Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Reconstructive Surgery in the Tropics
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11.This is done only after complete release of any trismus is carried out.
Sometimes the fixation of the mandible preventing the opening of the
mouth is secondary to scar contracture. Other times there may be bony
growth joining the mandible to the maxilla.
Sometimes the condyle of the mandible is fused to the temporal bone of the
temporomandibular joint. The scar and bony overgrowth can be resected. Another
solution is a resection of a 1 cm segment of mandible ramus so that a false joint will
develop allowing movement.
At other times a 2 cm section of the zygomatic arch needs to be resected and the
temporalis muscle taken from the outer surface of the temporal bone through a
longitudinal incision and placed as a lining of the maxilla or mandible to prevent
recurrent trismus and bony reapproximation.
If placement of an endotracheal tube is not possible at this point, a planned
tracheotomy is done so that a good airway can be maintained during surgery and for
the first five postoperative days. A parent or friend can be taught to give good postoperative
tracheotomy care when other staff are not available.
12.The Deltopectoral flap is then sutured in place without tension and the
proximal portion is tubed or skin grafted as indicated.
13.Large sutures of nylon are taken between the face and neck to encourage
the patient to refrain from pulling on the flap by head and neck movement.
Elbow splints are used until the patient is fully awake.
14.After two weeks the patient is encouraged to compress the proximal
pedicled flap between the thumb and fingers to encourage distal vascular
ingrowth. By blocking the principal blood supply for short time periods
of 30 seconds repeatedly, vessels from the surrounding area of the in-planted
flap are stimulated to help out.
15.The flap can be safely divided under I.V. ketamine drip anesthesia at three
weeks
16.If the tubed pedicle is not needed in the recipient area, it can be replaced
in its original location.
17.The breast in women is only slightly elevated by this operation. This is
not to the extent of bothering or disturbing the patient who is always very
appreciative of the significant help given to his or her facial appearance.
Latissimus Dorsi Myocutaneus Flap (Figs. 27-29)
This flap can be used by taking the entire muscle with split thickness skin graft
applied to it or it can be taken with both the muscle and its overlying skin. It is based
on the thoracodorsal artery from the third portion of the axillary artery. The artery
is on the deep side of the muscle.
Its primary uses are for replacement of all the skin of a major portion of the neck
for treating burn contracture, chest wall coverage problems and breast or chest wall
reconstruction.
1. The operation is done under general endotracheal anesthesia in the lateral
position so that the latissimus dorsi donor site can be included in the
prepped area on the same side as the expected skin and tissue defect.
2. Split thickness skin grafts are removed from the thigh or thighs and expanded
to cover the entire donor back area from the lower scapula to the
iliac crest and from the midline of the back to the posterior axillary line.
3. The flap is elevated by marking and incising the skin overlying the latissimus
dorsi muscle en bloc and elevating this from the underlying tissues
without any shearing force between the skin and muscle.
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