap
transfer Indeed leav ing the secondary defect ungnfted (P ig 6, 2)
is a useful way to ensure that a large area is aviilable through
which an} haematorm can dram instead of collecting under the
flap to cause tension infection and necrosis The grift can readd}
be applied 7 10 da>s later

When multiple sores arc present the planning of the several
flaps required must be co ordmated carcfullj so that the stnctlv
limited areas of available skin are used to the best advantage

Sacral ulcers

The approprnte t}pe of flap depends on the shape of the ulcer
Frequentl) suitable is the bilateral rotation flap of buttock skin
based on the inferior gluteal fold (Hg 6, 1) and this double flap is
espcciall} useful in the sacral pressure sore in the non paraplegic

lS 8 FUNDAMr\T\L TECHNIQUES OF PLXSTIC SURfinn

patient If the shape and extent of the ulcer mike this flap
unsuitable, alternates are the transposed or rotation flap based
on the lumbar region (Fig 6 , 3 ), or as a last resort, a tube
pedicle This latter procedure has man) technical difficulties,
and should not be light!) undertaken

Trochanteric ulcers

Initial!) , the main ca\ it) of the ulcer is the trochanteric bursa
and, if this alone is im oh ed. permanent closure m3} he ailuci ed
without interfering with the hone Trequentli, honour, the
trochanter and neck of femur project into the enut) and excision
of trochanter and appropriate cortex of the shaft is then require*
to let the soft tissues collapse and obliterate tb p ciut\ n t e
most severe instances a p) oirthrosis of the b t ' sc raps ant

once present, this complication is xirtin t0 trH c

ORTHOP \FDIC SLRCE1U

1S9

Fic 6 2

A sacral and a trochanteric ulcer in a paraplrg c show ng repo r of tl c
trochanteric ulcer

A Hie ulcers

B The trochanteric ulcer with the transposed flap outl ned
C rhe wedge of protruding trod antcr esc sed to el m mte the focal
point of pressure

D E The flap transferred at operation and to days later prior to appl cat on
of the split skin graft to the secondirv defect
r The end result

It is riot necessity always to graft the secondary defect at the time of tl e flap
transfer In th s pat ent the secondary defect was grafted 113 days later us ng
the exposed method of graft ng

■ 90 fundamental TECHNIQUES of P1ASTIC slRCFm

" ithout amputation It ,s probalih mis' ,n such citcumstancts to
concentrate on imprmmg the patient s general condition as much
as possible and accept the permanence of the pe oarthrosis

The ulcer is so undermined in most cases that free sbn
grafting ,s seldom practicable, a transposed flap must be used
(Fig 6, 2 ) Its precise situation and shape util depend on the

He 6. 3

A sacral ulcer and bilateral ischial 1 leers in a parapleg 1. showing rrpa ,r °f die sacral
ulcer b> a rotation flip of buttock skin and of the left nchul ulcer l } a transposed
flap of thigh skin ITie \ raj slows the extent of the ischieetomj on the left
side and the osteins of the right ischial tuberos tjf

si7e and shape of the ulcer, uith the proviso alvvjvs tlut the
secondan defect must be on in area free from subsequent
weight hearing

Ischial ulcers

The cavitv of the ulcer consists of the ischial bursa but as the
condition progresses and extends the ischial tubcrositv projects
into the cavit) and becomes the scat of chronic osteitis \ major
advance in the treatment of this tvpc of ulcer has been the excision
of the ischial tuberosit) jotnth with the appropriate soft tissue

ORTHOPAEDIC 'HJRGER\

I 9 I

Fig 6,4

The transposed flap used to repair the defect left follow ing excision of
the ischial ulcer and isch ectomy The cavity left by the ischiectomy
js filled by detaching at its loner end and mobilising such hamstring
musculature as is available

Tir 6, 5

Secondary rotation of a pre\ iousU used th gh flip to repair recurrent ulceration
The segment of flip beyond the line of the scar of the previous flip was
delayed prior to rot 3 t on of the flap

192 FUND \MENTAL TECHMQL fcs OF PL\«TIC SL ItOFRt

surgen (Hg 6, 3) E\en where the bone is not pathologically
imohed it is. still the mam cause of the ulceration, certainly its
excision has gTeatlj impro\ed the late results

Wien planning the appropriate flap the patitnt should have
the hip flexed to imitate the sitting posture to ensure that residual
scars do not oxerlic the tuberosit) The best flap is ter) broadly
based medially along the greater part of the thigh and mined
upwards (Fig 6, 4) Its superiority o\er other possible designs
is due to its generous dimensions which on the one liand make it
extremely safe and on the other permit further rotation (I ig 6, •>)
should the ulcer recur \n added advantage of this flap is that
it enables the atrophic remnant of the biceps muscle to be detached
at its loy'er end and mobilised by dniding approximately half
of the perforating y cssela The muscle can then he rolled up and
tucked into the dead space left by the ischicctamy

It cannot be emphasised too strongly that the procedures which
ha\e been described for the various types of decubitus ulceration
are onh a small facet in the oyerall care of the paraplegic and mu«t
be regarded as merely proyiding the ulcerated area with a fresh
start in the best conditions

ORTHOPAEDIC SURGERT

*93

BIRMOGRAPin

Skin co%cr in bony trauma

Ci-ahkf, R , Bvncnt T C & Snirr. S (1059) VoJrtn Trends in
Aendtvt Sure fry and \ledtarr London Jluttcnicrth
ConMUI, J U (1956) Plwtic aurRcry m bone problems Flmt
TfroMtr Sure 17, 1 29

Cmrntirr, J B (1955) Simultaneous replacement of «km and bone m
tccetit Irk. injurtcs lint J plait Surg 7, 343
L«n Lnntprn 1 * (1050) The open wound m trauma Lancet 1 74s

Skin co\cr in nerve Injunct

I ntiMOvni j R & WaUUT A II (1943) Certain plastic problem*
in the »urRcr> of peripheral nrnn Surg Gvrrr Obstei 76, 106

Pressure torct

Cannon 11 OltMtt J J OS111. J \\ A SniNMrrk U (t95°)
An approach Ut the treatment of pressure lore* fnn Surjj 133,760

Conwas It A CiRiititii 11 11 (195(1 Plastic surgical closure of
decubitus ulcers in patients tv uh paraplegia A mrr J Surg 91,946
(uiTTMiN*. { (1955) Hie problem of treatment of pressure sores m
spinal paraplegic* Uni J plait Surg 8, t«/j
Qsiwjbni R (1955! lie treatment of pressure sores in paraplegic
patient* lint J plait Surg 8, 214
\fmus M P A Hwm A O (t954l Hie patholoc) and treatment
of picture sores in paraplegia 7 )nf J plait Vurg 7, 179

CHAPTER SEVEN

Hand Surgery

I X surgery of the hand it is essentia! to avoid the pitfall of
seeing the hand in isolation ; the patient and his condition must
be Mewed as one Before the surgeon embarks on a timc-
consummg procedure he should gi\e serious thought to whether
the end-result is going to justify the time spent in obtaining it,
with the loss of work and income which the patient will suffer.
He must remember that the verx procedure mav give rise to
disabilities which could outweigh the possible advantages to be
derived from it, he must decide whether the patient is intelligent
enough to benefit from a complicated reconstruction and co-
operate fully during its various stages

\\ hen the alternative exists, a labouring man mat well be better
off with a partial amputation or free skin graft of his injured finger
than a more elaborate repair which will require immobilisation of
one or more fingers or even most of the hand, wrist, elbow and
shoulder

The possible complication of shoulder, arm and hand stiffness
is especiallj relevant to the older age group and mav be a major
consideration m deciding the best procedure.

When different modes of treatment arc equally feasible, it is
often worth while to explain the problem and its possible solutions
in simple terms to the patient so that he mav understand what
each will entail in time, discomfort and end-result. In this wav
co-operation during the actual procedure is more likely

HAND INJURIHS

In a hand injury the provision of skin cover In direct suture,
free skin graft, or flap takes absolute priority. Skin cover alone
halts the twin processes of infection and fibrosis which are parti-
cularh harmful in the hand. The appropriate method of skin

HAND SURGERY

*95

co\er depends so much on the type of injury and its extent that an
appreciation of the pathological features of the common injury
patterns is necessary to an understanding of the principles of
treatment

Hand injuries are of three main types — cutting and slicing
crushing and degloving As a rule an injur) helongs pre
dominant!} to one type but on occasion an injury his the
characteristics both of crushing and degloi mg

Cutting and Slicing Injuries

The extent of a cutting or slicing injury is clear cut and
preliminary clinical assessment of damage is stra ghtfon ard
Tendon and nerve damage are common and must be tested for
but if one excludes the guillotine amputation uhicl is so often
part of the injury associated bony damage is uncommon With
the exception of the partially sliced off flap the skin loss is
immediately obvious and even with it the devitalising effect of
crushing is not present to add to the difficulty of decid ng chn cally
whether the flap is viable

It is not proposed to discuss the merits of pnmarv tendon
repair discussion will be concerned rather with the means of
providing such skin cover as will permit tendon repair or graft
primarily or secondarily

The method of repair can usually be decided on the basis of
the preliminary clinical examination When there is no loss of
skin direct closure with minimal excision of the wound margins
should be carried out and 1 ere accurate suturing is as vital as in tl e
face in order to acheve rapid healing with minimal scarring
Skin loss must be made good by free skin graft or flap Tree skin
grafts commonly of spl t skin thickness are generally used except
when the raw area includes a structure which will not accept a
free skin graft when the pulp of the finger tip has been lost and
replacement requires more bulk than is present in a free skin graft
or when subsequent repair of a deep structure such as tendon is
contemplated In these circumstances flap cover must be pro
vided and the type of flap depends on the site and size of the defect
The possible flaps in the various circumstances will be discussed
on page 210

196 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCERV

The guillotine amputation which exposes bone is m man)
cases best closed b> tnmming the phalanx until the tissues will
close directl) over it without tension Free skin grafts do poorK
O'er such stumps Failure of the graft ov er the bone is common
and even with good take the scar adherent to the underljing bone
tends to make the graft alwajs vulnerable Flap cover maj be
indicated on occasion but in the majontv of patients amputation
is to be preferred

These considerations applj with particular force if one finger
alone is injured When more than one finger is inv oh ed a more
conservative approach is indicated and direct flaps from chest,
abdomen or the opposite forearm must be considered Cross
finger flaps are seldom feasible In the thumb a quite different
approach is essential and the principle becomes one of extreme
conservation Length must be maintained primarily at all costs
There should be no excessive trimming of a traumatic amputation
to get skin cover, a free skin graft or flap should be used as the
local circumstances dictate The overriding need for conservation
of finger tissue becomes less with passage towards the ulnar side
of the hand

Crushtng Injuries

A crushing injur) maj varj in severit) and extent from the
mildest subungual haematoma through the crush injur) of fingers
with or without bon) damage up to the power press injur) which
leaves a shapeless pulp of devitalised tissue \\ ith severe crushing
there is often a “bursting’ laceration The brunt of the injur)
is taken b) the soft tissues and bones rather than the tendons and
nerves Loss of skin and soft tissue bv the actual lnjurj is not a
feature but the real loss is often much greater than is at first
apparent for disruption of blood vessels and dev italisation of
tissues maj give rise to quite extensive skin necrosis This
“ hidden ’’ damage ma> result in unexpected!) sev ere oedema post-
operativel) and failure to guard against this oedema can further
dev italise the crushed tissues particularl) if the) have been closed
under tension

Pre operativ e appraisal of the situation can be most misleading,
onl) dunng actual cleansing and surgical exploration of the wound

HAND SURCERX

197

can the injur} be accurately assessed The important points in
such an assessment are

1 To determine what is definitely not viable The test
already described (page iji) to assess the viability of shin
must be rigidly applied here and non viable soft tissue
structures excised quite ruthlessly This may mean excision
of bone tendon etc when a segment of finger as a whole is
judged to be non viable

2 With the non \ lable tissue excised tl e position is assessed
afresh to decide which injured structures are worthy of
retention and shin cover The detailed decisions which this
implies must take into account such factors as the relative
importance of the fingers and the thumb the age intelligence
etc of the pat ent and the extent and seventy of the damage

Much that has been said of closure follow ing guillotine amputa
tion applies to the crushed finger With the sole exception of the
thumb where the conservative approach always applies there are
two opposing lines of argument On the one side the more
severe the damage to the individual components of a finger —
nerve tendon skin bone the stronger is the argument for ampu
tation though the finger as a whole may be viable for the less
chance there is of a useful d git resulting On the other s de the
greater the damage to other fingers and the rest of the hand the
stronger is the argument for retention of an injured digit even m
the knowledge that it may be stiff It is in the crushing injury
particularly that a useless finger should always be considered as a
potential source of skin Filleted it can be used to cover a skin
defect of adjoining dorsum or palm avoiding the need for graft
or flap

It is often stated that any lacerations which are present as part
of a crushing injury should only be loosely closed with a few
tacking sutures because of the tendency to post operative oedema
In our experience when no skin has been lost much better results
are obtained by suturing such lacerations as accurately as poss ble
with many fine sutures leaving no raw areas between sutures
When this has been followed by absolute immobilisation pre
ferably with plaster of Pans and scrupulous post operative
elevation for at least 48 hours oedema has not given rise to any
trouble It seems likely that the oedema which is so feared is the

198 FUNDAMENTAL TECHNIQUES OF PLASTIC SURTEin
result of failure to follow the latter part of the regime described ahoy e
Compared with a cutting injury of apparently comparable
secenty the crushing injury carries a much longer disability period
and the results are poorer The problem of the associated fneture
will be considered separately

Degloving Injuries

In degloung injuries of the hand as elsewhere the important
pathological factor is injury to the \ oscular s\stcm 1 he anato
mical characteristics of the palmar skin with its intimate attachment
to the palmar fascia make it less lublc to degloung but when it is
degloved the palmar aponeurosis is usually part of the tissue
avulsed Elsewhere the plane is the usual one between superficial
and deep fascia

In the pure degloung injury damage to deeper structures is
surprisingly uncommon though it must always he tested for
The important surgical decision is that of \ lability and the
tourniquet test may help (see page 1^2) Retention of skin is
only justifiable on the basis of positne clinical demonstration of an
actne skin circulation Skin which is not demonstnbly uablc
must be excised

The split skin graft is the usual method of co\ cr and should be
used unless tendon bone or joint is exposed Tun if it is felt
that subsequent coyer by a flap will be needed the split skin graft
is still the primary oner of choice especially when more than one
surface of the hand is imolyed Mhcn a direct flap is required
primarily it should he designed to co\er as much of the raw area
as possible w ith its initial attachment

It is often difficult to estimate the precise skin loss immediately
after the injury but o\er estimation is less serious than under
estimation If at the first post operative dressing skin necrosis
is found to be more extensw e than was expected and fresh slough
is present it should be excised and replaced with a split skm graft
forthwith In this way healing and mobilisation can be aclueycd
as rapidly as possible

Degloung of a single digit occurs occasionally and again with
the sole exception of the thumb amputation is usually adnsablc
The degloyed thumb should be inserted into a tubed flip raised
on the opposite arm or trunk (Fig 7, t)

A. Degloving of thumb with loss of distal phalanx, resurfaced w ith cross-arm
tubed flap. The use of the graft covering the forearm defect to line the
pedicle segment is shown, and the final result.

13. Use of a pectoral tubed flap to resurface a thumb degJoved in a crush-
de gloving injur) which damaged the index finger beyond salvage

200 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERV

Such a tubed flap may be the only way of salvaging the digit
but at least until recently it did have its limitations and unsatis-
factory features as a method of repair These were due firstl\ to
lack of sensation in the flap which resulted in poor utilisation of
the thumb by the patient and secondly to poor blood supply in
the tube which resulted in poor tip healing when the flap was
separated even after delays and later on inability to w ithstand cold
The recently developed neurovascular island flap used in
this situation has quite altered the picture In it the hemi pulp
of a less important finger functional!) usual!) the ulnar side
hemi pulp of the nng finger is raised pcdicled on the digital
vessels and nerve back to their origin m the palm and tunnelled
through palm and tube pedicle to a functionally suitable site near
the thumb tip where it is sutured in position (Fig 7, 2) The
residual pulp defect is free skin grafted This brings nerve and
blood suppl) to the tip with marked improvement m utilisation
and vascularit) The initial false projection of feeling in the
flap slowl) corrects as re education takes place

The technique is an exacting one and fortunatel) docs not
have to be carried out as an emergency Patients requiring it
should probably be referred to a hand surgeon

Finger-tip Injuries

Isolated finger tip injuries of all three types arc extremely
common and the influence on treatment of the mil jnd pulp
makes separate consideration of the injury necessary

The pulp with its skm the phalanx the nail and its bed
each or all may be damaged m varying degree The best treat
ment by proximal amputation free skin graft or flap depends at
least partly on the extent of the damage to each constituent
In the extreme case the choice may be clear cut it is in the mixed
injury that difficulty arises Severe crushing devitalising the nail
and phalanx while the pulp is still viable is best treated by ampu
tating the damaged segment and closing the defect with a flap of
pulp skin For the slicing injury which removes either pulp skin
or distal nail w ithout significantly damaging pulp or phalanx the
obvious measure is a free skm graft The majority of injuries
w hich lie betw een these extremes w ith loss of pulp and sometimes
pf bone are capable of being treated by flap free skin gra t or

202 FUNDAMFNTAL TECHNIQUES OF PLASTIC SURCERX

proximal amputation Themorebone iscxposcd the less suttableis
the site for a freeshm graft for the reasons al read) gnen (page 196)
The finger tip is one of the *cr) few sites where a whole shin
graft has been successful!) used in pnmar) trauma but it has no
real adtantage o*er a thich split skin graft Hie flap has its
main use where there has been loss of shin and pulp but where
bone and nail are undamaged The more bone has been lost
the less good will be the result

A finger tip injur) which occurs sufficient!) often to constitute
a distinct injur) pattern is the partialis avuhed finger tip which 1
left attached b* a pedicle of pulp \\ hen the injur* rs of the
crushing t)pc the nail is usually auilscd from its base with the
flap the ungual process of the phalanx ma) be intact hut denuded
or fractured with the distal fragment as part of the availed segment
\\ ith a cutting t)pe of injur) the nail ma) be cut tnns*crscl* the
distal half remaining attached to the a*u!scd flap

It is astonishing how small the pedicle need be to ensuresun ival
of the avulsed flap and a decision as to tiabilit) should onl* be
made when the flap has been replaced in its correct position to
eliminate the ad* erse effect of torsion and angulation of the pedicle
on the blood suppl) of the flap If it is not viable treatment is as
for a guillotine amputation With a vnble flap the fingertip
should be reconstituted after minimal excision of wound edges and
damaged pulp fat 1 he nail should be retained and replaced m
its bed to provide splintage and to ensure a smooth nail bed ifter
healing In this wa* the likelihood of distortion when the fresh
nail grow s in is reduced W hen the nail has been transected care
should be taken to get the edges accuratel* apposed for the same
reason

The Associated Fracture

A fracture as part of a finger injur) adds weight to the argil
ment m fa* our of amputation particular!) if there is sc*ere
comminution Before such a finger is retained skm co*er must
6c tiemonstrab/j a* ads We and if it is not available the finger
should he amputated unless damage to the remainder of the hand
makes retention imperative As alread* emphasised the thumb
is an exception to this general rule

If such a finger is retained the fracture and the soft tissue
damage which ine\itabl* accompanies it worsen the prognosis

HAND SI BOFJt;

201

as regards function and add to the problems of treatment If the
periosteum on either flexor or extensor surface lias been exten
so elj damaged bv displaced bom fragments there is corresponding
damage to the surface over which the tendons move and adhesions
rap id! j develop between the two surfaces

Internal fixation bj small plate or intramedul! ir\ bone peg has
been recommended blit good results can be achieved bv relative!;
simple methods without recourse to such fixation Die crjitnon
of success is function rather than anatomical perfection of bonv
contour With the shin closed the fracture should he reduced
and the finger immobilised in the position of function PI istcr of
Pans is not always nccessarv bulk of dressing often provides
entire!) adequate splinting

I he problem of subsequent care is to reconcile the needs i f
the fracture and those of the soft tissues Irnrn ibdisjti n for
the periods usual!; recommended for closed fractures meins a
stiff finger and at the end of tint period the mature tend m
adhesions added to the scarring of other soft tissues makes sub
sequent mobilisation virtuall) impossible V compromise is
neccssarv and it is our experience that b> the end of a wick to
10 da\s the fracture is sufiicicntlv sticky to permit gentle
active exercises within the painless range of movement M ;c
ments arc progressivelv increased at the end of the second wick
and bv the end of the third week n full regime of exercises emit
instituted

\\ hen dressings are still required for the skin component of the
injur) these should be is light os possible to allow the maximum
of unhindered movement In this situation Iuhcgau? is most
useful in providing good cover with a minimum of rostrum from
sheer hulk of dressing

uicinr siRorm

Plastic surgical principles apph also m elective surgery < f tl c
hand both in the surgerv of approach to deeper structures and in
reconstruction following injurv congenital anomilv etc

The pi icing of scars is important in the surgerv of approach
but it 1 m i much wider application in relation to grafts and
flaps mil will Ic discussed in relation to all three In the late

206 fundamental techniques of plastic surgery

well recognised that incisions along the middle of the palmar
aspect of a finger are contra indicated in general but given such a
scar a Z plasty can alleviate at least the contractural result
Use of the Z-plasty

Contractures The Z-plasty is only useful in the well defined
fairl) narrow linear contracture The diffuse broad contracture
requires the importation of skin bj flap or graft The bow string

Fic 7 s

The absence of major wr nkhng along the lateral 1 ne compared \ th both
palm and dorsum shows it to be neutral for skin tens on

contracture is suitable for one large Z-plasty the contracture of
less severe degree involving several joints requires multiple smaller
Z plasties to correspond with the flexion crease of each joint
A continuous multiple Z plastj can often be used most effectively

(F'g 7 > 6 ) ,

The contracted junction of a graft and the surrounding shin
can be lengthened w ith Z-plasties and these again should be placed
to correspond with the flexure lines

H eb deepening In minor degrees of sj ndactylj or post bum
« ebbing the Z plastj can be applied to the problem of deepening
the w eb (Fig 7, 7) If the web is looked on as a line of contracture

HAND SURGERY

a Z-plasty can be earned out with a dorsal and a palmar flap
Lengthening the web in this way has the effect of deepening it
Incidentally such a Z gives excellent exposure of the deep

20S FUNDAMFSTAL TECIIMQUFs OF PLASTIC Si RGER\

skin of the proximal phalangeal segment gnes good exposure
while at the same time correcting the«hin contracture so often
associated

Fic 7 7

The use of a Z-plastj n deepen ng the eb between the thumb anil ndcx
finger to increase the grasp of a thumb short as a result of trauma

Use of Free Skin Grafts

In a difficult situation where take of a graft is Iikclj to be
hazardous as with a granulating surface or in pnmarj trauma

HAND SURGERV

209

the overriding need is for successful take and the split skin
graft is therefore the graft of choice regardless of site Even
in the palm of hand and finger where secondary contracture is
inevitable it must still be used to be replaced if necessary by
a whole skin graft at a later date when conditions for take are
better

It is in the uncrushed injury that grafts take most easily
In the crush injury grafts take much less well probably due to an
element of devitalisation insufficient to jeopardise the viability of
the finger but of a degree to affect adversely the vascularisation
of the graft Recognition of this fact suggests the desirability
of more radical debridement of the recipient site m preparation
for the graft in crushing injuries

In elective surgery and the secondary repair of hand injuries
the split skin graft preferably thick can be used on the dorsum
On the palm between the fingers and in the webs where secondary
contracture would so often destroy the whole point of the
procedure a whole skin graft must be used

Although the size of a graft depends primarily on the dimensions
of the defect there are occasions where it becomes desirable to
carrv the graft beyond the original defect even though this may
mean excising normal skin The factors which determine such a
procedure have been discussed in relation to the placing of scars
m the hand

The method of applying and suturing the graft is similar
to that described for general use When applying the tie
over flavine wool and the subsequent pressure dressing care
should be taken to avoid undue pressure on the graft It is
the graft on dorsum of fingers and hand which is specially liable
to be adversely affected by too much pressure and the promi
nences caused by the heads of the metacarpals and proximal
phalanges are the most vulnerable areas Over these areas too
graft failure is most serious for exposure of tendon and joint
capsule is the inevitable result The prominences are increased
by marked flexion of the fingers and so the hand should be im
mobilised if anything on the extended side of the position of
function

The application of the dressing will be discussed under the
heading of post operativ e care

0

HAND SURGrm

21 1

r>c 7,8

Defect of the dorsum of the hand resulting from an electrical burn with loss of
extensor tendon The transposed Rap used to pro tide cover perm tied sub
sequent tendon repair h\ extensor indicts transplant

Ptc 7,9

Severe palmar contracture show ng initial inset of the ped cle into a neutral
unscarred area in preparation for subsequent exc sion of scarring release
of contracture and insett ngof pedicle in a single procedure

210 rUNbAMENfAL TECHNIQUES OF PLASTIC SURCERl

Use of Flaps

Different sources of skin van m the extent to which thev
reproduce the characteristics of the skin of the defect m sensation,
texture, appearance, etc Local skin is best, followed by forearm
skin, with trunk skin a poor third, but this aspect is onlj one
factor to be considered in an indiv idual case and the appropriate
tjpe of flap, its source, etc , tends to be gov erned more by the size
of the defect and its site

In preparing the recipient site for a flap of am kind the margin
should always be excised to health* tissue and this applies with
Special force to a granulating area, for onlj with radical excision
can the flap be soundl) sutured to good surgical material It is
advisable on occasion to bring a flap bevond the obvious defect
for the reasons mentioned in the placing of scars in the hand
(page 204) Difficulties will be avoided if it is remembered in
planning that the arm is at its most comfortable in the mid prone
position The more supination called for b\ the flap the more
difficult is the position to maintain voluntarily and as fixation
cannot be other than by elastoplast the most comfortable position
should be chosen

The elimination of raw surface both in the hind itself and on
the flap is desirable at all stages It is seldom if ever possible to
raise a reception flap in the hand and the split skin graft covering
the donor site of the flap must be extended to line the bridge
segment when a direct flap is used The tube pedicle though it
takes added time for tubing, does have the great advantage of
completely eliminating raw surface quite apart from the added
latitude of movement which its pedicle kngth permits while it is
attached to the hand

When a flap is being transferred as a preliminary to a recon-
structive procedure, e g of tendon, it is usually advisable to have
the transfer complete and the area quite healed before the deep
structure is treated so that the poasibibtv of sepsis can be quite
eliminated

Defects proximal to the webs

If a defect of the dorsum is small a rotation or transposed flap
is sometimes a possible method of repair (Fig 7, 8) Free skin
grafting of the secondarv defect is almost umversalli needed as

H\ND SUROER\ 211

Fic 7 S

Defect of the dorsum of the hand result ng from an electr cal burn h loss of
extensor tendon The transposed flap used to pro de cover perm tted sub
sequent tendon repa r by extensor nd c s transplant

Tic 7 9

Sc -ere palmar contracture sho ng n t al inset of the ped de into a neutral
unscarred area m preparat on for subsequent excis on of scarr ng release
of contracture and nsett ng of ped de n a s ngle p ocedure

212 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCtm

the amount of** slack " a\ailable on the dorsum is deceptnelv small
In practice, cases suitable for a rotation flap seldom occur and the
distant flap has a much wider usefulness Rotation flaps of the
palm cannot be recommended from an) point of \ lew because of
the characteristics of the skin itself and its intimate attachment to
the palmar aponeurosis

V

The use of a trunk flap to repair a defect of pulp of thumb

The points brought out m discussing the use of direct flaps
from chest and abdomen for defects of forearm appl) to the hand
also When a tube pedicle is used, particularl) for palmar defects,
it is worth while considering an inset of the pedicle into a neutral
unscarred zone (Fig 7, 9) so that excision of the scarring can be
followed b\ skin co\ er of the entire area m a single procedure
For the defect of intermediate size near the radial or ulnar side
a direct flap from the opposite forearm may be used The
cross arm flap is discussed in more detail for corer of finger

212 FUNDAMEKTAt TECHNIQUES OF PLASTIC SURGERY

the amount of “ slack *’a\ailable on the dorsum is deceptively small
In practice, cases suitable for a rotation flap seldom occur and the
distant flap has a much wider usefulness Rotation flaps of the
palm cannot be recommended from any point of % lew because of
the characteristics of the shm itself and its intimate attachment to
the palmar aponeurosis

The use of a trunk flap to repair a defect of pulp of thumb

The points brought out in discussing the use of direct flaps
from chest and abdomen for defects of forearm applv to the hand
also "When a tube pedicle is used, particularly for palmar defects,
it is worth while considering an inset of the pedicle into a neutral
unscarred zone (Fig 7, 9) so that excision of the scarring can be
followed by skin co\ er of the entire area in a single procedure
For the defect of intermediate size near the radial or ulnar side
a direct flap from the opposite forearm may be used The
cross arm flap is discussed in more detail for co\ er of finger

Fic 7, it

The conversion of an injury of several fingers into a single defect prior to (lip
cover The injury (A) of index, middle and ring fingers caused by friction
burning converted into a single defect (B) and covered by a direct abdominal
flap (C) The flap divided (D) and the fingers separated (E) The final
result (F) after thinning of Che segment of the flap on each finger

214 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCER1
I3efects distal to the webs

The defect maj be of one finger onlj or of several fingers and
according to circumstances a distant flap from trunk or opposite
forearm, or a local flap from adjoining finger or thenar eminence
rfiaj be used for cov er

Distant flaps When a single finger is invohed the decision of
whether or not a trunk flap can be used depends largelj on the
site of the defect for the other fingers maj make it impossible to
bring the defect and potential flap together readil) It is more for
pulp replacement that a trunk flap is used (Tig 7, 10) though ev en
here skin more near in character to normal pulp skin is preferable
where a suitable flap can be constructed

Defects of several fingers maj be dealt with simultaneoush b)
suturing the adjacent margin of each defect so that one large
defect is made which can then be covered with a single flap
(fig 7, 11) \\ hen the fingers come subsequently tobe separated it

will be found that the amount of skm needed for each finger is
greater than one might ha\e expected The thickness of the flap
makes this unavoidable e\en allowing for as much thinning as
possible and the flap should be of corresponding!) generous
dimensions

The extensive defect usuall) requires a trunk flap (Fig 4, 17)
because the alternate e sources are too limited in area For the
defect of intermediate size a cross arm flap from the other forearm
(figs 7, 1 and 7, 12) is a useful method of covering either the
dorsal or palmar surface of a finger The position is easj to
maintain and the flap can be of the direct type if the length
breadth ratio permits When the ratio makes such a flap risk)
the bipedicled strap flap may be used instead The flexor aspect
of the forearm is the obvious donor site but as long as the flap does
not encroach on the subcutaneous border of the ulna an) site
which permits a comfortable position during transfer maj be used

Fig 7 12

The use of a cross-arm flap in repairing an injur} of ihe thenar eminence
The injury (A) involving the metacarpo phalangeal joint prepared (B)
to receise the flap The flap outlined (C) and raised (D) The spl t
skin graft applied to the secondary defect (E) shotting the extension of
the graft (F) to line the pedicle segment of the flap (G) and the plaster
of Paris fixation of the arms (H) The flap immediately before divts on
(I) and divided and inset (J) The final result (K)

214 fundamental techniques of plastic surgfrt
Defects distal to the webs

The defect maj be of one finger only or of several fingers and
according to circumstances a distant flap from trunk or opposite
forearm, or a local flap from adjoining finger or thenar eminence
may be used for cov er

Distant flaps When a single finger is mv oh ed the decision of
whether or not a trunk flap can be used depends large!) on the
site of the defect for the other fingers may make it impossible to
bring the defect and potential flap together rendilj It is more for
pulp replacement that a trunk flap is used (Fig 7, 10) though even
here skin more near in character to normal pulp skin is preferable
v\ here a suitable flap can be constructed

Defects of several fingers mav be dealt with simultaneously bj
suturing the adjacent margin of each defect so that one large
defect is made which can then be covered with a single flap
(Fig 7 ,ii) W hen the fingers come subsequent!) to be separated it
wilt be found that the amount of skm needed for each finger is
greater than one might have expected The thickness of the flap
makes this unavoidable even allowing for as much thinning as
possible and the flap should be of corresponding!) generous
dimensions

The extensive defect usualt) requires a trunk flap (Fig 4, 17)
because the alternative sources are too limited in area For the
defect of intermediate size a cross arm flap from the other forearm
(Figs 7, 1 and 7, \z) is a useful method of covering either the
dorsal or palmar surface of a finger The position is easy to
maintain and the flap can be of the direct t)pe if the length-
breadth ratio permits When the ratio makes such a flap nskv
the bipedicled strap flap tna> be used instead The flexor aspect
of the forearm is the obvious donor site but as long as the flap does
not encroach on the subcutaneous border of the ulna any site
which permits a comfortable position during transfer mav be used

Fig 7 . **

The use of a cross arm flap in repamngan injury of the thenar eminence
The injury (A) involving the metacarpo phalangeal joint prepared (B)
to receive the Hap The flap outlined (C) and raised (D) The split
skin graft applied to the secondary defect (F) showing the extension of
the graft (F) to line the pedicle segment of the flap (G) and the plaster
of Paris fixation of the arms (H) The flap immediately before division
( 1 ) and divided and inset (J) The final result (K)

216 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY
Local flaps These can be taken from an adjoining finger or the
thenar eminence as cross finger and thenar flaps

Cross finger flap (Figs 7, 13, 7, 14 and 7, 15) This type of flap
can provide coter for a defect of the palmar aspect of a finger,

Fic 7, 13

A cross finger flap used to resurface the pulp of thun'b The injur> (A)
prepared to recede the flap (B) The flap raised before (C) and after (D)
incising Cleland s ligaments and sutured in position (E) The flap (I) and
the split skin graft applied to the secondary defect (G) shortI> before dmding
the pedicle The final result (II)

particularly in the middle and proximal phalangeal segments,
since it can only be taken from the dorsum and side of the donoT
finger It is most useful for defects of between one and two
phalangeal segments Smaller defects increase the length breadth
ratio while the technical difficulties increase if the area to be
cotered is much longer than this The flap finds one of its most
effectn e uses in co\ enng the thumb Whether pulp or tip is

HAND SURGERY

Fic 7, 14

A cross f nger flap used to preserve length in a traumatic partial amputa
tion of thumb This type of flap can only be used readily when the thumb

has already been shortened and with its twist of pedicle it must be planned
with great care

2lS FUNDAMENTAL TECHNIQUES OF PLASTIC SURCERI

being covered the thumb can readilj be positioned so that the
flap from index finger is not under tension and its pedicle is not
subject to undue torsion

The distally based cross finger flip used to cover a guillotined index
finger tip The injury (A) and the flap (B) sutured in position with a
split skin graft appl ed to the secondary defect (C) The dress ng 1 4 days
later (D) and the end result (E)

This is a common injury and when the preservation of length of the finger
is considered desirable the flap is a most useful one The distal basing
of the flap does not jeopardise its viability

The flap must be raised with care to avoid bating the digital
nene and artcrj or extensor expansion and the secontlan defect
on the donor finger is covered tilth a thick, split skin graft

The reach of a cross finger flap can be increased if a point is
made of dividing Cleland s skin ligaments These ligaments as
they appear in this surgical procedure form a fibrous septum just

JI\ND SURGERY

219

dorsal to the neuro v ascular bundle and bind the skin of the neutral
line to the side of each phalanx Their division frees the shm of
the neutral line and adds grcatlv to the mobility and reach of the
flap itself

A modification of the cross finger flap as described can be used
to resurface the tip of a finger when the relative lengths of donor
and recipient fingers are suitable and the mobilitv of the recipient
finger adequate (Pig 7, 16) It is important to av oid encroaching
on the nail bed of the donor finger w hen the flap is constructed
The index, finger is the one which most often sustains an injury
requiring this particular flap

Thenar flap It is well recognised that flexion of an\ of the four
fingers brings its pulp to llmost the same point of the thenar
eminence and this f3ct can be used in resurfacing pulp or finger tip
defects by a flap raised on the thenar eminence (rig 7, 1-)
The flap has its main use m the hand with relatively thin palmar
skin the calloused hand of the manual worker is quite unsuitcd
for the procedure If the patient is unable to bring the finger
requiring cover to lie against the thenar eminence easily and with
a complete absence of discomfort the flap should never be ton
templated This excludes it as a rule from being considered for
the index and little fingers

The dimensions and site of the defect determine how the flap
should be based Tor a defect of tilt greater part of the pulp a
side based flap offers the best length breadth ratio I J esecondirv
defect is covered with a thick split skin graft

Planning with jaconet so effective elsewhere does not work
well with the thenar flap lhe blood stuncd imprint of the
flexed finger is more useful m giving the appropriate site and shape
of the fl ip to be raised

This flap has its enthusiastic advocates but it is not without
unsatisfactory ispects A tender scar in the thenar area is a
serious disability and occasionally occurs and the finger immobi
hsed tn flexion for the period necessary is sometimes difficult to
mobilise In addition it is difficult to avoid maceration of skm
in the operative sue from the dost proximitv of flap and palm
for the area sweats virtuallv continuously at ordimry tempera
tures It is a flap to use spmnglv and only when the indications
are clear

HVSD SURGrRV

221

posr-omun\T care

Following a surgical procedure in the hand a period of immobi-
lisation is generallj desirable and this is prouded bj the dressing
on occasion reinforced bj plaster of Paris At the same time
measures should be taken to prevent oedema developing in the
hand

Dressing of the hand

If a graft has been applied it is usually wise, regardless of the
site of the graft, to immobilise the entire hand in the position of
function Following the tie over dressing careful padding of the
whole hand, in the webs and between the fingers must be carried
out before appl} ing the circumferential crcpc bandages 1 he aim
in padding u to com ert the hind into a cylinder so tint pressure is
even!) distributed Failure to pad the palm and dorsum ade
quatelj causes undue pressure on the radial and ulnar suits and
sores mtj result Onlj the finger tips are left visible to indicate
the vascular state of the hand

When no graft has been used absolute immobilisation ma> be
less necessar} and the regime can be suitably relaxed

Prevention of oedema

Oedema fluid provides the raw material of stiff fingers and is
prevented b\ elevation When a graft has been applied or there
has been extensive soft tissue dissection the hand should be
elevated, preferablv in plaster of Pans

A well padded cast should encncle the arm as fjr proxunalh as
the upper humerus (Fig 7, 18) so that the weight is taken on
the upper arm and not on the wrist and hand In more minor
procedures elevation on 1 pillow or in a sling without plaster of
Paris is adequate

Do 7, 17

The use of a thenar flap to repair a defect (A) of pulp of f nger The
defect is dwplaied full j (B)bj excising marginal tarring and ihc flap is
outt ned with Bonne) s Blue (C) on the thenar eminence elevated (D)
and sutured 10 the defect (b) A »pJ t skin graft is sutured to the
secondary defect (O ond a tie-over dressing (G) is applied The ltip
« shot* n just before (H)and after (I) division of the pedideand insetting
of the flip The final result (J)

HANt> SURGFR\

221

rOST-OPFRAHVE CAKE

Following a surgical procedure in the hand a period of immobi-
lisation is generally desirable and this is pro\ ided by the dressing
on occasion reinforced by plaster of Paris At the same ttme
measures should be taken to prev ent oedema de\ eloping in the
hand

Dressing of the hand

If a graft has been applied it is usually w i$e, regardless of the
site of the graft, to immobilise the entire hand in the position of
function Following the tie over dressing careful paddtng of the
whole hand in the webs and between the fingers, must be carried
out before applying the circumferential crepe bandages The aim
in padding is to com ert the hand into a cy Imdcr so that pressure is
evenly distributed Failure to pad the palm and dorsum ade-
quately causes undue pressure on the radial and ulnar sides and
sores may result Only the finger Ups are left visible to indicate
the vascular state of the hand

When no graft has been used absolute immobilisation may be
less necessary and the regime can be suitably relaxed

Prevention of oedema

Oedema fluid provides the raw material of stiff fingers and is
prevented by elevation When a graft has been applied or there
has been extensive soft tissue dissection the hand should be
elevated preferably m plaster of Paris

A well padded cast should encircle the arm as far proximallv as
the upper humerus (Fig 7, 18) so that the weight is tal en on
the upper arm and not on the wrist and hand In more minor
procedures elevation on a pillow or in a sling without plaster of
Paris is adequate

Fic 7, 17

The use of a thenar flap to repair a defect (A) of pulp of finger The
defect is displaced full) (11) bv excising marg nal scamng and the flap is
outlined with Ilonncy s Ulue (C) on t! e thenar eminence elevated (D)
and sutured to t! e defect (t) A split slun graft is sutured to the
secondary defect (O and a tie-over dressing <G) is applied 'l he flap

is shown just before (II) and after (I) division of the pedicle and insetting
of the flap The final result (J)

222 FUNDAMFNTAL TECHNIQLTS OF PI A STIC fURGFRl
Subsequent dressings

Unless there is a good reason most dressings in hand injuries
should be left untouched for a \\ eeh and many can safely be left
for longer The less the injury and dressings are interfering urith
hand function the less the need for early dressing and, if there art
no clinical signs to suggest infection, the first dressing can often be

Fic 7 , 1 8

The plaster of Paris cast applied post-operati>elv.

left until the tenth to twelfth day. This applies c\ en to the injur)
in\ obing a graft. When the function of the hand is significant!)
limited by the dressings, particular!) in older patients, the first
dressing should generall) be done on the seventh day and the bulk
of dressings thereafter should be reduced to a minimum so that
mo\emewt of the fingers can he instituted as rapidl) and iritcnsiv civ
as possible _ ,

A similar approach applies to the dress! r CC,M

procedures.

HAND SURGERY

223

BIBLIOGRAPHY

Hand injuries

Evans E M (1949) The treatment of major injuries of the hand
Brit J plast Surg 2, 150

Furlong R (1957) Injuries of the Hand London J S.A Churchill

Rank B K &. Wakefield A R (i960) Surgery of Repair as applied to
Hand Injuries 2nd Ed Edinburgh E &. S Livingstone

Reid D A C (1956) Experience of a hand surgery service Brit J
plast Surg 9, 11

Finger-tip injuries

Barcla\ T L (1955) The late results of finger tip injuries Bnt J
plast Surg 8, 38

FLATT A E (1955) Nail bed injuries Bnt J plast Surg 8, 34

Cross arm flaps

McCash C R (1956) Cro>s arm bridge flaps in the repair of flexion
contractures of the fingers Bnt J plast Surg 9, 25

Cross finger and theaar flaps

Cimns R M (1957) Cross finger pedicle flap in hand surgery Ann
Surg 14 5, 650

Flatt A E (1957) The thenar flap J Bone Jt Surg 39!!, 80

Tempest M N (19^4) The emergency treatment of digital injuries
Bnt J plast Surg 7, 153

Neurovascular isfand flaps

Littler J \V (1960) Neurovascular skin island transfer in recon
structive hand surgery Transactions of the International Society of
Plastic Surgeon 2nd Congress p 175 Edinburgh E &. S
L» mgstone

Tubiana R A Dupakc J (1961) Restoration of sensibility in the
hand by neurovascular skin island transfer y Bone yt Surg 43B,
474

CHAPTER EIGHT

Surgery of the Eyelids

S KIN co\er of the ejelids is usually required as a result of
loss from trauma or surgical excision for malignanc)

EYELID INJURIES

The extremel) rich blood supph of the ejelids permits sun i\al
of flaps with the most tenuous of attachments It follows that
the approach to the treatment of trauma in this region must be
ultra conservatne wound excision should be minimal and the
surgeon s chief aim should be to replace tissues in their proper
anatomical site (Fig 8 i) The sexerel) damaged ejelid may
present a \eritable jig saw puzzle but reassembling the various
parts correctl) is not labour wasted e\en if secondan operations
are required to correct shin or deep contractures the) will be cas>
and successful in direct proportion to the care taken and the
accurac) achiexed at the pnmar) operation

When an e) ehd injur) is first seen there often appears to be
actual loss of tissue but the true loss can be assessed onl) as the
repair proceeds and is almost ahvaj s less than at first seemed likely
In repairing these injuries there are certain he) structures which
correctl) placed as a first step can act as landmarks

Tear duct system When the lower lid canaliculus has been
sexered it is desirable to reconstitute it where possible
Failure to do so ma) result in an intractable ep pi ora and late
reconstruction is not possible A careful search should be
made for the cut end leading to the lacrimal sac but if it
cannot be found passage of a n)lon thread or probe through
the canaliculus of the intact lid and lacrimal sac w ill sometimes
help m identifxmg it (rig 8, i) In the same wax if the
segment in the lid cannot be seen passage of a n)Ion or silk
worm gut thread through the punctum will show the cut end
of the canaliculus where it emerges Passage of the thread
224

«SURGER\ OF THE EULIDS

into the other orifice will allow healing in continuity This
procedure is easier to describe than earn out but it is worth
attempting where possible The tendenc\ to stricture e\en
when the canaliculus is reconstituted is marked and despite

A Repair of an injur) it thout t ssue loss a -ul ng the lo er 1 d from s
med a! attachment showing an attempt to restore the cont mi t) of the
canal cuius by thread ng monofilament nylon through the lacrimal
punctum and into the lacr mai sac

The final result sho -s the excellent appearance h ch can be ach e -ed
b) accurate reconst tut on of the medial canthus
B The result of fa lure to reconstruct the canthus acct ratel) follow ng an
injur) s milar to A

The repair of an iyur) s milar to A as part of a more exters -e fac al soft t ssue
injury s sho n n F g i 10

passage of probes drainage of tears is often poor Fortunately
even with complete failure to reconstitute the canaliculus the
epiphora is not invariably severe

Ltd margin ^ anous methods of stepping incisions or w ounds
of the lid margin hav e been described but careful matching is
quite adequate if the wound edge is made to evert a little bj
the suture In anv case it would be quite unjustifiable to
traumatise still further tissues already damaged bj the injur)
The various landmarks of the lid margin — the ejelashes the

326 FUNDAMENTAL TECHNIQUES OF PLASTIC SL RGERA

grej Ime, the junction of conjunct a and sbn, all can be used
for matching purposes

T arsal plates In each ejelid the tarsal plate is dosclj
adherent to the conjunctiva and in trauma the two behave as
a single structure It is advisable where possible to avoid
sutures in the conjunctiva but matching of the tarsal plates
can be used to fix the margins of the associated conjunctiva
which in an) case heals ver) rapidl)

Conjunctna At the completion of an) repair it is essential
to hate a situation which will permit cover of the cornea with
lid conjunctiva dunng sleep and a tarsorrhaphv is sometimes

Fie 8,2

The interweaving suture (after Stallard)

needed to ensure this Sutures of the conjunctna cause
irritation of the cornea where the two come into contact, thev
are difficult to remove, and arc best avoided \Wien the)
cannot be avoided, a continuous “interweaving” suture
(r ig 8, 2 ) brought out to the shin surface at each end is useful
It draw s the conjunctn a together vv ell, there is no interlocking
and it is readil) removed The smooth surface of nvlon
thread can be turned to advantage m this situation for east
removal

Palpebral ligaments The tarsal plates which give to the
ejelids such ngiditv as the) possess have their mam attach-
ment to the bon) orbit via the medial and lateral palpebral
ligaments and if either of these ligaments has been div ided
traumaticall), it must be reconstituted as far as possible bv
suture The medial ligament is the more powerful structure
and damage to it is correspond mglv serious, for the whole
medial canthal region drifts forward and lateralis giving the
appearance of a unilateral hvpertelonsm It is stated th3t
this appearance onlv results if the posterior attachment of the
ligament behind the lacrimal sac is divided but, at least as
far as trauma is concerned, this is largclv an academic point
Unfortunatel) it is extremel) difficult to reconstitute the

SURGERY OF THE EYELIDS 227

ligamentous attachment and though the immediate post
operative position of the lids following wiring, etc , of the
ligament to its bony insertion mav be good, the sy stem tend"
to drift bach to its pre operative position

USE OF GRAFTS

Ideally a graft replacing eyelid shin must fulfil certain require
ments which arise from the functional anatomy of the region
Firstly, the lach of rigidity of the normal tarsal plate mahes the
eyelids prone to cicatncal ectropion or entropion if there is the
slightest contracture on the surface of the lid or in the socket
Secondly, evehd shin is extremely thin and in the upper hd
particular!} is onl} loosely attached deepl} because of the need
for rapid movement of the C}ehds The low er eyelid is less mobile
than the upper and the part of the upper lid corresponding to the
tarsal plate is in its turn less mobile than that above the upper
palpebral furrow

Skin grafted to an e}elid should be as thin as normal e}ehd
skin, especially when the most mobile skin is being replaced, and
in addition should be free of a tendenc} to secondary contraction
Unfortunately the best shin, which comes from the upper eyelid
is extremely limited m quantity at best and may not be available
at all and so a compromise has generally to be reached (Fig 8, 3)
For less mobile areas the canthi the lower e>ehd and the tarsal
segment of the upper eyelid post auricular whole thickness skin
provides the best substitute, gives an excellent colour and texture
match, and its extreme vascularity makes take easy

In the upper part of the upper eyelid, the need for extreme
mobility is paramount and a thm split skm graft from the anterior
or medial aspect of the upper arm is usually used With the
knowledge that such a graft will undergo gross secondary con
traction, the defect is stretched to its maximum and indeed over
corrected so that the largest possible area of skin can be inserted
in expectation, of secondary contraction Despite this, the graft
area nearly always does end up a little shorter than normal in the
v erttcal dimension
Preparation for grafting

Following surgical excision and immediately following trauma,
the actual skm defect is already visible, but in the late repair of

Fig. 8, 3

The free skin graft* used in the various ejclid sites,

A. Post-burn ectropion of bothejehds. Upper lid skin replaced by split -
skin from upper aim and loner ejejid skin replaced by post-auricular
whole thickness skin.

B. Rodent ulcer of medial canthus involving the caruncle and adjoining
ejelids replaced after excision by post -auricular whole thickness skin.

C. Rodent ulcer of skin overljing the upper tarsal plate replaced after
excision by post-auricular whole thickness skin.

SURGERY Or THE £\ ELIDS

trauma, the defect usually shows as ectropion and must be
demonstrated afresh as a raw surface so that it may be corrected
If the shin loss has been localised the scarred area is well
delineated and can be dealt with excising the scarring so that the
eyelid may lie against the eyeball When the resulting defect is
in the upper part of the upper ejelid and a split shin graft is felt
to be appropriate additional transverse incisions medially and
laterally beyond the area of actual scarring are ad\isable so that
the original defect may be o\er corrected to allow for the

The method of correct ng diffuse ectropion of the lower eyelid and the insertion
of a post auricular whole skin graft

subsequent contraction of the graft When a post auricular whole
shin graft is felt to be adequate such ot er correction is less
necessary

The ectropion which results from a full thickness shin Joss burn
is more diffuse and to demonstrate the extent of the skin lost a
different method is used (Fig 8, 4) With shm hooks on the lid
margin to put the skin on the stretch an incision is made approxi
mately 2 mm on the skin side of the eyelashes and parallel to
them If the contracture has distorted the canthus and the
lateral is the one liable to be pulled off the eyeball the incision
should be prolonged bey ond it so that any skin loss in a transverse
as well as a vertical direction may be corrected An incision
confined to the actual hd margin in such circumstances tends to
leave slight residual ectropion towards the canthus

Maintaining tension on the hooks the knife blade is worked
away from the lid margin parallel to and just deep to the skin
surface separ iting skin from underlying muscle As dissection pro
ceeds the ectropion becomes increasingly corrected and the skin

230 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCERY

defect displaced The lidshould be freed until it lies spontaneously
against the eyeball along its entire length and can readily be
stretched well over its fellow eyelid E\ en after extensive freeing
the bd may still tend to lie off the globe and this is generally due to
residual areas of scarring m the orbicularis muscle These patches
of scarring are felt rather than seen and must be excised completely
with fine scissors. Even what would seem to be a most radical
excision of much of the muscle leaves no disability; only if the
levator palpebrae superioris is divided will there be ptosis. The
undermining of the lid margin for a millimetre or so to give a good
suture line completes the preparation for the graft.

The extent of the defect of eyelid made surgically is usually
governed by pathological considerations but on occasion additional
normal shin has to be excised to give a better line to the junction
of graft and surrounding shin. An example of such a situation is
the extending of excision a little beyond the canthus, if the junction
of graft and surrounding eyelid is approaching it. Also, just as
straight vertical scars from the lid margin are best avoided lest
contraction of the scar cause ectropion, a vertical junction of graft
and eyelid is undesirable When it is unavoidable, the defect
should be fully displayed so that the maximum of shin can be
inserted to allow for any subsequent contraction.

The application of the graft

The method of apply ing a whole shin graft differs only in minor
details from elsevv here. It is safer to suture away from the ej ebatl
though this may mean suturing from a less to a more mobile
structure and the sutures along the ejelid margin should not be
tied too tightly as they cut through readily. In the same way the
sutures tied over the flavine wool bolus should not put too much
strain on the sutures. Undue pressure is not necessary'; these
grafts take v ery readilj' if haematoma is avoided.

With a split-shin graft the same technique of appljing the
graft can be used, but the object is to stretch the defect to allow
as much skm as possible to be inserted and the flavine wool
technique does not lend itself readily to this The stretching and
over-correction is better achieved using the STENT mould
technique (Fig. 8, 5) STENT is a dental moulding compound
which softens to malleability in hot water and hardens to rigidity
m cold and it can be used to take an accurate impression of the

F

Fic 8, 5

The STENT technique of grafting an eyel d The ectrop on of upper lid
(A) is corrected (B) and a STENT mould (C) of the defect is made The
spf t sit in graft w ltft raw surface outwards is draped round the moufd
(D and E) and inserted into the defect (F)

the mould which is going to be inserted into the defect The
mould with shin is then laid into the raw area Sutures through
the shin edges of the defect are tied over the mould half burying it
so that the maximum contact of raw surface and graft is obtained

232 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

and in this \vaj the maximum of graft is inserted There is no
question of suturing the graft edge to edge to the defect An)
obvious excess is tnmmed off when the tie-over sutures are tied,
the graft takes to the margin of the defect and at the first dressing,
usuaih 7 dav slater, the skin be)ond the edge of the defect, dry and
paper) b) now is easiU trimmed off

Before the dressing is applied it is a!wa)S advisable with either
technique to ‘ vaseline M the evelashes avva) from the e)eball
To distnbute pressure the dressing is built up around the flavine
wool or mould and a crepe bandage is applied Unless it is felt
that mov ement of theeveball underneath will irritate the cornea, and
with a simple graft of skin alone this is seldom true, there is no need
to cover the other e)e Some surgeons carr) out a temporan
tarsorrhaph) stmuhaneouslv but this is quite unnecessarv

Post-operative care

Apart from failure of the graft to take, and this fortunatel) is
extreme!* rare, the onh complication to be feared is corneal
ulceration and this is usuallv the result of trichiasis which has not
been dealt with immediatel) The patient must be specificall)
asked if he feels anything in his e>e and a positive replv is an
absolute indication to take down the dressing and inspect the eye
for the offending e)elash This applies regardless of the conse-
quences to the graft though fortunatel) take and vaSCulansation
are so rapid that the graft is seldom jeopardised b) a careful
inspection Patients occasionallv complain of some pain but give
a negative repl) to the direct question about the feeling of a foreign
bod) In such cases there is seldom need to take down the
dressing, gentle easing of the bandage is usuall) adequate

The graft is dressed on the seventh dav and a further dressing
is often wise for a further week, or so, not so much to provide
pressure as immobihtv The lids are so mobile that even after
a 100 per cent take some loss ma) occur if unlimited lid movements
are allowed too soon

USE OF FLAPS

When a full thickness defect of e)elid has to be repaired a flap
max be necessar) for skin cover, but for skm replacement alone
it is less often used following excision of a malignant lesion,

SURGERY OF THE F\ ELIOS

233

it is not eas) to justifj its use if skin alone is imohed though on
grounds other than pathological it will give an entirelj adequate
result A flap can be most useful, however, in the awkwardly

Fig 8, 6

The use of 0 single pedicled flap from upper eselid in covering the defect
left after excising a pigmented papilloma near the lid margin
A The lesion
B The flap outlined
C The flap transferred

D The final result after excision of the bridge segment

placed simple lesion whose excision leaves a defect Papillomata
near the lid margin for example often require more than minimal
clearance to prevent recurrence and leave a raw area which cannot
readilj be closed bj direct suture

Lower lid defects are particularly amenable to flap repairs and
the results are functional!) excellent because the bulk of e>ehd

Fic 8,7

The use of a temporal bridge pedicle to provide coser after excision of the
recurrence of a rodent ulcer in the centre of s previously applied post auricular
whole skin graft

A The lesion

B The excision leaving conjunctival lining and the temporal flap
outlined

C D The flap transferred with secondary defect split skin grafted
E The final result after return of bridge segment of flap

SURGERY OF THE EYELIDS

235

movement is bj the upper ejehd and a localised deficiencj of
orbicularis has little effect on function hen the defect does not
extend bejond the ejehd on to the cheek a flap of skin from the
upper ejehd above the upper palpebral furrow can be used
(Fig 8, 6) The vasculantv of the region permits a flap of quite
outrageous length breadth ratio to be used and depending on
the length site etc of the defect the flap maj be used with a
single pedicle at either canthus or swung down as a bipedicled
strap flap 11 hen the defect does not extend to the canthus the
flap maj be used as a bridge pedicle and the unused segment
which \erj rapidlj tubes itself can either be returned to its
donor site or excised whichever is more convenient These
repairs are most often needed in the older age groups and the added
laxitj of the upper ejehd which *0 often goes with age makes
closure of the secondary defect easier If the secondarj defect
can be closed bj direct suture without producing ectropion this
is the course to pursue If not a split skin graft must be used
When the defect extends bejond the confines of the lower lid
a broader flap is needed and the forehead is the usual source for
the medial canthal region a glabellar tjpe of flap can be used
(Fig 5, 17) for the lateral canthus and the remainder of the
lower lid a temporal flap is suitable (Fig 8 7)

There is a moderate amount of skin available m the upper
ejehd for closure bj direct suture without producing ectropion
and flaps are less often needed

BIBLIOGRAPHY

Schofield A L (1954) A rev ew of bums of the eyel ds and the r
treatment Bnt J plast Surg 7, 67
Stallaiid H B (1958) Eye Surgery 3rd Ed Bristol J W right
&. Sons

CHAPTER NINE

MaxiUo -facial Injuries

ALTHOUGH the treatment of fractures of the maxillo facial
ZA complex usualh invokes dental techniques of which
surgeons need know only the principles such patients are
still the concern of the surgeon for it is he who recognises the
injury and undertakes the early care of the patient Furthermore
some of the less severe fractures can readily be treated b)
straightforward surgical methods

EARLY CARE

The great majority of patients with maxillo facial injuries
require no special care of the fracture other than adequate and
repeated cleansing of the mouth Mandibular fractures apart,
maxillo facial fractures do not
tend to be sufficiently mobile to
make pain from this source a prob-
lem in earl} management Even
with mandibular fractures dis-
comfort due to mobility of the
fracture is seldom marked and a
surprisingly small proportion re-
quire the support of a barrel
bandage (Fig 9, 1)

In the small group who require
special care the difficulties are
either respiratory or caused by
haemorrhage.

Respiratory difficulty. This can
vary greatly m seventy and is due
«her to swelling of the tongue
from haematoma spreading from
a mandibular fracture or to inability to control the tongue in
those bilateral mandibular fractures where the anterior fragment
236

MAXILLO F\CIAL INJURIES 237

which carries most of the muscular attachments of the tongue is
mobile

Haemorrhage Bleeding particular!) in maxillary fractures ma)
occasionally be brisk but is seldom prolonged It stops spon
taneousl) if a free air way is provided Unfortunately unless
steps are taken to prevent blood from trickling back into the
pharynx the respiratory difficulties are likely to be intensified with
resulting restlessness which in turn will increase the bleeding
The positioning of the patient to prevent this is described below

Nurs ng the max Ho fac al njury prone with the head to one s de

The measures required in any particular patient depend on the
severity of the respiratory embarrassment but adequate suction
should always be at at (able Such patients breathe more easily if
they can be sat up but when this is not possible it is most important
not to leave them 1 ) mg flat on their backs The correct position
is prone with head turned to the side (Fig 9, 2) A suture
through the tongue to hold it forward may be necessary

It must be stressed however that any tendency to serious
respiratory difficulty is an indication for immediate tracheotomy
and this should be done early for respirator) embarrassment tends
to increase rapidl) Severe and uncontrollable bleeding may call
for ligation of the external carotid arter)

ASSOCIATED INJURIES

Maxiflo facial fractures do occur as isolated injuries but with
car and motor ejele accidents as a common cause other injuries
are verj liable to be sustained simultaneously The injuries most
likely to affect the management of the maxillo facial component

238 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCEIU

are soft tissue facial injuries, cranial injuries, chest injuries
and eye injuries. J '

Injuries other than these interfere less significant with the
treatment of the maxillo facial fracture and the only difficult}
which is apt to arise, other than that of co-operating with the
orthopaedic surgeon to reduce the number of anaesthetics bj
working on face and limb in a single operating session, is the
administrative one of deciding whether to treat the patient in
orthopaedic or maxillo-facial unit Ideally he should be treated
m an accident centre with the appropriate specialties comerging
on him but this ideal is still found only in isolated places and the
situation has usually to be resolved by considering tbe relatne
seventy of the several injuries

Soft tissue facial injuries

The soft tissue injury should be treated on its own merits with
the minimum of delay along the lines discussed in Chapter One
Its management is seldom significantly influenced b\ the simul-
taneous presence of a maxillo facial fracture E\en when the
fracture is compound the wound can be closed with safet)
Fixation of the fracture, as will be explained later, is usually tia
the teeth or b) the alveolus itself if the patient is edentulous and
so the soft tissue closure very rarely interferes with the definime
fracture treatment

Exceptionally, when an interosseous wire (see page 262) is
used to fix the fracture in addition to the dental fixation it ma> be
possible to use the soft tissue laceration for the surgical approach
but such an occurrence is extremely rare

Cranial injuries

Brain damage with or without a skull fracture is quite common
in association with a manllo-facial injury. The unconsciousness
which results affects the management of the patient in one of two

I If the patient is deeply unconscious and on this score
alone would be consrdered'for tracheotomt the presence of a
fracture of mariUa or mandible with the added breathing
difficulties which it causes adds great weight to the argument
m fat our of tneheotomj Eten where the let el of un-
consciousness would not bj itself merit tneheotomj there

MAXILLO FACIAL INJURIES 239

should be no hesjtatjon in carrying one out if the fracture is
adding significant!) to the difficulties of management and
there are virtues in carding out the procedure prop hy tactically
rather than waiting until it becomes a therapeutic necessit)
Though a tracheotomy is apt to have an unnecessary morbidity
in many cases because of unsatisfactory care and poor
facilities for humidifying the inspired air it can nevertheless
be life saving in this situation

2 If a tracheotomy is not considered necessary then the
fitting of metal cap splints (see page 258) and ev en the taking
of dental impressions should be postponed until the patient
is sufficiently conscious to be co operative
A further sign of cranial injury which may complicate the
management of a maxillo facial fracture is cerebro spinal
rhinorrhoea

Cerebro spinal rhinorrhoea I eakage of cerebro spinal fluid
from the nose is evidence of a fracture of the cribriform plate with
a dural tear It is an easy clinical diagnosis— a water clear fluid
dropping from the nose sometimes increased in volume by
dropping the head forward or straining usually developing within
48 hours of the injury though it may suddenly appear some days
or even weeks after the injury

The natural history of the condition if left untreated is in some
dispute Some leaks stop spontaneously when the fracture is
fixed and there is no further trouble some appear to stop but
meningitis develops after a variable and somet mes quite long
period of freedom from all symptoms some continue to leak fluid
w ith the ev entual dev elopment of meningitis ev en after reduction
and fixation of the fracture of maxilla

Tt is the proportion of patients falling into each category which
is disputed and this makes treatment difficult to discuss In any
case it is probably wise to enlist the help of the neurosurgeon as
soon as the condition is diagnosed and all such patients should be
given adequate antibiotic cover It is well recognised that
movement of the fractured maxilla causes considerable movement
of the cribriform plate and the fractured neighbouring bony
fragments The fracture shoutd therefore be reduced and fixed
at the earliest possible moment so that the dural tear may get the
best chance to heal

240 FUNDAMENTAL TECHNIQUES OF PLASTIC SLRGERl

If the leak is small in volume and becomes less fair!) raptdlv
it can safelj be left to stop spontaneously The chances of late
meningitis are probablj remote

The leak which is large in volume or which persists should be
surgicallj closed At a joint procedure w ith the neurosurgeon the
dural tear is repaired with a fascia! graft and the maxilla is reduced
and fixed

Chest injuries

The presence of fractured ribs along with a maxiffo facial
fracture does not usual!} complicate their mutual management
The maxillo facial injur) is onl) hkel) to make treatment of the
chest injury more difficult by adding to the respirator) embarrass
ment if there is a flail segment with paradoxical respiration In
such a situation a tracheotomy will help to sol\e both problems
Oddi) enough the combination of se\ erely crushed chest and
maxillo facial fracture is not a particular!) common one

Eye injuries

The surprising thing about e)e injuries in this context is their
rarity When one does occur the damage tends to be irreparable
either with disruption of the contents of the ejebalJ or set ere
damage to the optic nerve When damage is suspected the
opinion of an ophthalmic surgeon should be sought without delaj,
not so much from a therapeutic point of view for there is seldom
much to be done to sa\ e sight if this has already been lost but be
cause of the possibility of s)mpathetic ophthalmia if the meal tract
has been damaged The proptosis which results from bruising or
actual haemorrhage into the orbital fat subsides spontaneous!) as
does subconjunctival haemorrhage when it occurs

Eyeball and optic nerve apart, the most frequent injury is a
fracture of the orbital floor through which orbital fat may herniate
into the antrum This injur) occurs usuall) as part of a fracture
of the malar complex and will be discussed along with that injur)

PATTERNS OF INJURE

The maxillo facial bon) complexes are the mandible, max-
illa, malar, and nose, the last three constituting the middle third
of face (Fig 9, 3) These complexes roughlv correspond to their

MAKILLO FACIAL INJURIES 24I

anatomical counterparts and each has its own distinctive injurj
patterns While a pattern maj occur alone se\eral patterns of
fracture may exist together either in a single bonj complex or in
more than one at the same time For example a fractured maxilla
may occur atone or along with fractures of one or both malars

The maxillo fac al bon> complexes — maxilla
nose malars mand ble The stippled segment
nd cates the m ddle th rd of face

and/or nose In either case it is looselj described as a middle
third fracture

In fractures of mandible and maxilla it is not uncommon for
teeth to be loosened quite apart from those in the line of the mam
fracture and these are described as being alveolar fractures
because they are due to localised fractures of the aheolar plates
of maxilla or mandible in relation to the loosened teeth
Q

242 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

Malar

There are three main types of fracture (Fig 9 4)

Simple fracture The fractured bone consisting of the malar
complex remains in a single piece which is displaced medially and

Fic 9 4

The types of malar fracture

backwards often tilted either mediallj or laterally and usuallj
impacted The line of fracture runs from the infra orbital
foramen downwards and laterally over the anterior wall of the

MAXILLO FACIAL INJURIES 243

antrum compressing the infra orbital nene and tearing the
branches of the superior dental nerve which cross the fracture line
Comminuted fracture The fracture pattern is general I) similar to
that of the simple fracture but the bone is comminuted with
depression of the orbital floor Impaction is less marked as a
feature

A B

Fig 9 s

Patterns of nasal fracture
A Pattern from lateral v olence
B Pattern from head on violence

Arch fracture This consists of a localised depression of the
zygomatic arch In its medially displaced position it tends to
impinge on the coronoid process of the mandible

Nose

The nose consists not merely of the nasal bones but also of
the nasal septum and both may be damaged Fractures follow
two patterns due to lateral violence and head on violence (Fig 9,5)
Lateral noleitce The nasal bone on the side of the injury is
fractured and displaced towards the septum the septum is
deviated or fractured and the nasal bone on the side away from
the injury is fractured and displaced away from the septum so that
the upper part of the nose as a whole is deviated Depending

244 fundamental techniques or plastic surgery

on the seventy of the violence one or more of these displacements
may be present and the degree of comminution is very variable
Head on violence This gives rise to saddling of the nose and
broadening of its upper half as a result of the depression and
splaying of the fractured nasal bones Such a displacement
naturally cannot take place without severelj damaging the septum

The common sites of fracture of the mandible
and this takes the form of gross buckling of the septum or actual
septal fracture Dislocation of the lower attachment of the septal
cartilage with buckling of its columellar margin usuallj gives rise
to dev lation of the nose towards its tip

Mandible

The sites of fracture (Fig 9, 6) are condylar neck, angle,
body near mental foramen, symphysis Fractures at these
sites maj occur singl} or in several common combinations
namely both condyles, both angles, body and opposite angle,
body and opposite condyle, both sides of body (Fig 9, 7)

M \XILLO-FACIAL INJURIES

245

hile the displacements may be the result of the direction of
the v lolence they depend large!} on muscle pull The muscles
which elev ate the mandible — masseter, medial pterygoid tem
poralts — are all inserted behind the first molar, the muscles —
gemoh\oid, mylohyoid digastric — which depress the mandible are
all attached in front of the first molar (Fig 9, 8) Consequently
the predominant displacement of a posterior fragment is upwards

The common sites of b lateral mandibular fractures in order of frequency

and of an anterior fragment downwards though the direction of
the fracture line particularly near the angle may considerably
influence the amount of displacement either permitting or
preventing it (Tig 9, g)

The condylar fracture is a special case The condylar head is
pulled forward by the lateral pterygoid muscle and when both
condyles are fractured the displacement of both heads causes the
patient to gag on his molars giving an open bite’ (Fig 9, 10)

Maxilla

The fracture patterns depend on two factors — the site and
direction of the violence and the anatomical lines of weakness of
the maxilla Two patterns commonly result (Fig 9, 11)

246 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCER1

Fic 9, 8

The lines of muscle pull which influence
displacement of fragments in mandibular
fractures

Upwards — ma«seter, temporalis medial
pterygoid

Dottmiards — geniohyoid, m> lohj old,
digastric

Direction of Fracture Direction of Fracture

PREVENTS PERMITS

Displacement Displacement

Fic 9,9

The efTect of the direction of the fracture line on the displacement of
angle fractures of mandible und-r the influence of muscle pul!

MAXILLOFACIAL INJURIFS 247

The palatal segment of the complex shears off the remainder through
a horizontal line corresponding in le\ el to the floor of the nose
and the lower part of each antrum The palate as a whole is
displaced backwards and impacted with an upward tilt so that the
patient tends to gag on his molars \\ ith
an "open bite" (Tig 9, iia)

On occasion, when the violence has
heen predominant!} unilateral, one half
of the maxilla is fractured in this wa} ,
an added fracture line running back
along the mid line of the hard palate
The displacement of the fractured
palatal segment then tends more to
be upwards with impaction into the
antrum (Hg 9, ixb)

The maxillary complex ts fractured as
a tchole The fracture lines run up
wards and mediallj across the anterior
wall of the antrum towards the mfra- JJEfSSu* “

orbital foramen on each side and across

the nasal bones to meet in the mid line at the glabellar region
The displacement is usuall} backwards with a tilt causing an * open
bite” The degree of impaction vanes great!) from the massn el)
displaced and impacted fracture to the so called "floating"
fracture where impaction is minimal (Fig 9, 11c)

It must be recognised that when the maxilla is displaced m
this wa) it is earning the nasal complex with it The nasal
complex of course maj itself be fractured independently m an)
of the wa)S ahead) discussed

Furthermore the maxillaty fracture line passing medial to the
malar corresponds to the antral line of a malar fracture and such a
fracture may be present either on one or both sides along with a
maxdlar) fracture (see middle third fractures)

Middle Third of Face

While a fracture of the middle third of the face is a traumatic
entit) it is one which is apt to be extremely confusing because it
appears to be devoid of all pattern A pattern can readily be
made to emerge as soon as it is appreciated that the fracture can

248 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

be broken down into the three constituents namely the fracture
of maxilla the fracture of molars and the fracture of nose (Figs 9,3
and 9, 1 id )

METHODS OF DIAGNOSIS

Maxillo facial fractures should be diagnosed clinically and
confirmed by X ray

Clinical Picture

Malar

The clinical picture can be related very closely to the patho
logical anatomy of the fracture (Fig 9, 12)

Snelhng and bruising of the overlying soft tissues is very
variable Sometimes it is almost completely absent sometimes it
progresses rapidly until it is severe enough to virtually close the
eye and mask any underlying bony deformity Subconjunctival
haemorrhage is not uncommon

Alteration of bony contour is usually in the direction of flattening
of the cheek prominence Comparing the inferior orbital margin
with the normal on the opposite side a step in the vicinity of the
infra orbital foramen can readily be felt as a rule If the overlying
soft tissue swelling is severe enough however it may be very
difficult to detect the step It is sometimes possible to feel the
line of the fracture m the upper 1 ccal sulcus as it runs downwards
and laterally over the anterior wall of the antrum

Anaesthesia of the structures supplied by the nerves injured is
readily detected Branches of the superior dental nerv es may be
divided by the fracture making the teeth of the affected segment
anaesthetic to percussion The extent of the area made anaesthetic
by the damage to the infra orbital nerve is very variable but the
two areas most noticeably affected are the upper hp and the alar
region of the nose The sensory loss can vary from mdd
paraesthesia to complete anaesthesia and m practice it is best to
ask the patient to compare the affected area with a corresponding
point on the normal side

The actual mechanism of injury to the nerve i& not explicable
on the basis of neuronotmesis avonotmesis etc for in some
patients recovery begins on regaining consciousness after the

MAXILLO-FACIAL INJURIES 249

anaesthetic In such cases recovery is mvariablj speed) and
complete In others reco\ery is slow and incomplete and it is

Fracture of Fracture of

Palatal Segment Maxillary Complex

Fracture of Middle Fracture

half of (maxillary complex

Palatal Seqment nose 6- hath maters)

Fic 9 11

The common in ur> patterns of maxilla and middle third of face

possible that m those the injury has seierel) damaged or even
completel) divided the ner\e m the infra orbital canal

j Diplopia maj occur as a transient phenomenon in the simple
fracture and temporal reduction cures it When it persists

250 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCERI

post -operand} ,t ,s ustiallj found that the lateral part of the
orbital floor has been se\ erelj comminuted and depressed The
upper \ lsual fiel d tends to be predominant!) affected The precise
cause is not complete!) understood but it is thought to be due to
damage to the sling mechanism of the e)eball from fibrosis and
adhesions to the damaged orbital floor

MAMLLO FACIAL INJURIES

Nose

The clinical appearance of the nose and septum is the index of
diagnosis Some swelling is inevitable in patients in whom the
diagnosis is being considered but a change of bridge contour or a
new asymmetry are diagnostic and frequently the best judge of
this is the patient himself In any case a fractured nose apart
from its septal element is treated on the grounds of appearance
alone and an \ ray showing a fracture is of no significance unless
there is associated nasal deformity

Even when the nose is not appreciably deviated or depressed
the septum should be examined for haematoma This shows w ith
gross bulging of the septal mucosa and it may either be unilateral
or bilateral

Mandible

The site of fracture is usually indicated by swelling and local
pain on movement or man pulation of the mandible In fractures
other than those of the condylar neck there is a sublingual haema
toma and if the fracture is compound into the mouth there is
tearing or at least bruising of the mucosa

In the tooth bearing segment of the mandible displacement
may be clinically apparent with an obvious break in the line of the
teeth or the patient may volunteer the information that the teeth
don t close properly

A condylar fracture is less obvious and the only sign may be
pre auricular pain with or without swelling There is restriction
of movement and dcviat on of the mandible to the damaged side
on opening with gagging of the molars on the affected side on
closure The great majority of patients with a fracture elsewhere
in the mandible who complain of pain in the vicinity of the
temporo mandibular joint are found to have a fracture of the
condylar neck

A bilateral condylar fracture often shows clinically with an
inability of the patient to close the incisors because of the gagging
of the molars giv ing an open bite

If the fracture is between lingula and mental foramen and
there is displacement of any degree damage to the inferior dental
nerve may cause anaesthesia of the lower lip In the suspected
fracture of the body a most useful method of clinical examination
is bimanual ultra and extra oral palpation feeling along the inner

2J2 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

and outer plates of mandible mtra oral!} and the lower border
extra onllj (Hg 9, 13) Local swelling and tenderness is
suggestive of fracture and an actual step is diagnostic

It is usual!) possible to make a fairl) accurate assessment
clinical!) but, particular!) if displacement is minimal, X-ra)

Combined mtra and «tra oral palpation in
examination of the mandible for fracture

examination maj be required to confirm the diagnosis and indeed
when the diagnosis is suspected X ra)-s should ahva)s be taken

Maxilla and middle third of face

Although isolated fractures of the maxilla do occur the fracture
occurs sufficient!) often with fractures of malar and nose that the
clinical picture will be discussed under the heading of middle
third fracture In any case it is onl) after clinical examination
that the actual fracture pattern can be separated from the hotch-

MWILLO FACIAL INJURIES 253

potch of middle third fractures into the component fractures of
maxilla malar, and nose

It is often possible to diagnose a middle third fracture on
inspection alone The face as a whole but predominantly its
middle third is diffusely swollen with oedema of cheeks and
eyelids and looks like a football It is a \ery ty’pical appearance
(Fig 9, 14)

In the severely displaced fracture there is an obvious dish
face deformity despite the masking effect of the oedema There
is obvious failure of the teeth to occlude properly when the patient
closes his mouth The upper incisors instead of occluding as
they do in most patients in front of the lower incisors occlude
behind or they fad to occlude at all because of the presence of an
open bite This sign is naturally difficult to elicit in the edentulous

W 1 en there is difficulty m deciding whether any displacement
of the maxillary complex is present the patient should be asked to
bite on his back teeth or on his dentures if he is edentulous If

254 fundamental techniques op plastic surgery

he sajs that the teeth are closing normally then any fracture is
undisplaced

Mobility of the maxillary complex is tested for (rig o, ir) b\
grasping the maxilla just above the incisors between finger and
thumb of one hand while the other finger and thumb feel across
the bridge of the nose and hold the head steady The maxilla is
rocked backwards and forwards while independent movement of
maxilla is felt for Movement of the maxilla with detectable

Fic 9 , 15

Method of testing for mobil ty of the maxillary
complex in a suspected middle third fracture

movement at the nasal bridge suggests that the entire maxillary
complex is fractured while movement of the maxilla without
detectable mo\ ement at the nasal bridge suggests a fracture of the
palatal segment alone Each half of the palatal segment is then
tested against the other for independent mobility and loose teeth
are tested for to exclude alveolar fractures

As alreadj stressed middle third fractures may include
fractures of either or both malars and/or nose and the presence of
these must be tested for independently by the methods already
indicated

In short, maxillary fractures per se are diagnosed on the basis
of occlusion of the teeth, and fractures of additional bones are
diagnosed by actively examining the patient for their presence

MAMLLO FACIAL INJURIES 2^^

X-ray Diagnosis

Malar The view used routinely is the 30° ocaptto-mental
projection — the sinus view but minor degrees of displacement
can be demonstrated more readd) by increasing the tube angle
and consequent^ the obliquit) of the \ lew up to 6o° The pomts
to look for are irregularities or definite fracture lines near the
infra orbital foramen the z\gomatic arch and the lateral wall of
the antrum and the line of the orbital floor should be compared
with the normal side Blood in the antrum maj make it appear
opaque

Nose The fracture is treated on the basis of the clinical examina
tion and \ rays are quite unnecessary

Mandible Of the possible views used to demonstrate particular
parts of the mandible the two most general!) useful are the
postero-anterior projection and the lateral oblique projection If
further views are considered necessarv the easiest wa) is to specif)
the particular parts of the bone which it is desired to demonstrate
Occlusal films are sometimes ver) helpful

Maxilla and middle third The diagnosis should be made on
clinical examination and nearl) ever) case can be diagnosed and
treated without the need for an X ra) In an) case the interpreta
tion of the X ra) is frequentl) more difficult than that of the
clinical examination but the views most Iikel) to be helpful are the
30° occipito-mental projection and the lateral projection

REDUCTION AND FIXATION METHODS
The teeth are used as an indirect method of fixing jaw fractures
Their firm attachment to the alveolus coupled with the fact that
it is their occlusion which is of prime importance from the point
of view of subsequent function makes them extremel) effective for
this purpose It is usuallv onl) when teeth are absent that the
ah eolus is approached more directl) for splinting purposes

In reducing a fracture of mandible or maxilla the aim is to
bring the teeth of the fractured fragments into a normal relationship
with those of its unfractured counterpart because the fracture
must of necessit) be in good position if the teeth are occluding
normall) With an edentulous patient the fractured alveolus

256 fundamental techniques of plastic surcerv

for similar reasons, is brought into the position it would occupy if
dentures were being worn

In fixing a fracture of mandible or maxilla, the fractured bone
once reduced must be anchored to an immovable structure The
mandible when fractured is thus anchored to the maxilla, the
maxilla when fractured is anchored to the skull as well as to
the mandible

It should be appreciated in discussing the actual methods of

Fic 9 16

The steps in eyelet wiring

fixation as the) appl) to the mandible that reduction of the fracture
on to the maxilla in correct occlusion as the guide to proper
reduction, and fixation to the maxilla in this position as a suitable
point of anchorage are m practice achieved simultaneous!) because
reduction and fixation are to the same structure, namely the
maxilla The separation into two distinct steps becomes more
apparent with maxillary fractures where reduction is on to the
mandible and fixation is to skull and mandible
When teeth are present in sufficient numbers on both fragments
the) are fixed in proper occlusion b) eyelet taring, arch taring, or
cap splinting

Eyelet wiring (Fig 9, 16) The fixing device in this method is a
5 inch length of 25 S W G stainless steel wire which has been

MAXILLO FACIAL INJURIES Zrf

doubled on itself and twisted tightlv two or three times leaving a
small evelet at the end

The double wire is passed inwards between the necks of two
adjacent teeth until the twisted segment is ljing between the necks
with the e\elet on the outer side The wire is then separated into
its two strands one being turned forward and one back and each
is passed outwards through the next interspace so that a loop is
formed round the necks of the two adjoining teeth The loops

Tic 9 17

The steps in arch wiring

are completed bj bending the wires towards one another passing
one through the ejelet and finall} twisting them tightlj together
before cutting off the excess and turning in the end so that it will
not catch on tongue or cheek

Se\ era! sets of these wares are applied at intervals round the
ah eolar arch and also at corresponding points on the opposite jaw
When the fracture has been manuallj reduced and the mandible
closed on to the maxilla it is held in this position b) looping
further wires through the ejelets which oppose one another and
twisting them tight)} together

Arch wiring (Tig 9, 17) This technique is an alternative to
evelet wiring and uses a narrow malleable metal bar made of
flattened soft German silver wire and accurate!) moulded round
the alveolar arch on its outer aspect at the level of the necks of
the teeth to which it is then wired With an arch bar similarl)

258 FUT.DAMENTAL TECHMQLES OF PLASTIC SURCER1

applied to the maxilla the ttto can be fixed together tilth lures
Alternant el) the arch bar on the fractured bone can be fixed to
eje/et wires on the unfractured alveolus

Two such bars fitted one inside and one outside the arch and
wired together between the necks of the teeth prov ide much firmer

fixation but to make accurateH
fitting bars necessitates the tak-
ing of impressions and the con-
struction of a plaster of Parts
model of teeth and gums on to
which the bars can be moulded
before the) can be applied to the
patient

These methods, evelet and
arch wiring, can be used in an
emergencj in mandibular frac-
tures when other methods are not
available and the\ maj suffice
as the definitive fixation when
the fracture has no tendencj to
displacement and the dentition
is full and health) though m
practice the wires fixing upper
and lower teeth require periodic
adjustment and tightening Un
fortunatel) relativelj few frac-
tures fulfil these criteria and
the methods consequent! 1 have

Metal cap splints The splints are
cemented to the teeth and in this
-\>a> provide fixation for a fracture of
mandible or maxilla

a limited usefulness

Cap splinting (Fig 9, 18) This
is much the most commonI\ used

method in Great Britain It is a highlv developed technique
in which correcth articulated models of the teeth and gums of
mandible and maxilla are made m plaster of Pans \\ orhing with
these models as a basis, cast-metal cap splints are made of the
entire dentition, fitting accuratelv over all the teeth except those
purposel) excluded, namel) ones in the actual fracture line and
those which are hopelessl) carious

Properl) made and fitted these splints do no damage to gum

m willo fvci\l i\;uRrc< 2^9

or tooth and when cemented in position thex provide a \cr>
posittx e fixation

B) planning on the articulated model it is possible to incorporate
hooks at corresponding points on upper and lower splints so that
the two sets of splints can he wired together or fixed wuh elastic
bands In this \va\ the fractured bone can be reduced and fixed
against the unfractured bone in correct positron The clastic

bands are extreme!) useful m c\crtmg prolonged traction when
immediate reduction is not possible

Although this describes the technique in essence there arc man)
modifications of detail One of these is the use of the loci tng bar
(rig 9, 19) In this the metal cap splint is made in two sections
one on each side of the fracture line and the mechanic in making
the splints incorporates a small fitting near the adjoining end of
each to permit the screwing of a connecting bar to each splint so
that the sections are comcrted into a single rigid unit It is not
possible to luxe the locking bar prefabricated like the splint and
instead a plaster of Paris impression it. made of the fittings in their
correct relative positions with the fracture reduced \ suitable
bar is then nude on the spot b) the dental mechanic VI ith tht
bar screwed tighth m place the now single splint is wired to its
fellow in the usual wax

I he method is an extremcl) versatile one and can be applied
to all fractures of the teeth hearing segments

l60 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGC1U

When teeth are not present it mil be appreciated that if the
patient s dentures could be fitted and the fracture reduced on to
the dentures with upper and lower occluding correctly the fracture
would be accurately reduced It it possible when well fitting
dentures exist to do this but often
the denture has been broken is lost
or fits so badlj as to be useless
Nevertheless the principle is still
used Impressions are taken and

dentures without teeth —so called
Gunning splints are made (Pig 9
20) These splints are circumfer
entially wired on to the upper and
lower jaws and subsequently to each
other to obtain fixation (Fig 9, 21)

In fractures of the edentulous
mandible w ith minimal displacement
and particularl) in the elderly pattern
it is often enough when Gunning
splints have been fitted merely to
support the mandible against the
maxilla with a firm barrel bandage
without circumferential wires The
absence of teeth makes it a little less
essential to get absolutely accurate
reduction for a denture can sub
sequentty be fitted to compensate

Fig 9 20 for an) slight irregulant) of alveolar

Gunn ng spl nts showing the
gutta percha 1 n ng between the
t vo apt nts and between each
spl nt and the al eolus

alignment

Saddle and interosseous wiring
While a combination of the methods

described suffices for most fractures a problem which often

arises is that of the posterior fragment of mandible which has
no teeth on it to provide a fixing point In such a situation
it is sometimes possible to maintain adequate reduction when
displacement is minimal by extending the metal cap splint
backwards through the use of a horizontal saddle (Fig 9 22)
The posterior fragment tending as it does to displace upwards
and medially is in this way sufficient!) well controlled

ni^Sp hfAJU

i circunifcrcm ally wired 1 1 mand blc and niaxilli and

MAX 1 LLO TACIAL INJURIES 263

the wire must be remoxed but it should if possible be retained
until the fracture is. stickx so tint rcdnplatemcnt will not
occur

Simple loop wire

Figure of 8 Wire

Tie 9 13

Interosseous 1 ing

Plaster head cap (Pig 9 24) It has "been pointed out
the fractured maxilla is reduced on to the mand ble ta p .
occlusion the final anchoring fixation is to the skull ^ 3
pro\ ided b\ means of a plaster head cap

A cap of plaster of Pans encircling the scalp brou bt (i o;
bejond the external occipital protuberance posterior^ 1 1 on JO

264 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCERI

the supra-orbitil ridges anterior!}, is sufficient!} firmb anchored
to the skull to proude a solid 3nd fixed base The nmillin
splint, metal cap or Gunning, is fixed to the head cap bj a senes
of rods connected b) unnersal joints When the fracture has

Kic 9, 24

Planter head cap used as a point of
anchorage in maxillar) fractures
showing the metal rod incorporated in
the plaster to which fixation is achietcd
by the means indicated in Hj, 9, 25

been reduced and the splints wired together the final fixation is
achieved b> tightening the universal joints to make the whole
s)stem of rods quite rigid (Fig 9, 25)

TRrATMrrs i

Malar

The finding of a malar fracture on an \-nv plate does not
alwajs mean that surgical treatment of the fracture is ncccssarj
The need or not for surger) is decided rather on the clinical
examination

The presence of infraorbital nerve anaestbesn, trismus,
diplopia, obvious flattening of the cheek prominence— all of

MAM LLO I *CIAL INJURIES 263

these are in indication for suigm Anaesthesia of the teeth
b> itself is not an ind cation as the e!e\ation of tl e malar will

Tig g zj

Method of f xit on of a max llary spl nl metal
cap or C unn n£ to the plaster head cap by
means of a sj stem of rods and un ersal jo nts

make no difference to this symptom It is the case where the
slightest suggestion of flattening of check is the on!) clinical find ng
that can cause d fficulta and whether or not the fracture needs to
be reduced must be an md \idual decision one which incidentally

266 FUNDAMENTAL TECHMQUrs Or PL\STtC SLfcrTRV

can reasonabh be shared with the patient But it must 1 c stressed
that the decision to treat or not must be made as earlv as possible
There is no place for a wait and see approach These fractures
fix in their impacted position with great rapiditv and the chances
of reducing a fractured malar more than a few da vs old arc not
good and become much poorer as the days pass

Another difficult group is the one with an undisplaced fracture
or even an apparently normal \ rot but with infra orbital
anaesthesia It is mv practice to elevate these malars even
although no actual movement of the malar is felt because once
treated recover) of sensation is uniformly rapid and complete
Many of these would doubtless recover sensation spontaneoush
but there is the remote possibility of the non recovering nerve
developing a very distressing and intractable neuralgia Though
the incidence of this complication is probably ven small indeed the
simplicity of surgical treatment makes it preferable to taking the
risk of a possible late neuralgia if the fracture is left untreated
Surgical treatment consists of elevation and this is achieved
either by a temporal approach or bv opening the antrum mtra
orally and inserting an antral pack The temporal approach is
suitable for most of the simple fractures The deciding factor is
reall) whether or not the malar is more or less in a single piece
and capable of being reduced by everting leverage on the anterior
part of the zygomatic arch The arch fracture of course falls into
this group When the fracture is comminuted to lever the arch
would naturally only reduce part of the bone and because of tins
it has to be reconstituted and supported bv an antral pack There
is a further small group where the fracture after a temporal
reduction tends to redisplace and it is necessary sometimes also
to pack these

Temporal reduction (Fig 9 26) This method depends on the
anatomical fact that while the temporal fascia is attached along
the zygomatic arch the temporalis muscle runs under it and a
lever inserted between fascia and muscle can slide down deep to
the arch to evert its leverage

^ ith the hair shav ed for 1 inch or so back from the temple an
oblique 3 1 inch incision is made as far deeply as the temporal
fascia taking care m placing it to ivoid the superficial temporal
vessels It is worth pausing with retractors in the wound at this

MWILI O-FACIAL INJURIES

267

point to positneH identifv the fascia before incising it in the
same direction and for the same length as the shin There is
often a vessel running on the deep surface of the fascia and it is

Incision placed to avoid
superficial temporal vessels

Incising Elevator

temporal fascia inserted

Fig 9, 26

Temporal reduction of a maUr fracture

advisable to cut ca refull) under direct vision \s a pathfinder
for the lever Mclndoe’s. scissors are inserted under the fascii and
slid along the surface of the temporalis muscle deep to the
zjgomatic arch

268 FUNDAMENTAL TECHNIQUES OF PLASTIC SURCEM

Various levers ha\e been devised and used to elevate the bone
but the most commonly available and an eminenth satisfactory
one is the orthopaedic Bristow’s periosteal elevator It is slid
along the path found by the scissors and once under the arch it
should be brought as far forward as the arch allows so that leverage
can be exerted anteriorly if necessar) as well as laterally If
added leverage is required a swab may be placed between elevator
and scalp The degree of force needed depends on the degree of
impaction and the delaj in treatment but considerable force can
safel) be used In closing the incision it is onl) necessar} to
suture the skin

Antral reduction (Fig 9, 27) An incision is made in the upper
buccal sulcus in the canine region and the soft tissues arc stripped
off the outer wall of the antrum In the tvpc of malar fracture
requiring a pack there is usuall) comminution of the wall and the
index finger can be put stnght into the antrum When the
opening is too small bone can be nibbled awa) to allow easj finger
access If as ver) rarelj happens the particular part of the antral
wall is intact an opening must be chiselled into the antrum and
enlarged y\ ith rongeurs for access

The finger m the antrum carefull} pushes out the walls to a
correct position and the most important wall is the orbital floor
The cavit) is then packed y\ith i-inch ribbon gauze soaked in
Whitehead’s y amish (Pig lodoformi Co t B P C ) and tight!}
yvrung out The striking feature of such a pick is the way it is
found as clean, dry, and non smelling on removal as when inserted
Enough packing is inserted to maintain the orbital floor at its
correct level and buttress out the cheek prominence The end of
the gauze is left protruding into the mouth to give an eis) start
for its removal m 10-14 ** ,s usua * though not essential to

parti} suture the mucosal inciston

It is important not to pack too vigorousl} towards the orbit in
case some of the pack gets pushed into the orbit itself giving rise
to severe proptosis If such an occurrence is suspected an \-rav
should be taken and if it confirms the diagnosis the pack must be
removed immediate!) and a fresh one inserted with great care
Patients with antral packs almost ahvavs dev clop a mild diffuse
swelling of the cheek and this, only subsides slowly after the pick
is remov ed It requires no treatment other than reassurance

MWILLO-FACIAL INJURIES

269

Ttc 9 27

Reduction of a fractured malar b\ the antral approach and maintenance of
reduction b> an antral pack

2J0 rUND^MENTlL TLCHf, IQlIFX Or FUSTIC SLUCCM

Diplopia occasionally persists after deration and the incidence
ot this rather distressing complication is highest whin the lateral
part of the orbital floor has been see ere!', comminuted Orthoptic
training exercises can then help m re educating cie movements
and as a last resort bone grafts have been inserted to build up a
smooth orbital floor at a more
normal level

Nose

I\asal fractures requiring re-
duction should be treated with
the minimum of delaj for thev
tend to fix in their displaced
position in a matter of dajs
The surgical approach depends
on whether the fracture has re-
sulted in deviation or collapse
of the nasal bones

Deviation This t\pc of dis-
placement is caused hv lateral
Molence and it can sometimes
be corrected bj simple thumb
pressure (Fig 9, 38) p irticularh
f-, c 9 2 8 if t fit fracture is verv recent

„ , r , , . . Unfortunatch tins manoeuvre

Reduction ot a nasal fracture b> simple i i i

thumb prcs«urc is apt to leave untouched the

side depressed bj the fracture
and reduces onl} the nasal bone which has been pushed out
Manipulation from inside using Walaham’s nasal forceps is then
required (Fig 9, 29) W ith the particular forceps for the side of
the nose being manipulated the slim blade is inserted into the
nostril and the broader blade outside T he blades are closed over
the nasal bone which is then mobilised with a rocking movement
of the forceps first laterallv and then medialh to distmpict it It
is important to cozer the limb of the forceps pressing on the skin x-ith
rubber tubing to protect it from undue local prissure With both
bones mobilised finger manipulation can mould them into a sym-
metrical position The septum should be inspected and if ncccs
sarj reduced into a central position using \\ alsham’s septal forceps

MAMLLO r\ClAL INJURIFS 271

as described below In practice reduction of the nasal bones
frequcnth reduces the septal displacement simultaneous

Collapse This displacement is the result of head on violence
and it is essential from the point of \ lew of treatment to recognise

Method of mampulat ng a nasal fracture us me \tal hams nasal foretps Note
the use of rubber tubing to protect the skin front undue local pressure

that the nose cannot collapse without cither buckling of the septum
or fracture, and straightening or reconstitution automat icalh
corrects the nasal collapse A\ alsham s scptnl forceps arc most
efFectite for this purpose The blades of the tightK closed forceps

270 fundamental teciimqui-e of plastic 'deceit

Diplopia occasionally pers.sts after delation and the incidence
01 this rather distressing complication is highest nhen the lateral
part of the orbital floor lias been set erely comminuted Orthoptic
training eternises con then help m re-educating etc motements
and as a last resort bone grafts hate been inserted to build up a
smooth orbital floor at a more
normal In cl

Nose

Nasal fractures requiring re-
duction should he treated with
the minimum of dela) for thu
tend to fi\ in their displaced
position in a matter of days
The surgical approach depends
on whether the fracture has re-
sulted in deviation or collapse
of the nasal bones

Deviation. This t\pc of dis-
placement js caused by Literal
Molence and it can somettmes
be corrected bv simple thumb
pressure {r ig 9, 28) particular!)
r , c 9 2 s «f the fracture is very recent

_ . t , r . . , Unfortunate!) this manoeuvre

Reduction of a nasal fracture bj simple J . .

thumb pressure is apt to leave untouched the

side depressed h) the fracture
and reduces onl) the nasal bone which has been pushed out
Manipulation from inside using Walsham’s nasal forceps is then
required (Fig 9, 29) With the particular forceps for the side of
the nose being manipulated the slim blade is inserted into the
nostril and the broader blade outside The blades arc closed over
the nasal bone which is then mobilised with a rocking movement
of the forceps first laterall) and then mediallv to disimpact it It
ts important to cot er the limb of the forceps pressing on the skin tath
rubber tubing to protect it from undue local pressure With both
bones mobilised finger manipulation can mould them into a svm-
metrtcal position The septum should be inspected and if neces-
sary reduced into a central position using W’alsham’s septal forceps

Mt\!l I O-Ftf Ml ISjl J IM 2yi

a. described 1 clow In practise rrduui >n of tin. nml bones
imjttcrtlc reduce* the ■stpul displacement Mmulnnroush

Collapse Tins displacement ts the result it litad on \iuknce
ail ii i> csuntnl from the point of \tcw c f trcitment to rtct^mst

Mtt*i »1 cf Trjr puta r„ a natal fracture in rg \\ at I am » naol fr>rcrp\ ^ tc
* ux nf tu* ber I I n,l ptnicvt Ihc »V n (i w it'd cl *cnl pf co ire

the nose cannot c< llapsc without either hucMing of the *cptum
w fracture and straightening or reconstitution automiticalh
corrects the nasal toll ipse Walsh-im s septal forceps arc most
e ectne for this purpose Hie blades of the ttghtl\ do cd fc reeps

272 FUNDAMENTAL TECHNIQUES OF PLASTIC SUKOEK*

are so made that the\ remain apart Ic-n ing a gap corresponding
to the thickness of the septum \\ ith a blade inserted into each
nostril along the nasal floor the forceps are closed and swung up
towards the nasal bridge (fig 9, 30) As the) mmc upwards the

The use of \\ aJsham s septal forceps to stra chten the nasal septum

blades straighten the septum or reduce an\ fractures Flic
correction is completed as the) reach the bridge and lift the whole
bridge line forward from its collapsed position I he manoeutre
can be repeated if neccssars when correction is on!) partial at the
first attempt An) associated broadening of the nasal bones can
be reduced b) finger pressure if necessary after mobilisation with t
■\\alsham s nasal forceps

M V\ILLO*FACHL INJUMfS

273

Septal haematoma. In a nasal injurv the state of the septum is
as important as that of the nasal hones, and its management has
been described It should also be examined for bieroatoma which
if present can he evacuated b\ incising the muco*t

Packing and immobilisation 1 ullc gras packing of the nostrils
is adi liable if there is the slightest mohihti of the nasil bones or

The p aiicr <>f f Jrn natal tp) nt u« d in the m! tie I fratlurt of note an I ftlnrp
n th * plaiirr head cap in the na al fracture occurr np »» port of a m ddlc th rd
fracture

septum after manipulation On the one hind it provides support
for the ■septum in its reduced position and helps to prevent the
occurrence or recurrence of lucmatomi On tltc other tt pros ides
some counter pressure for the piaster of Paris immobilising the
nisal bones and prevents them from collapsing inwards It can
he raum ed 10 .48 hours

A plaster of Pans splint moulded to the nose (I ig 9, ^1)
should he left in place for a week and worn at night for a further
week or so

Particuhrh when it occurs as part of 1 severe middle third
fracture the comminution of the nasal hones m 15 he so gross tint
the fragments cannot be maintained in 1 n irrmv ind fortv ird
position with splint and pickinc alone A through ami throuch

272 FUNDAMENTAL TECHNIQUES OF PLASTIC SURGERY

are so made that they remain apart leaving a gap corresponding
to the thickness of the septum \\ ith a blade inserted into each
nostril along the nasal floor the forceps are “closed ’ and swung up
towards the nasal bridge (Fig 9, 30) As they move upwards the

The use of Mahham s septal forceps to straighten the nasal septum

blades straighten the septum or reduce any fractures The
correction is completed as they reach the bridge and lift the whole
bridge line forward from its collapsed position The manoeuvre
can be repeated if necessarv when correction is only partial at the
first attempt Any associated broadening of the nasal bones can
be reduced by finger pressure if necessary after mobilisation with
Walsham s nasal forceps

MAXILLO-FACIAL INJURIES 273

Septal haematoma In a nasal mjur\ the state of the septum is
as important as that of the nasal bones and its management has
been described It should also be examined for haematoma which
if present can be evacuated b\ incising the mucosa

Packing and immobilisation Tulle gras packing of the nostrils
is advisable if there is the slightest mobility of the nasal bones or

The p’ister of Pans nasal spl nt us d in the isolated fracture of nose and alorg
with a plaster head cap in the nasal fracture occurring as part of a m ddlc th rd
fracture

septum after manipulation On the one hand it pro\ ides support
for the septum in its reduced position and helps to prevent the
occurrence or recurrence of haematoma On the other it prov ides
some counter pressure for the plaster of Pans immobilising the
nasal bones and prevents them from collapsing inwards It can
be remov ed in 48 hours

A plaster of Paris splint moulded to the nose (Fig 9, 31)
should be left in place for a week and worn at night for a further
week or so

Particularlv when it occurs as part of a severe middle third
fracture the comminution of the nasal bones maj be so gross that
the fragments cannot be maintained in a narrow and forward
position with splint and packing alone A through and through
suture tted hghtlj to prevent cutting in with post operative
s

274 FUNDAMENTAL techniques of plastic SURGERV

oedema oxer a strip of padded metal or rubber tubing (Fig g, 32)
is ven useful in such circumstances and can be pulled forward
against the rods attaching the intra oral splint to the plaster of
Pans head cap if necessary

When a particular fracture is seen too late for primary reduction
or when the result of reduction is unsatisfactory the nose should

fracture occurs as part of a middle th rd fracture Note the « re hold ng the
no e forward to the \ertical metal rod A dental roll of cotton > ool can be
used for padd ng agz nst the nose

be left until all reaction has settled when a formal endonasal
reconstruction can be considered

Mandible

When the fracture is of the tooth bearing segment treatment is
usualh by upper and lower metal cap splints or Gunning splints
wired together though if displacement is minimal eyelet or arch
wiring may be sufficient If displacement is severe and manual
reduction impossible dental fixation may require to be augmented
by interosseous wiring Particularly is this so if the fracture is
bilateral or at the symphysis Metal cap splints used in con
junction with interosseous wiring provide a sufficientlv positive
fixation but with Gunning splints circumferential wiring of the

MAMLL.O-FACIAL INJURITs 275

splints to mandible and maxilla is neirl\ ahvavs necexsarj The
problem of the edentulous posterior fragment is solv ed either bv
using a saddle or b\ interosseous Miring

With condvlar fractures no attempt is made to reduce the
fragment whether or not the condvle is in the joint or dislocated
The “joint” is treated as a psembrthrosia and re education of the
muscles is relied on to establish
good function With a fracture
of bodj and condvle the bod}
fracture dictates treatment
Some patients have minimal
upset with a single cond}!ar
fracture and are able to chew
soft foods fairl} quickl} with
or without a period of rest de
pending on the degree of initial
discomfort If pain is severe
fixation with e>elet wires or
metal cap splints maj be neccs
sar} for 2-3 weeks In sub
sequent re-education of the muscles a training flange cn the splint
(fig 9» 33) ma > b e required to tram the mandible to close in correct
occlusion

Bilateral cond}lar fractures require reduction of the open bite
either manuall} or b) clastic traction on the fixing splints followed
b} active exercises of the mandible in 2-3 weeks

I'ractures other than simple cond}lar fractures are usuall)
tested for union m 4 weeks If there is clinical union the splints
can he removed but if the fracture is still spring} the splints
should be wired together again until union is chnicall} apparent
I ractures of the s}mph>sis and those which have become infected
tend to be stow to unite It should be recognised that Vra}
evidence of union maj not be present for man) months

Middle third of face

These fractures should be treated with the minimum of dclaj
as thc> tend to fix rapidl} in their displaced and often impacted
position

The malars to some extent and the nose complete!) are
supported b} the maxilla and it follows that the} can only

Trninint; fiance incorporated into nutal
cap splint to t ra ,n the mandible 10 close
into correct occlusion

276 FUNDAMENTAL TECHNIQUES OF PLASTIC SLRCEK\

be properl) built on a solid foundation of maxilla reduced and
fixed in pos t on The first step then is to reduce and fix the
maxilla

If the maxilla is floating or onlj slighth impacted it maj be
possible to reduce it b) finger manipulation failing which it is
necessarj to disimpact it with Walsham s nasal forceps (Fig 9 34)

Dis mpact on of a rraxillarj fracture us ng \\ al ham s mat forceps

Note the do vn sird d reel on of the leverage used to d s mpact the
fractured bone

Using upper and lower metal cap spl nts or Gunning splints wired
in position the maxilla is then reduced on to the mand ble and
wared to the mandibular splint It is then fixed to a plaster of
Pans head cap (Fig 9 2 3 )

The malar is then reduced m most instances b\ the intra oral
insertion of an antral pack Quite apart from the fact that the
presence of the head cap makes the use of the temporal approach
awkward the malar fracture occurring as part of a middle third
fracture tends not to be of the type suitable for temporal reduction
If it is felt that the fracture must be reduced b) a temporal approach
the head cap should be cut back for a su table distance to allow
the incision to be made

The fractured nose is reduced in the waj alreadj described
and depending on the predominant d splacement lateral or

MAMLLO FACIAL INJURIES 277

backwards a plaster of Paris splint or a through and through
suture may be the appropriate fixation

Where there has been a longitudinal fracture of the palate the
maxillary cap splint is made in. two parts with attachments for a
locking bar (see page 259) which is applied after reduction

The wires from maxilla to mandible proudmg accessory
fixation can safely be removed in 4 weeks Depending on the
clinical assessment of union the attachment to the head cap is
remo\ ed simultaneously or retained for a further 2 weeks

Fractures of maxilla and mandible

The principle of reducing the fractured bone on to the un
fractured cannot be applied straight away when maxilla and
mandible are both fractured and steps must be taken to get the
mandible into a reduced and rigid single unit on to which the
maxilla can be reduced This usual!} means the use of inter-
osseous wiring to fix the fracture or fractures of mandible in an
accurately reduced position Reduction of the maxilla and
fixation to mandible and head cap can then proceed m the usual
waj

BIBLIOGRAPHY

Dawson R L G & r ordyce G L (1953) Complex fractures of
the middle third of the face and their early treatment Brit J Surg
4 i> 254

Fm \\ k & U ard T (1936) Tl e Dental Treah eut of Maxilla facial
Injuries 2nd Ed Oxford Blackwell Scientific Publications

Lew in \\ (1954) Cerebrospinal fluid rhinorrhoea in closed head

injuries Brtt J Surg 42, 1

INDEX

Bold type denotes illustrations on pages apart from those containing
the textual reference

A

Anal Assure use of split skin graft
>74 >75

Anal fistula use of split skin graft 174
175

Anal stenosis use of split skin graft
174 *75

Anal surgerv use of split skin graft
174 *75

Arch wiring 33 7

Avulsion injuries — see Skin loss
traumatic

B

Barrel bandage 236
Breast cancer skin coter tn t“3
Bonj trauma — re bkin coter bonv
trauma in
Bums t47

C

Cap splinting 258 259
Cerebro-spinal rhinorrhoea 239 240
Cetrimide use of 1 8
Cheek repair of 132, 16S 171
Chlorhexidine use of 18 86
Cleland s ligaments 2t6 218
Cross arm flaps — see Flaps types
cross arm

Cross finger flaps — tec Haps t'pes
cross finger

Cross leg flaps — see Flaps types
cross leg

Crushing injuries hand of — see In
juries hand of crushing
Cutting injuries hand of — see In
juries hand of cutting

D

Decubitus ulcers — see Pressure sores
Demoting injuries
hand of — see Injuries hand of
de gloving

limbs of — see Skin loss traumatic
limbs
Detaj, 104 106
physiological 106
surgical so 3 106

Dermatome

drum — see Drum dermatome
electric — see Flectric dermatome
Direct flap 118 e( seq
dela\ use of pj
diusion of flap 131 123
immohil sat on 124 127
lower limb in i’6
upper limb in 124 121;
joint stiffness m 127 r»8
lower limb — see Flaps tv pes cross
leg

plaster of Paris prefabricated 126
127

raw areas asoidanccof 120 I2X
sepsis elimination of 107
upper limb use in i->3
Dissecting forceps 21 23
Adson 22, 23
Gillies 22, 23
Me Indoe 22, 23
Dog ear 31
excision of 31

failure to excise result of 31 32
rotation flap in 139
transposed flap in 139
Donor areas

split skin graft 65
grafting of 78
healing of 76 77
care of 77 78
whole skin graft
direct suture of 63
grafting of 63
Drum dermatome 72-75
graft cutting 73, “4
graft thickness 74
indications for use 72
lubrication 74
mode of use 72 73
use of lacquer 74 7J
remotal of graft 75

E

Ear 168 170 272, 173
excision

partial 170 172, 173
total *67 *69, *72, 173
prosthesis use of X72

279

280 fundamental techniques of plastic surcert

Ear (contd )

repair, methods of, 168, 170, 172,

Ectropion, ejelids, of 229
correction of, 229 232
diffuse, 229
localised, 229

Electric dermatome, 75. 7&
advantages, 75, 76
burns, use in, 76
disadvantages, 75
mode of use, 7s, 76
Exposed grafting, 89-93
E\c injuries, 240
Ejelet wiring, 256, 257
Ejehds,

ectropion of — see Ectropion, ejelids,
of

flaps use of, 232-233
glabellar, 169, 235
temporal, 234, 235
upper eveltd, 233, 23s
injuries — see Injuries, cvelids, of
grafting, method of,
flavine wool using, 230
SiTFNT, using 230-232
grafts,

preparation for, 227-230
tvpes, 227. 228
use of, 227 233
post operative care, 232

F

Finger-tip injuries — see Injuries,

fing'r-tip, of.

Flaps,

care of, 107. 108
definition, 95
difference from graft, 95
effect of,

haematoma, 107, it6
kinking, 102, 103
oedema, 103
tension, 102, 103

haematoma, effect of — see Flaps,
effect of haematoma
head and neck, of, 139 el seq
carrier segment, 142
planning, 141, >42
seconder) defect, 141
supra-orbnal, 140, 141, 170
temporal, 140, 167. 234
transfer, 142
immobilisation, 124-127
joint stiffness m, 127, 128
kinking, effect of— fee Flaps, effect
of kinking

neck, of — see Flaps, head and neck of

Flaps (contd )
necrosis of,

clinical picture, 103, 104

prevention,

detav , b) , 105, 106
flap care, h>, 107, 108
initial design, b\, J04
treatment of, 108, 109
neuroca'cuhr island, 200, zoi
oedema, effect of — #ee Flips, effect
of oedema
planning of,
deciding type, 96-9S
defining defect, 9 (>, 97
in reverse, 99 100, 141, 142
planning transfer, 99 101
site of defect, 9S
size of defect, 98
time factor, 98, 99
ravv areas, avoidance of,
split skin graft, use of, 120, til,
199, 215, 2x6, 217
irap-door, u<e of, 120, 13X
sepsis, elimination of, 107
tension, effect of — see naps, effect
of tension

t>pes,

cross-arm, 98, 199, 212, 214, 215
cross-finger, 98, 216-219
cross leg, 98. »23, 124
cheek, *3*. >68. 17*
direct— me Direct JUp
ejelid, 232-235
fan, 163, 164

forehead, 140. 141, 165. **7. 234
glabellar, 166, 269, 235
hp switch, i6t, 162
lower lip, 165.
naso labial, 168
rotation— fee flotation flips
temporal, 140. J&7. 234
thenar, 219. 220

transposed — ice Transposed flaps
tube pedicle — fee Tube pedicle
upper lip, 165, 167
use in,

bonv trauma, 182 185
hand surged , 210 220
neoplasia of head and neck, 157-

ncoplasu of skin, 156
nerve injuries, 185
non -paraplegics 186
osteomicluis. 185
paraplegic*, 1 86-192
plantar wans t76 178
radrodcrrntlitu, 154 15**
radionecfO s,< . *54-*5**
tendon injuries , 185
ulcers, ischul, 190 192

iNDEX

281

Flaps, use in (contd )

ulcers, sacral, 1S7, 188, 189
ulcers, trochanteric, 188, 189, 190
vascular adjustments, rot, 102
vascular aspects, 10 1 et seq.
vascular changes, toi, 103
vascular insufficiency,, 102, 103
tiabihu of, 15, 104
flat me wool,
ejehd grafts, use in, 230
grafts, use in 83
preparation of, 83

Forceps, dissecting — see Dissecting I
forceps !

Fractures,
alteolar, 24

linger — see Injuries, hand, of,

associated fracture
malar, of, 242, 243, 248 250, 255,
264-270

antral reduction, 268, 269
arch fracture, 242, 243
clinical picture, 248 250
comminuted fracture, 242, 243
diplopia in, 249, 270
simple fracture, 242
temporal reduction, 266 268
X-ray examination, 257
mandible, of, 244, 245, 251, 252,

25S, 274, 275
clinical picture, 251, 252
displacements, 245 246
examination for, 231, 252
sites, 244, 245
angle, 244
body, 244
condole, 244. 2 47
symphysis, 244
treatment, 274, 275
maxilla, 245, 247, 249, 252-254, 255,
275-277-

clinical picture, 252-254
diagnosis, 252, 255
patterns of fracture, 245, 247, 249
treatment, 275 277
types, 245 2 47. 249
X-ra\ examination, 255
maxilla and mandible, 277
middle third, of, 241, 247, 249,
252-235 275. 276
clinical picture, 252 254
components, 248, 249, 253
diagnosis, 252-255
examination for, 254
treatment, 275“ 2 77
X-rav examination, 255
nose, of, 243, 244, 251,255,270 274
clinical picture, 251
septal injury in, 243, 244
treatment, 270-274

Fractures, nose, of (contd)
tvpes, 243. 244. 270 272
X-ray examination, 255
skin loss in, 181-185
Free slan graft, 50 et seq , and see
Split skin graft and Whole
skin graft

l application of graft, So 82, 87, 8S
bridging phenomenon, 57
dressing of, 83, 87, 88
effect of haematoma, 55
factors in take, 53 56
graftable areas, 53, 54
influence of immobility, 56
influence of pressure, 56
influence of recipient site, 53, 54
‘ physiological fixation’ , 55, 80
pressure dressing 83, SS
recipient area, 78 et seq.
take, process of 52, 53
ungraftable areas, 53, 54
vascularisation of, 52, 53

G

Glabellar flap, 166, 169, 235
Granulating area, 84-89
antibiotics use of, 86
bacterial flora, 85, 86
B proteus, 86
Bact. coh, 86
Ps. pyoiyaneo, 85
Staph, aurcits 86
Str pyoqenes, 85
clinical appearance, 84
clinical assessment, 84
graft, apphcttion of, 87 89
| graft preparing for, 86, 87

. pressure, use of, 87

stamp grafts, use of, 8S, 89
unsatisfactory, t\pes, 84
Gravitational ulcers — see Varicose

ulceration

Gunning splints, 260, 261

H

Hand injuries — see Injuries, hand
Haematoma,

free skin grafts, in, 53, 54, 55
I pressure, pretention b\, 32
tube pedicles, in 1 16
Hand surgert ,

defects distal to webs, 214 220
cross-arm flaps, use of, 214, 215
cross-finger flaps, use of, 216-219
distant flaps, use of, 212, 2x3, 214
local flaps, use of. 214-220
thenar flaps, use of, 219, 220
defects of scteral fingers, 213, 214
defects proximal to webs, 210-212

2§2 rUNDAMLNTAL TrCHMQUrs

Hand surgerv, defects proximal to
n cbs (contd )

cross arm flaps, use of, 212
direct flaps use of, 123, zil, :i;
transposed flaps, use of, 210 212
tube pedicles use of, 210 212
direct flaps, use of, 125, zti, 215
dressings graft, of 209
dressings, post-operative, 221
flaps, use of, 210 220
free skin grafts use of, 208 209
local flaps, use of, 210 212
oedema preventionof, 197, 198, 221
plaster of Pins use of, 222
post operate e care 221 222
split skin grafts, use of 208, 209
themr flaps use of, 219 220
transposed flips, use of, 210 212
\v hole skin grafts, use of, 209
Z-plistv use of 206 2 08
central Anger «cars, in, 206
contractures, in 206 207
palmar scars, in 206 208
web deepening in, 206, 207, 208
Head cap 263, 264, 265, 273, 274
Hihitane, use of, 18 86
Hidrademtis, 178, 179

excision and grafting, i;8, 179
pathological features, 178, 179
Hook skin, 21, 22, 26
Humbv knife, 65-73
lubrication of, 68
preparation of, 68
setting of, 68, 69
Hypertrophic scirx — see Keloids

Injuries, degloung — see Skin loss,
traumatic, limbs
Injuries evelids, of, 224-227
anatomicnl considerations, 224-226
conjunctiva in, 226
landmarks in, 224-226
lid margin in, 225, 226
palpebral ligaments m, 226, 227
reconstitution, 224
tarsal plates in, 226
tear duct, reconstitution of, 224,
225

Injuries, finger -tip, of, 200-202
clinical feilures, 200-202
flips, indication* for, 200 202
grafts, indications for, 200 202
partial avulsion, 202
proximal amputation, use of, 200
types, 200 202
Injuries, hand, of
associated fracture, 202, 203
cutting and slicing, 195*

or piavjic si'bofry

Injuries, band, of cutting and slicing
(eontd )

assessment, 105
clinical examination , 195
flaps, indications for, 195, 196
split-skin grafts, use of, 195, 196
crushing, 196-198

pathological features, 196
post-operative core, 197, 198
suture, use of, 197
degloung, njS, 200
assessment of, 198
clinical examination in, 198
split skin grafts in, 198
tourniquet test tn. 198
skin coicr in, 194, «95
Injuries, mixillo-fjcul, 236 el seq„ see
also fractures of separate
complexes

associated injuries. 237 240
chest injuries, 240
cranial injuries, 238 240
eye injuries, 240
facial soft tissue injuries. 23S
eerebro-spinal rlnnorrhoea, 239, 240
clinical picture, 24S 254
carl) care, 236 237
methods of reduction and fixation,

255 2f’4

patterns of injury, 24° *4 S
tracheotome, use in, 237*^4°
treatment, 264-277
X-ra\ examination 2jj
Injuries, nerves, of — see Skin cover,
nerve injuries, tn

Injuries, tendons, of —set Skin cover,
tendon injuries, in

Injuries, thumb, of, 19^1 >!>$• >99.
201

Instruments, surgical,

drum dermatome — see Wrum
dermatome

electric dermatome — see Heetnc
dermatome

forceps, dissecting, 22, 23
Adson, 22, 23
Cullies, 22, 23
Mclmloe, 22, 23
knife,

Plair, 65, 66
Ilumby, 65 66
needles. 2 1
needle holders,

Cullies, 2i, 22
Ktlner, r 1 , 22
scissors, 23
skin hook. 21, 22
Interosseous w irmc, 262, 263
Ischial ulcers, 190 192
blind flap, 200, 201

INDEX

J

Joint stiffness jn flap usage, 127, 128
R

Keloids, 34-39
ACTH, use of, is
ace, influence of, 35
clinical picture, 35
cortisone, use of, 35
line of election, 33
problem in practice, 36 39
race, influence of, 35
sex, influence of, 35
site, influence of, 35
surgery , use of, 39
time, efteci of, 35
treatment, 35, 36
X-ravs, u«e of 36, 39

L

Langer’a lines, 4
Lateral line of finger, 204, 206
Lines of election, 4, 3
face, m, 4
flexures, in, 4
Lip repairs, 159 166
full-thickness defect, 159 164 165,

1 66

direct closure, b>, 150 169
fan flap, by, 163 166
lip-switch flap, by, tfit, 162
partial thickness defect, 165, 167,
16S

forehead flaps, by, 16s, 167
neck flaps, by, 165, 168 ,

Lip shave, 160, 161

M

Malar fracture, see Fractures, malar, of
Mastectomy , use of spht-skin graft |
fol’owing, 173

Materials, suture — see Suture materials
Maxilla, fracture of — see Fractures,
maxilla, of

Maxillo-facnl injuries - — see Injuries,
maxilto-facial
Methtcilhn, 86

Middle third fracture — see Fractures,
middle third, of

Middle third of face components, 241
N

Nasal fractures — see Fractures, nose,
of

Ncedtes, 2t

Neoplasia of head and neck — see Skin
loss, post -surgical, neoplasia,
head and neck

283

Neoplasia of skin — see Skin loss,
post-surgical, neoplasia, skin
Nerve miuries — see Skin cover, nerve
miuries, in

Neurovascular island flap, 200, 201
Nose fracture — see Fractures, nose, of
Nose, methods of repair, 140, 141, 169

O

I Osteomvelitis, skin cover in, 185

r

Paraplegics — see Pressure sores para-
plegics, in

I Pedicle — see lube pedicle

‘Physiological fixation *, 55, 56, 80
I Placing the scar— see Scars, placing of
j Planning of flip — see I lap planning
■ Plantar warts, 176 »7S
' flaps, use of, 177

grafts u«c of, 176, 177
marginal recurrence, 176, 177
Pressure dressings,

grafts, use in, 83, 84 87, 88
wounds, use in, 32
Pressure sores
non-piraplegics, in, 186
flaps, use of, 186
grafts, use of. 186
paraplegics, in,

ischial ulcers, 190 192
sacral ulcers, 187 18S 189
treatment iSh tqz
trochanteric ulcers, 188-190
Provtheses, 140, 158, 172, 173

R

Radiodermatitis — see Skin loss post-
radiational

Radionecrosis — see Skin loss post-
radiational

Recipient area, 7S et seq.
surgically clean, 7S-S4
haemostasis 78 So

adrenaline, use of, 78, 79
chin syringe use of 80
ligatures, use of, 79
marginal bleeders, 79
nosadrtsrsiine, u«e of 7S 79
orange stick use of, 80
sucker, use of, 79
time, use of 79

vaso-constrictors use of 78 79
preparation 78-80
Reverse planning, 99, 100, 141, 142
Rotation flaps,

back-cut, closure of, 138 139
back cut, use of, 133, 138

2S4 FU:\DA 1 IENTAL TECHNIQUTS Or PLASTIC SCBCFB1

Rotation Paps (contd)
design of, 134, 135, *37-139
dog-ear in, 138
planning of 134.135
principles, 131-133
tascular limitations, 174

S

Sacra! ulcers, 167, 1S8, 189
Saddle use of, 260, 261
Scalp avulsion — see Skin loss,
traumatic, scatn
Scar length, 31

Scars, lines of election for — see I ines
of election
Scars placing of,
hand in ->04 206
hair line, inside, 5
line of election, in, $
natural junction, in, 5
natural line, in, 5
wrinkle m s
Scars, stretching of, 7
Scars, tattooed — see T nttooed sorting
Scissors, 23

Scrotum, avulsion of — see Skin loss,
traumatic, scrotum
Septal haemotoma, 251, 273
Septal injur), 243, 244, 271, 272
Skin, avulsion of — see Skin loss,
traumatic, limbs and In-
juries, hand, of, degloung
Skin cotcr,

bon> trauma in, 181-185
cross-leg flap 183
direct flap, 182, 183
distant flip 182, 183
local flap, 182
primart suture, iSr
hand injurx in — see Injuries, hand,
of

nersc injury, in, 185
osteomjelitis, in, tS?
tendon injury, in, 185
Skin heating of, 3
Skin hook — see Hook, skin
Skin loss infective, 15b
grafting criteria, 1 ch
split skm graft, use of, 156
Skin loss post-surgical, 156 el *0/.
anal surgcr> , in, « 74 « 75
breast cancer, in 173
grautattonal ulcer, in, 175. 176
hidradcmtis, in, 17S, 179
neoplasia, head arid neck,
flaps, use of, 159
grafts, use of, 157. 158
prostheses, use of, 158, *72, «7J
repairs — see Anatomical Region

Skin-loss, post -surgical (mnhi )
neophsia, skin,
flaps, me of, 157
grafts, use nf, 157
Skm loss, post-rad lational, 154-156
biopst , use of, 1 56
car, m, 154
fljps, use of, 154
grafts, me of, 154
mastectomy scar, in, 154
oral cant), in, 154
pathological factors, 154. 156
sequcstrectomt, 154, 156
treatment, 154, 156
Skin loss, traumatic,
limbs, of, iso 1 S3
a tubed skin, use of, 153
bonv mjurt in, 153. 181-185
clinical tests, 152
joint injuries in, 153, 181-185
mechanism, (5*
slough excision, 152
treatment, 152, 153
grafts, use of, 152, 153
tourniquet test, 152
ttpes, « si
scrotum, of, 153
scalp, of, 147-tso
complete, 148-150
grafts, use of, 148, 149, 150
mechanism, 147, 148
partial, 148

pcricrani il lots, 148, 150
subsequent care, ISO
treatment, 148, 149, 150
Skin neoplasia— see Skm Joss, post-
surgical, neoplasia, skm
•'kin sterilisation, 17, «8
Skm suturing, 23, 24-2S
instrumental tting, 23
atraumatic handling, 24, 26
Slicing injuries — ter Injuries, hind,
of, cutting and dicing
Slough removal. 86, 87
cusol, use of, 86, 87
phosphoric acid, use of. 87
pyrusieacid, use of, 87
Mreptodomase, use of, 67
streptokinase, me of, 87
trypsin, U«c of, 87
surgical, 86, 87

electric dermatome, l*> , 87
Ilumbv knife, hi, 87
Split skm grafts, 64 el set]., and irf clut
I ree skin grafts
anal surgery, use in, t“4 <75
application of, 8i, 82,87, 88
assessment of thickness, 70 72
bleeding pattern, b\. 7°, 7*
tran'luccncs of graft, l'», 70. 7*

INDEX

SpliC-skm grafts (canid )
bony trauma, use in, 182-185
definition, 51

degloving iniurtcs, use in, 152, *53
donor area — fee Donor areas spbt-
skin graft
donor sites, 65
placing of arm, 67, 68
placing of leg, 66, 67
ear, use in, 172, 173
exposed method, 69, 91, 92
eyelids, use m, 227-232
forehead, use in, 148, 149
gravitational ulcer, use in 175,

176

hand surgery , use in, 208 209
head and neck neoplasia, use in 1 57
159

hid rad nut is, use in, 178, 179
hjiluromdase, use of, 93
infective skin loss, use in, 156
instruments for cutting,

Blair kmfe 65, 66
drum dermatome —see Prom
dermatome

electric dermatome — see Electric
dermatome

Humby knife — see Humby knife
local anaesthesia, u«e of, 93
mastectomv, in, 173
properties, 51
radiodermatitis, in, 154
radionecrosis, in, 154
refrigeration of skin, 93
scalp avulsion, use in, 148-150
scrotal avulsion, use in, 153
skin neoplasia, u«e in, 157, 15#
stamp grafts — fee Stamp grafts
storage of, 93
suturing of, 81 82
Vies of 64
wounds, use in, 14
varicose ulcer, use m, 175 *7^

Stamp grafts, 8S, 89, 90
advantages, 88, 89
disadvantages, 88, 89
indications for use, 89
Sterilisation, skin of 17. 18
Stitchcraft, 18 el seq.

STENT, use of, 230 2 32

Surgical imqnMfteMs — *** 3?&Vsvv- '•

merits, surgical
Suture marks, 14 15, 16
Suture materials, iB, 20 2t
cat-gut, 20
linen, so
mlon, at
silk, 29

silk- worm gut, 21
stainless steel, 20

Sutures — see Wounds, suture of
Sutures, removal of, 33, 34

T

Tattooed scarring, 14, 15
prevention of, 14

Tendon injuries — see Skin cover,
I tendon injury, in

1 Three point suture, 29, 30
| Thumb injuries, 196, 19S, *99, 201
Tourniquet test, 152
I hand intunes, use in, 198
I Tracbeotomv, 237-240
Transposed flaps,
back cut in, 137
design of, 134-137
1 dog ear in, 139
I planning of, 134 136
principles, 133, 134
vascular limitations of, 134
Trap-door scarring, treatment, 9 it
Trochanteric ulcers, 188-190
lube pedicle, 109, et seq , see also
Flaps

abdominal, 110, xix
acromto pectoral, 109, 110
circulation tests, 115, 116
double attachment, 117, 118
haematoma, effect of, 116
interval care of 115
raising of, uo itz
transferor! carrier, 116, 117
transfer to earner, 112-114
waltzing, 1 1 8, 119
Tumours,

influence of pathology on treatment,
»S6 i59

head and neck, in 157 159
skin, in, 156, 157

U

Ulcers, decubitus — set Pressure sores
Undercutting, 18, 19
face, use in, 18, 19
limbs, use in, 18, X9
sc-ilp, use in, ib, 19
tension, use in eliminating, 18
trunk use in, 18, 19
wound preparation, use in, 18

V

Varicose ulceration, 175, 176
excision and grafting, 175, 176
grafting of ulcer, 175
\ nbility of flaps, assessment, 15

sS6

FLNDAMFSTAL TCCIIMQLC' OF FL\^Tl( *>LK(.m

W

I

Uarts phmar~ see I Ian tar warn
W hole skin jrr»ft 47 n teq tee oho
l rcc akin craft
a pp! cation of craft 8t

cuttnuj Kraft 6* 63 64 I

definition 51

donor site* 5 60 |

ahdonen 60
antccubital fosta jg 60
care of 6a
Rroin 59 60
post auricular j S
supraclaiicular 59
thich 60

dre sink of craft 83 84
e el dt use in * .j*
hand surcert use in .0 )
method of use (>o 6.
ptttern mak nc of (1
pattern materia!* 60
plxruar watts use in fft I

properties 51 s" I

scrota! avulsion use in 153
tutunni 81

tattoo nc matth ng po nts 6t 6* I
Wounds .

care of 3 et teq
errors in treatment 14 tj 16
facial 14
hcalinj, of 3
match np 14 ’24
mctlodof 14

results of fa lure ty 16 !

poM-opcrat sc cate 3 34

post -opera 1 1 vc support 34
preparat on of 12 tS 1

conservative tre-tment 13 14 j
dirt ren sal of 12
excision 13
non traumai ed 12
tan xxd scarf nc 14 *5 •

traumatised 12 14
undercut! nj* editc 18 19 j

stretching of J

prrseni on 1 ) 18 ’S I

cat pit 28

continuous intradentsal jR
t n lercuttmj, H
/ p!a t\ 6

skin tnueo a! suture 14
split skin craft use of 14
suture remosal ’4
Wounds suture of T .S
<!oc-ear leelXc-ear
tec! niquc 23 34 »8

pretention of inters ion ’5 sf
three ]-*>int suture .9 JO

W ounds suture of (eon! I >
types of 24 8

continuous S
Uin-ft" 27
wtra iermal s- t S
I oter and 0 er 27, .8

1 interrupted '4 .8

1 cat cut 27 x

I simple loop 34 .3

xert cal mattress .< 5^ ;
Wound trns ion f t8
1 effect of ft
1 pretention tS

I v undercut! ni. if
1 hy / plast) ( j}>

Wounds tt pc of dress it 3- j\

) Wounds tub I tv assessment it

/-plast t r 12 49 4)
ancle sire effect of 4* 43
hasic manocimc 40 41 4a
construct n of 4 41
contracture* u*e n 40-4 1
defn t n 49
flam

Woof supplt of 48 4 1
ntcrosM of 4S

pretention of neerotu 48 4/
hand aurgert in— tee Hands tpe
J pit tt use of
lateral trn« on d Ifut on of 44
Jmblcigt! eifeel t f 41
muUipte 44 47 48
coni nuous 4-
parallcl 47
sket 4“ 48
dBCottintu us 47
c olution of 47

factors tn 44 4- 4S
plann nt 4J 4- 4R
select tort of llip* 4t
scan u*r in ( 1?
carry tW - 8

p! emc / 1 1
1 «r> ttauma

r I n

of *

tention red >tfi}*ut n- <
trap door scar n jo
tsout d lefitl e jual atiori of 7
sac of 44

tensw n red ifntn non of 4
t! eorx of 49 44