Surgery and Healing in the Developing World - Dartmouth-Hitchcock
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Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Surgery and Healing in the Developing World - Dartmouth-Hitchcock Surgery and Healing in the Developing World - Dartmouth-Hitchcock

dartmouth.hitchcock.org
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21.06.2013 Views

Reconstructive Surgery in the Tropics 255 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. 26

26 256 Surgery and Healing in the Developing World Figure 29. Latissimus myocutaneous flap. Figure 27. Severe burn scar contracture right neck. Figure 28. Latissimus dorsi right back donor area 2 weeks after surgery. 4. This is achieved by hemostat held traction sutures which are sutured on the margin of both muscle and skin being elevated. 5. A subcutaneous pocket is developed that joins the donor area to the recipient area of the neck, chest or even portions of the face. 6. The branch of the thoracodorsal artery to the serratus anterior muscle is divided to extend the range of the flap to its new recipient area. 7. The latissimus dorsi myocutaneus flap is replaced while the recipient area is fully prepared.

26<br />

256 <strong>Surgery</strong> <strong>and</strong> <strong>Heal<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> Develop<strong>in</strong>g <strong>World</strong><br />

Figure 29. Latissimus myocutaneous flap.<br />

Figure 27. Severe burn scar contracture right neck.<br />

Figure 28. Latissimus dorsi right back donor area 2<br />

weeks after surgery.<br />

4. This is achieved by hemostat held traction sutures which are sutured on<br />

<strong>the</strong> marg<strong>in</strong> of both muscle <strong>and</strong> sk<strong>in</strong> be<strong>in</strong>g elevated.<br />

5. A subcutaneous pocket is developed that jo<strong>in</strong>s <strong>the</strong> donor area to <strong>the</strong> recipient<br />

area of <strong>the</strong> neck, chest or even portions of <strong>the</strong> face.<br />

6. The branch of <strong>the</strong> thoracodorsal artery to <strong>the</strong> serratus anterior muscle is<br />

divided to extend <strong>the</strong> range of <strong>the</strong> flap to its new recipient area.<br />

7. The latissimus dorsi myocutaneus flap is replaced while <strong>the</strong> recipient area<br />

is fully prepared.

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