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Plastic Surgery Operative Procedures
(ver batim from medical legal reports)
May 24th, 1998.
Under general anestetic, the patient's dressings were taken off.
The wounds were irrigated out with copious amounts of saline and inspected. The wound on the right leg was felt closable on the left medial knee. It now requires a medial gastroc flap, therefore, an incision was made in the mid line on the left calf. Dissection was carried down to identify the mid line raphe, thesural nerve, the short saphenous vein. once having done this, the sural nerve was protected. The saphenous vein was protected. Its tributaries were divided.
The medial head of the gastroc was elevated off taken up at its tendinous insertion of the soleus and now dissected proximally. Once having elevated the flap, the wound defect was irrigated out, tunnel was created between that area and the position of the gastroc deep to the subcutaneous tissue and through the fascia. Once having done this, the muscle was dessected free enough toturn 180 degrees so it could be lifted superiorly and taken across the defect.
The tendinous portion of the gastroc. flap was sutured to the periosteum mid line beyond the orthopedic plate giving full coverage of muscle belly over the plate in the whole area of the exposed portion of the plate. Once having done this, it was stiched in place using # 0 Vicryl. This being done, the split thickness skin was harvested from the leg and applied to the muscle over the the defect and a little bit in the lower mid line incision in the shin.
Once having done this, a secondary defect was closed primarily using # 0 Vicryl and staples. The leg was dressed with Sofra-tulle, gauze, stumpdressing and Kling and tensor.
The patient tolerated the procedure well and was returnedto the recovery room in good condition.
Operation date: July 21, 1999: U.B.C. Hospital
Preop. Diagnosis: Status post multiple fractures, left lower extremity
Operative Procedure
The patient was seen preoperatively. He sustained severe lower extremity trauma last May with mutiple compound fractures of both his feamur and proximal tibia. He has had numerous related surgeries.
His present problem relates to the fact that he has had M.R.S.A. Osteomyelitis with exposed plate which require placement of antibiotic beads over the pre-tibial area, as well as free flap coverage. The antibiotic beads have now become exposed with only a very thin layer of membrane about the dermis covering a number of the beads over the pretibial area. Imediately deep to these beads lies the tibial plate which creates problems with respect to soft tissue coverage.
The nature of the planned surgery including the risks and benefits were explained to the patient.
He was given a general anesthetic with laryngeal mask in the supine position. The left leg was shaved and prepped with aqueous chlorhexidine and free draped. There was approximately four exposed beads which had almost protruded through the skin.
An incision was made directly over these in the area of the tibial tubercle. The silk suture holding the beads together was unfortunately found to be rotten and therefore the beads were removed piecemeal, as well as the fragments of silk suture.
In total 12 beads were removed. I am not certain that this represents all the beads but certainly no beads were left in the immediate subcutaneous position and any of those beads still remaining can safely stay in place.
Immediately deep to the beads, the tibial plate was exposed and the situation, once the beads had been taken out, was such that the plate itself was no longer covered by reasonable soft tissue.
Accordingly, multiple flap closure of that area was carried out. A large transposition flap measuring 10 cm along one margin, by 4 cm along the other margin, proximally based along the medial aspect of the knee was designed. This was raised in the deep subcutaneous tissue using a combination of scalpel and cautery. The flap was rotated into place. As the flap rotated, it covered a small portion on pre-existing skin graft over the distal end of the previous gracilis flap. The skin graft was removed. In order to allow closure, a rotation advancement flap was created on the lateral aspect of the wound, in order to advance this skin to meet the transposition flap.
- 1) Removal of exposed antibotic beads, left knee.
- 2) Reconstruction of exposed tibial plate with multiple flaps and split-thickness skin graft.
Operation Preformed:
Postop. Diagnosis: Same
Once the flaps had been elevated, closure was carried out with deep sutures of 3-0 Biosyn, followed by multiple interrupted skin sutures of 4-0 Surgipro. The resulting flap donor site defect measured about 4x8 cm and was based over the proximal medial leg in the shape of a cresent. In order to cover this, a split-thickness skin graft of approriate siae was harvested from the left anterior thigh using an air Zimmer dermatome. The graft was meshed 1.5:1.0 and was applied to the defect where it was stapled in place. Jelonet and Acriflavine gauze were used to hold the graft in place, followed by a bulky dressing and Kling bandage. The skin graft donor site was dress with tincture of Benzoin and Op site followed by a light circumferential gauze dressing.
Upon completion of this case, the flaps appeared to be well vascularized and were sutured without undue tension.
Estimated blood loss was 50 ml
The patient was discharged to the recovery area with sponge, and needle and instrument count correct.
These are only two of many procedures performed over a two and a half year period. Additional Operative Procedures will be posted at a later date.
