Surgery and Healing in the Developing World - Dartmouth-Hitchcock

26
250 Surgery and Healing in the Developing World
Place the chisel across the crest of the ileum 1 cm from the anterior superior
iliac spine. The chisel should pass deeply into the bone for 3 cm. Place the
chisel across the iliac crest again 6 cm farther along the iliac crest. The
chisel should penetrate 3 cm into the bone. Join the two vertical incisions
on both the inner and outer surface of the ileum.
The thin presenting and most superficial portion nearest the anterior superior
iliac spine is used for attachment to the nasal bone. The thicker lower
limb of the L shaped bone graft farthest from the iliac spine joins to the
maxilla in the midline where the nasal septum would normally be. Smaller
sections of bone from the bone graft taken from the iliac crest are placed
laterally to support the flare of the nares. This is all on overlay over the
turned in flaps used for the very important inside lining of the nose. Without
this inside lining, the bone graft will become infected and disappear.
The nose, without the bone support, will shrink and shrivel up. It will no
longer keep a normal nose profile.
7. The forehead flap is elevated.
A. Use pressure on each side of the incision. Start at the distal portion of the
flap and move proximally. Place clamps on the multiple bleeders on the
nonflap side or use a continuous absorbable running suture for hemostasis
along the nonflap incision margin. The running suture also decreases the
forehead area requiring grafting. Place three sutures in the distal flap margin
to atraumatically elevate the flap. This approximates the fascia and subcutaneous
tissue with the skin to avoid small vessel injury.
B. Bevel this incision away from the flap to avoid a prominent demarcation of
skin graft with the scalp skin margin and to avoid injury to vessels supporting
the flap skin.
C. Take special care not to damage the periosteum over the frontal bone as
elevation of the flap is continued in an easily seen and developed plane just
above this.
D. If more flap length is needed the incision can be continued proximally over
the middle of the temporal muscle in the scalp hair and onto the face in
front of the tragus of the ear.
E. The flap can be covered with a moist saline sponge after folding it back over
a gauze roll to avoid kinking while the operation progresses.
F. Secure good hemostasis with a continuous running suture, being careful
not to injure the vessels supplying blood to the forehead periosteum.
G. Place the thick split thickness skin graft over the forehead and suture it in
place.
H. A sterile wet dressing will hold this in place while the rest of the operation
is done.
I. Bilateral nasolabial flaps are turned over on themselves. These are based
superiorly and swung superiorly. Dermal and skin sutures close the nasolabial
donor areas.
J. A superior turnover flap is made from the remaining skin in the midline
above the future nose. Leave 1/3 of this undissected proximally for adequate
flap circulation. Elevate 2/3 of the total flap distance for turning
over for the inner nasal lining.