Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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276 Surgery and Healing in the Developing World
Gram stain can be taken, infected sutures removed, and collections of pus or hematomas
drained.
C. Necrosis of the distal flap.
If care is taken to follow the directions for each flap elevation, distal flap necrosis
and loss should not happen. Other tips to follow should include:
a. Avoid stretching and tightness. Don’t reach too far from the site of
origin.
b. Use of large sutures near the flap to discourage patient movement
during the healing process.
c. Use of a skin graft on the back and under surface of a flap if tubing the
flap seems tight.
d. Careful dissection with the blunt-nosed dissecting scissors in the direction
of the vessels being saved.
e. Elevation of local flaps, leaving one-third of the length unelevated and
undissected.
f. Avoiding tight peripheral sutures when attaching the flap to its new
location.
g. Sutures from recipient site to subcuticular layer of the flap then back
to recipient skin can make a significant difference in distal blood supply.
h. Making sure that a wide surface of attachment is present for the newly
placed flap.
D. Failure of flap attachment to the new site.
The ways to avoid this problem are as follows: Increase the surface of attachment
for the flap by the use of well-vascularized turn over flaps.
It is good to have a second and third alternative flap plan that can be adopted if
the first plan fails. An excellent third flap is the biceps flap elevated from the shoulder
towards the anticubital space. Even though it is an antegrade flap its vasculature
is excellent. Early surgeons used this flap for nose replacement. It’s lower 10 cm
portion is raised, and a skin graft is placed on its under surface as well as the upper
arm. Further elevation is done three weeks later for a total length of 20 cm.
E. Airway Obstruction.
The surgeon must take a major role in the anesthesia in the tropical setting.
Packing used around endotracheal tubes for operations about the mouth is a source
of problems even when long black stay sutures are used to mark them. With trismus
and the inability to open the mouth, airway obstruction can be a major problem.
Don’t hesitate to use a tracheotomy for 5 days. Associate this with good teaching to
the patient’s family members and the on-duty nursing and auxiliary staff. It is possible
to operatively remove the cause of trismus before intubation of the patient
while an I.V. infusion of ketamine is given along with atropine premedication for
the increased secretions, which will come from the use of ketamine. Placing a plastic
tube and suturing this in the nostrils will assist in maintaining an airway for operations
on the nose.
F. Corneal injury.
During any operation with the patient under general anesthesia the eyes must be
protected along with any nerve which could be affected by long pressure. This is
especially true during operations on the face. Tape the eyelids closed with steristrips
or suture them closed with 6o chromic suture. This will protect the cornea. Do this
after the application of eye antibiotic ointment is used.