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tips
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Felix C Behan FRCS, FRACS
Associate Professor of Surgery
University of Melbourne
Plastic and Reconstructive Surgeon
Department of Surgical Oncology
Peter MacCallum Cancer Centre
Melbourne, & Western Health
Sydney Edinburgh London New York Philadelphia St Louis Toronto
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Churchill Livingstone
is an imprint of Elsevier
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Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
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This edition © 2014 Elsevier Australia
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This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright
Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval
system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or
otherwise) without prior written permission from the publisher.
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Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been
possible. The publisher apologises for any accidental infringement and would welcome any information to
redress the situation.
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This publication has been carefully reviewed and checked to ensure that the content is as accurate and current
as possible at time of publication. We would recommend, however, that the reader verify any procedures,
treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the
publisher assume any liability for injury and/or damage to persons or property arising from any error in or
omission from this publication.
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National Library of Australia Cataloguing-in-Publication entry
___________________________________________________________________
Behan, Felix C., author.
Title:
Surgical tips and skills / Felix Behan.
ISBN:
9780729540995 (paperback)
Notes:
Includes index.
Subjects:
Surgery–Textbooks.
Surgery–Technique.
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Author:
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Dewey Number:
617.9
___________________________________________________________________
Content Strategist: Larissa Norrie
Senior Content Development Specialist: Neli Bryant
Project Managers: Karthikeyan Murthy and Rochelle Deighton
Edited by Linda Littlemore
Proofread by Tim Learner
Cover and internal design by Stan Lamond
Index by Robert Swanson
Typeset by Toppan Best-set Premedia Limited
Printed in China by China Translation & Printing Services Limited
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Foreword
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relatively simple, but neat surgical tips
to improve surgical outcomes. This book
is divided into three sections, Basic,
Intermediate and Advanced, and there
is something in the book for aspiring
surgeons, as well as for the most
experienced. The basic and intermediate
sections contain many surgical tips,
including suturing techniques, harvesting
of skin grafts and their applications, simple
means of immobilisation and innovative
methods of establishing drainage to
improve the results of many plastic surgery
procedures. The advanced section has
beautifully illustrated examples of keystone
fascio-cutaneous flap reconstructions, which
many experienced surgeons would be
pleased to claim as their own.
The nature of plastic surgery has
changed over the last 50 years and is
dominated by cosmetic surgery and
microsurgery with a decline in the art of
local tissue repair, which is the fundamental
basis of plastic surgery. It is to be hoped
this book may stimulate a resurgence of the
more classical aspects of the specialty. With
the passage of time and the tightening of
resources, there will inevitably be more
scrutiny by health administrators of the cost
of plastic surgery procedures. It will become
increasingly difficult to justify operations
that require expensive resources, multiple
surgeons and prolonged operating times
when there are simple less expensive
alternatives readily available to produce
results often superior in terms of function
and appearance. Professor Behan has
shown the way – plastic surgeons need
to sit up, take notice and embrace local
fascio-cutaneous reconstruction as an
alternative to microsurgery or risk losing
a large part of our specialty.
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The skills of a plastic surgeon are acquired
in many ways. Most surgeons learn their
craft from an experienced surgeon and then
modify their practice in the light of their
own experiences. It is not surprising that
changes in operative technique usually
occur slowly and only rapidly when a new
technology is introduced. This has been
most obvious in plastic surgery during the
emergence of microsurgery, which has
provided a method for the reconstruction of
many major defects. Unfortunately, simpler
more traditional classical methods of tissue
transfer involving less operating time and
hospitalisation are sometimes forgotten.
Almost 100 years ago, a Melbourne plastic
surgeon, Jerry Moore, wrote a seminal book
on plastic surgery based purely on his
personal experience and innovation. It is
pleasing to be asked to write a foreword
to an equally important book, Surgical Tips
and Skills by Felix Behan, which may also
change the face of plastic surgery. Like
Moore, Professor Behan is an original
thinker, and some 40 years ago he realised
it is possible to raise composite flaps using
embryological dermatomes, as these
include skin, neurovascular tissue and
fascia. He gradually developed his own
ideas of local tissue rearrangement based
on this principle, enabling him to close
defects that were previously irreparable. My
late brother Robert Marshall, surgeon and
anatomist, grasped this principle of the
vertical orientation of the circulation of
the skin and underlying tissue, and was
sufficiently impressed to include it in his
book, Living Anatomy, Structure as a Mirror
of Function, in 2001.
Professor Behan has continued his
innovative approach for more than 40
years, and shares with us in his new
book numerous examples of remarkable
reconstructions using local fascio-cutaneous
keystone flaps, as well as including many
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Donald R. Marshall
AM MB MS FRACS FACS
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Contents
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Preface xi
Acknowledgments xiii
Rreviewers xiv
Acronyms used throughout the text – key words xv
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DEGREE OF COMPLEXITY
Preoperative
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Wound preparation – pre-wash technique 6
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Exsanguination problems in hand surgery 4
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Draping technique for hand surgery operating table 2
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Basic
Unpleasant aromas in theatre 7
Intraoperative
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Preoperative theatre preparation
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Aesthetic closure – ocular design with extended limbs (ODEL) 10
Dog-ear revision in wound closure 13
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Fenestrated full thickness graft 15
Postoperative
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Drain tube fixation without silk 17
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Drain tube identification with site specificity 19
Hand splint – ongoing use postoperatively when blood staining may have occurred 20
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Hand splintage – technique 1 – single roll plaster splintage 21
Hand splintage – technique 2 – grafted finger tips 22
Hand surgery – horseshoe pillow elevation technique 25
Major wound drainage technique 26
Wound drainage – mini suction system using a Luer-lock syringe 28
Non-operative
FCB assessment of hand function – motor and sensory 32
Ring removal from a swollen digit using multiple silk strands 33
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DEGREE OF COMPLEXITY
Intermediate
Intraoperative
Aesthetic closure – major head and neck reconstruction using the KPIF 38
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Biopsy excisional technique – ODEL 39
Carpal tunnel open technique 43
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Carpal tunnel release for recurrence – open method 45
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Chronic ulcer grafting technique on a lower limb 53
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Cutting diathermy technique 55
Donor site dressing 58
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Donor site re-grafting technique 60
Dorsum of hand surgical closure technique 63
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Foreign body giant cell granuloma 65
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Grafting technique for a chronic ulcer on the dorsum of a diabetic foot 68
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HEMMING suture 71
Joint exposure technique 74
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Nasal fracture 76
Scalp staples in hair-bearing tissue 80
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Seroma of the axilla drainage technique 81
Seroma of the groin drainage technique 83
Skin graft harvest using the dermatome 85
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Skin grafting technique – abdominal wall defect 89
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Skin grafting technique – fenestration 91
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Skin grafting technique – negative pressure dressing support 94
Thumb tip injury 96
Wound debridement – use of the dermatome 98
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Z-plasty – closure of the triangulate flap – the 3-point closure refinement 99
Intraoperative to postoperative
Nail bed injury 102
Penrose drainage technique – Dupuytren’s surgery 106
Non-operative
Chronic ulcer of the lower limb – dressing technique 108
Mallet deformity – type I – the BEST procedure 110
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DEGREE OF COMPLEXITY
Advanced
Intraoperative
Abdominal wall defects – case series no. 1 116
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Abdominal wall defects – a double KPIF procedure in a yin-yang fashion – case series
no. 2 120
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Aesthetic closure of a neck defect – case series no. 3 124
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Aesthetic closure (melanoma) – case series no. 4 128
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Ankle joint double KPIF – case series no. 5 131
Bony defects around the knee joint (KPIF) – case series no. 6 135
Cheek melanoma – reconstruction in an irradiated field – case series no. 7 139
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Closure of dorsal hand defect (KPIF) – case series no. 8 142
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Delayed facial nerve neuropraxia following SCC excision – McLaughlin tarsorrhaphy – case
series no. 9 145
DRAPE procedure as salvage for recurrent disease – case series no. 10 148
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DRAPE procedure – malar melanoma – case series no. 11 152
DRAPE procedure – melanoma of the cheek – case series no. 12 155
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DRAPE procedure – melanoma of the forehead – case series no. 13 159
DRAPE procedure – melanoma of the temple – case series no. 14 162
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DRAPE procedure – morphoeic BCC of (R) and (L) temples – clinical series no. 15 165
Ear surgery – preauricular sinus procedure – case series no. 16 170
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Ear surgery – scaphoid fossa reconstruction technique using a postauricular KPIF – case
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Ear surgery – simple ear dressing technique – case series no. 18 174
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Facial mitotic lesions – BCC on the forehead – case series no. 19 178
Facial mitotic lesions – preauricular BCC – case series no. 20 181
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Facial nerve palsy – McLaughlin tarsorrhaphy as a delayed procedure – case series
no. 21 184
Facial recurrence of multiple mitotic lesions following superficial radiotherapy – case series
no. 22 187
Fingertip injuries – reconstruction of multiple digits – case series no. 23 189
Fingertip injury – donor site harvest of full thickness skin graft – case series no. 24 192
Fingertip injury – neurovascular island flap-on-flap reconstruction – case series no. 25 195
Forearm melanoma – circumferential KPIF – case series no. 26 198
Gouty tophi of the thumb – case series no. 27 201
Harvesting conchal cartilage for CMC arthroplasty – case series no. 28 204
Head and neck – atypical fibroxanthoma on the scalp – KPIF (AFX) – case series no. 29 208
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Head and neck – closure of a large head and neck defect with an island deltopectoral flap
(IDPF) and KPIF from the cheek – case series no. 30 211
Head and neck – large melanoma defect (8 × 6 cm) of the (L) cheek repaired with KPIF
– case series no. 31 214
Head and neck – neck defect in an irradiated field – pectoralis major island flap – case series
no. 32 218
Head and neck – parotid defect – facial SMAS KPIF – case series no. 33 221
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Head and neck – parotid defect – posterior nuchal KPIF – case series no. 34 223
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Head and neck – radionecrotic (R) neck ulcer – case series no. 36 232
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Head and neck – periparotid defect – cervicosubmental (CSM) KPIF – case series no. 35 227
Head and neck – SCC of the external auditory canal – case series no. 37 235
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Inner canthal KPIF – case series no. 38 238
Lateral malleolar defect (tattoo removal) – case series no. 39 241
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Lateral malleolar orthopaedic defect – closure with KPIF Ω variant – case series no. 40 244
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Lateral malleolus metal exposure post ORIF – case series no. 41 248
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Lip defect – closure after SCC excision – case series no. 42 250
Malar and zygomatic arch complex – multifocal SCC – case series no. 43 255
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Malar eminence mitotic lesion treated with crescentic excision – case series no. 44 257
Nasal bridge defect – case series no. 45 260
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Nasal defect – large composite graft to alar – case series no. 46 263
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Nasolabial fold – recurrent morphoeic BCC – case series no. 47 267
Necrotising fasciitis of the groin – case series no. 48 270
Palmar defect – KPIF closure – case series no. 49 273
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Palmar trauma – KPIF closure – case series no. 50 275
Post mastectomy reconstruction using a KPIF – case series no. 51 278
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Sacral pressure area – closure with a gluteus maximus KPIF – case series no. 52 282
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Tendon repair – modified Kessler technique – case series no. 53 285
Trophic ulceration – anterior superior iliac spine treated with KPIF – case series no. 54 288
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Trophic ulceration – buttock treated with a KPIF – case series no. 55 290
Trophic ulceration – greater trochanteric area – case series no. 56 294
Trophic ulceration – olecranon (elbow) – case series no. 57 297
Trophic ulceration – wrist – case series no. 58 300
Trunk defect – case series no. 59 303
Upper limb laceration – problems with wound closure of the frail integument – case series
no. 60 307
Variation of locking mattress suture – case series no. 61 309
Variation of locking mattress suture – case series no. 62 311
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Index 314
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Preface
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regions of the body, has created a ‘How To
Do’ guide on some reconstructive facets
that others find difficult. It is interesting that
the Annals of the Royal College of Surgeons
of England is now in the 10th year of
‘Technical Tips’ – meaning people like to
read pearls of wisdom. The science of the
keystone has many elements, with recent
publications looking at the evidence – the
flaps are closed under tension and the
vascular dynamics characteristically
displayed contradict established principles of
plastic surgery, requiring further elucidation.
The anatomical construction of skin, fat
and fascia, a prerequisite to any successful
keystone flap, is indispensable and the
mark-outs within the dermatomes echo the
embryological development of the human.
Speaking in Paris recently, a senior plastic
surgeon, Dr Arnoldo Fournier, said to me:
‘Felix, you have captured the art of
reconstruction by these principles’. He was
referring to the fact that every keystone
aligned along the dermatomes has both
somatic and autonomic support to
supplement the arterial and venous
connections while not negating any
lymphatic and humeral input. Microsurgery
is based on an artery, a vein and possibly
a nerve and thus has a different structural
arrangement. Historically I must publicly
recognise the contribution of Professor
Gordon Clunie in relation to the publication
of scientific material as editor of the ANZ
Journal of Surgery. He told me that with
any new scientific principle “launch it
locally, and you will get full recognition”.
His other famous recommendation was “if
you have anything to say in print, find the
time to publish”. Professor Bob Thomas
also gave me sound advice in 2003, when
the first article on the Keystone was
submitted to the ANZ Journal of Surgery
with multiple authors. He said, “This is a
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Surgical Tips and Skills is a compilation
covering aspects of surgical development
with ongoing refinements in surgical
technique based on experience. The fact
that one keeps seeking higher standards of
surgical outcome leads one to question
one’s own ability. Eventually, the
accumulation of this experience bears fruit.
One has only to compare the techniques
and achievements of one’s earlier years to
see the advantage of this maturation
process.
This text is essentially a summary of 40
years of experience practising surgery in
both the public and the private domains.
The advent of digital photography with
video back-up supersedes reams of text,
which are sometimes hard to comprehend.
The alphabetical sequence, common to
modern surgical textbooks for ready
reference, is an attempt to cover the gamut
of reconstructive cases that present in any
surgical domain, based on one central
tenet: the simplest way is usually the best.
With the advantage of external reviewers,
the levels of expertise were factored in to
create three sections of the book covering
Basic, Intermediate and Advanced stages
of this technical development.
As a consequence, the principles of
evidence-based medicine – initiatives to
improve health management and health
outcomes while reducing health costs – are
reflected in all these cases, with Level 5
(expert evidence and opinions) and Level 4
(retrospective case series). All the singular
cases illustrated are just examples of the
many that have been compiled and have
either been presented internationally at
meetings or are in the process of separate
publication, or both.
This compilation, drawn from
approximately 3000 keystone flap
reconstructions over the past 20 years in all
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comprehensively illustrated presentation will
encourage many more of my colleagues, at
whatever stage of their careers, to
re-explore loco-regional reconstruction in
conjunction with microsurgical expertise..
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good idea. It’s yours and have it as a single
author.”
This ‘technical tips’-style of publication is
a means of illustrating how to employ these
techniques. I hope this straightforward,
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INTERMEDIATE
Carpal tunnel open technique
The advantage of an open carpal tunnel
technique is that it allows one to visualise
the dimensions, neural compression and
any aberrant branches in the vicinity, which
are often seen where there is a large
palmaris brevis.
Solution
Refer to Figures 1 and 2 for an open carpal
tunnel technique showing the aberrant
branch of the median nerve and Figures 3
and 4 for a transverse ligament
reconstruction.
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Problems
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Visualising the aberrant branches of the
median nerve.
INTRAOPERATIVE
Introduction
1/2
Notes _____________________
___________________________
___________________________
Figure 2: The aberrant branch
of the recurrent median nerve
piercing the palmaris brevis
muscle. An enlarged palmaris
brevis is an indicator of this
possible anatomical variation
and should serve as a warning
Notes _____________________
___________________________
___________________________
___________________________
SURGICAL TIPS AND SKILLS
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Figure 1: Following the release
of the transverse palmar
ligament distal to the wrist
crease, any tightness proximal
to this site can be released.
The use of a Howarth elevator
prevents damage to the
epidermal lining when the
fibres are released
___________________________
___________________________
43
INTERMEDIATE
2/2
Carpal tunnel open technique
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INTRAOPERATIVE
Figure 3: This transverse
triangulate ligament
reconstruction, based distally
(opposite to the Netscher
principle), is fashioned in a
triangulate manner from the
remnants of the palmar fascia.
It is turned at right angles and
repairs loosely the carpal
ligament to prevent any
perineural communications to
the subdermal plexus during
the healing process. It makes
an important contribution to
minimising pillar pain
Notes _____________________
Outcome
Notes _____________________
___________________________
___________________________
___________________________
___________________________
___________________________
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Figure 4: The Penrose drain,
pre-washed and sections in
half, is installed before
definitive closure. It is removed
between 24 and 48 h (when it
ceases to function)
SURGICAL TIPS AND SKILLS
44
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The procedure takes 25 minutes. Full
recovery of hand function and intact
sensation. No recorded complications.
Bibliography
Drake, R.L., Vogl, A.W., Mitchell, A.W.M. (Eds.), 2012. Gray ’s basic anatomy. Elsevier Churchill
Livingstone, Philadelphia, pp. 364–365.
Green, D.P., 2005. Chapter 1: ‘General principles’. In: Green, D.P., Hotchkiss, R.N., Pederson, W.C.,
Wolfe, S.W. (Eds.), Green’s operative hand surgery, fifth ed. Elsevier Churchill Livingstone, Philadelphia,
pp. 3–24.
Netscher, D.T., 2003. The benefit of transverse carpal ligament reconstruction following open carpal
tunnel release. Plast Reconstr Surg 111 (6), 2020–2022.
Netscher, D.T., Dinh, T., Cohen, V., Thornby, J., 1998. Division of the transverse carpal ligament and flexor
tendon excursion: open and endoscopic carpal tunnel release. Plast Reconstr Surg 102 (3), 773–778.
Xu, L., Huang, F., Hou, C., 2011. Treatment for carpal tunnel syndrome by coronal Z-type lengthening of
the transverse carpal ligament. J Pak Med Assoc 61, 1068–1071.