Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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258 Surgery and Healing in the Developing World
A B
Figure 31. Epigastric flap. A) Anterior view of right superficial epigastric abdominal flap
at 3 weeks with right hand overliying lower abdomen. B) Superior and lateral view of
epigastric flap just before division.
2. The abdominal donor area is closed with interrupted nylon mattress sutures
over an interrupted Scarpa’s fascia closure using absorbable suture.
3. The injured hand is then placed comfortably where the flap will cover the
defect without tension.
4. Large nylon sutures are used between the forearm and abdominal wall to
limit movement of the injured hand in relation to the axial pattern flap
based on the superficial epigastric artery.
5. The flap can be divided after three weeks.
The Groin Flap (Fig. 32)
This flap is categorized as an axial pattern flap and is based on the superficial
circumflex iliac artery, which passes laterally and inferior to the inguinal ligament
and laterally toward the anterior superior iliac spine. This flap is useful for coverage
of various portions of the hand. It’s principle advantage is its comfort for the patient.
A portion of the iliac crest can be carried with the flap to replace a lost thumb. The
skin and subcutaneous tissues are normally thin and not bulky so that hand coverage
including portions of the fingers is quite feasible. Great care is necessary as one
comes over the proximal sartorius muscle where the superficial circumflex artery can
be first visualized. The flap is divided at 3 weeks.
The Paravulvar Flap (Figs. 33-38)
These flaps are based on vessels coming from the pudental artery and vein lateral
to the rectum and anus. They are used most frequently for repair of vesicovaginal
fistula when the anterior vaginal wall is inadequate. Also over a neo-urethral repair
when the urethra is nonexistent and must be reconstructed or when the vaginal
opening is stenotic from trauma, infection and or previous vulvectomies. It can
easily be used to make a neovagina or enlarge the vaginal orifice.
Underlying the vulva is fatty tissue that can be used separately over a two layer
interrupted vesicovaginal fistula repair before the anterior vaginal wall is closed.
This increases the chance of successful repair. This is secured through a longitudinal