Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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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.