Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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Reconstructive Surgery in the Tropics 265 Figure 43. Diagrammatic presentation of fascio-cutaneous flap from lateral aspect below knee for anterior upper tibial deep tissue loss. Figure 44. Fascio-cutaneous flap. Complete healing at 6 months. Injury was associated with bullet wound and fracture. Figure 45. Immediate fascio-cutaneous flap from lateral lower leg to defect in anterior lower leg with associated compound fracture of tibia and fibula. Figure 46. Fascio-cutaneous flap. Complete skin healing in the same patient at 1 month. 26
26 266 Surgery and Healing in the Developing World anterior and medial lower leg, which don’t respond to simpler treatment or when the patient refuses a cross-leg flap solution. The patient must agree to a slight thickness of the lower leg postoperatively. The rotation of the flap to the desired recipient area must be done without tension or twisting. It is released from its base only enough to make this possible. After 6 weeks the transferred pedicle can be, flattened or thinned, but only if less than one half of the surface area is done at a time. Lateral Fascio-Cutaneous Flap for the Same Leg This flap includes both the skin and subcutaneous tissue and the fascia overlying the muscle. It can be longer than two times its width. It is most frequently used to cover the lower tibia after an open fracture. One must be sure not to use this flap if these tissues have been damaged in any way by the trauma causing the fracture or tissue loss. It must be made one-third longer than you think is necessary for tension-free coverage of the defect. The donor area is skin grafted at the same time as the surgery. If the associated fracture is immobilized with external fixators, these will need to be placed in such a way as not to interfere with the transfer and placement of this fascio-cutaneous flap. It is the fastest and easiest way to cover a difficult area of the tibia where there is significant loss of skin. It is much easier and much less bloody than the use of the reverse soleus or gastrocnemius muscle flap of the lower leg. Becoming proficient with these flaps will mean that many more patients will regularly be assisted to improved function, appearance and health. It is hoped that you will bring much joy and relief to patients and their families by these operations Cleft Lip Repair (Figs. 47-56) 1. The anesthesia for children can be with ketamine. For adults, a local field-block anesthesia works well. 2. Measure the distance between the commisssure and cupid’s bow carefully preferably with calipers. 3. Mark this point so that both sides of the lip will be of equal length. 4. Measure the distance from the collumela to cupid’s bow on the normal side. This distance must be matched exactly in your repair of the cleft lip. 5. Make the markings for the incision as shown in the diagram. 6. Following Tennison’s technique of cleft lip repair: 7. Make the marking a to 2 exactly equal to a’ to 2' as pictured in Figure 55. 8. Make the marking 1 to 2 exactly equal to 1' to 2'. 9. 2' will fit into the notch between point a and 1 on the cleft side. 10.Make 1 to 3a equal to 1' to 2', which is also the same as 1' to 3' on the good lip side. 11.Make the incisions with a sharp knife without cutting the oral mucosa. 12.Make the incision in the lips between 3 and 4 and also 3', 2' and 4'. It is good to leave extra lip on the cleft lip side so that the area of the repair will have fullness. This prevents an indentation or ‘whistle’ deformity. 13.Make the incision at 45% to line 1 to 3 rather than at 90%. 14.Suture the mucosa together starting at the nostril with 5-0 chromic and progress to the posterior lip margin. 15.Undermine the margin of the nose on the cleft side beneath the muscles anterior to the mucosa until the nose can be brought towards the midline. 16.Measure the opening and circumference of the good nostril and make sure the cleft lip nostril will have a similar circumference.
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Surgery and Healing in the Developi
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Contents Foreword .................
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25. Dentistry .....................
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Editor Contributors Harold P. Adolp
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Foreword Surgery and Healing in the
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“poor, but modern”, as for exam
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There may be at least one considera
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It is that higher accountability th
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1 2 Surgery and Healing in the Deve
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CHAPTER 2 Surgery in Developing Cou
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2 10 Surgery and Healing in the Dev
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CHAPTER 4 International Surgical Ed
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CHAPTER 9 Lab-in-a-Suitcase: Saving
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10 72 Surgery and Healing in the De
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CHAPTER 12 Communication in the Thi
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CHAPTER 13 Anesthesia in the Third
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13 100 Surgery and Healing in the D
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CHAPTER 15 Basic Obstetrics and Obs
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CHAPTER 16 Pointers for American Su
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CHAPTER 20 Chronic Pyogenic Osteomy
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CHAPTER 23 Cleft Lip and Palate Sur
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Metabolic Maladaptation 315 Biologi
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Metabolic Maladaptation 317 from io
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Metabolic Maladaptation 319 25. Lon
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CHAPTER 1 CHAPTER 30 Nutrition and
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Nutrition and Development in Africa
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CHAPTER 1 CHAPTER 31 Uterine Ruptur
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Uterine Ruptures in Rural Zaire Tab
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Uterine Ruptures in Rural Zaire 329
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CHAPTER 1 CHAPTER 32 Vesicovaginal
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Vesicovaginal Fistula in Democratic
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CHAPTER 1 CHAPTER 33 Ophthalmology
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Ophthalmology Figure 2. Refractive
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Ophthalmology Figure 4. A tonometer
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Ophthalmology 341 ml of 40 mg/ml IV
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Ophthalmology Figure 6. Axis determ
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Ophthalmology 345 thalmic set prepa
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Ophthalmology 347 Procedures Region
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Accommodating Deficits in Material
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Abscesses and Other Infections Trea
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CHAPTER 1 CHAPTER 36 Surgical Train
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Surgical Training of Nurses for Rur
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Training of Medical Assitants in Mo
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CHAPTER 1 CHAPTER 38 Training Surge
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Training Surgeons in the Developing
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Mobile Surgery Figure 1. 405 of tec
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Mobile Surgery Figure 3. 407 Childr
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Mobile Surgery 409 We have realized
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CHAPTER 1 CHAPTER 40 Public Health
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Public Health Problems on Burma Fro
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Medical Adventures in the Nigerian
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CHAPTER 1 CHAPTER 42 Wanted Glenn G
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Wanted 431 Studies Center (//www.am
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Wanted 433 MacArthur (The John D. a
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Wanted 435 most pathologic presenta
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Wanted 437 “outliers” in the he
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World Health 439 challenge: name fo
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CHAPTER 1 CHAPTER 44 Treating Other
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Treating Others: Human Sciences in
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Treating Others: Human Sciences in
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CHAPTER 1 CHAPTER 45 The Impact of
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The Impact of a Volunteer Medical M
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CHAPTER 1 CHAPTER 46 Field Notes on
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Field Notes on a Typical Day in a H
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Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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