Flaps
Flaps. Where have you been my whole life?
I’ll tell you.
You’ve been hiding out with those plastic surgeons.
I mean, I’ve done a few for fistulas and a couple for exposed bone in an emergency, but now...
Now my eyes are open. Born as an ob/gyn and grown into a general surgeon of sorts by necessity, I feel like my hands have been freed, untied. Everyone needs a flap! You get a flap. You get a flap! YOU get a flap! Everybody gets a flap!!!
In the short time that Bill was here, I have learned so much from him. And the key is in the flaps! Now you can’t just start cutting into tissue and expect any old place to be a successful flap. You have to know your blood vessel anatomy! (And preferably nerve anatomy as well.) Or it dies.
One of the first cases that we did together was Charlot. Charlot became my patient postoperatively after he had had a repair from his antral gastric perforation. I re-repaired him quite nicely I thought. I took down the whole repair site that had broken down. I freed up the edges and closed him how I normally would. It was a large perforation, 2cm and along the superior border, so maybe that’s why it didn’t work in the first place. I didn’t let him eat for five days. Then I slowly advanced his diet. He was doing fine for a couple of days on liquids. Until he wasn’t. I planned to take him back that morning for a wash out. But when I removed the dressings, I found stomach contents. Then I realized that Dr. Bill had arrived in the night. He was a general surgeon, with a plastics speciality. Did he just want to do cleft lips and head tumors? Or would he help a girl out with this complicated case.
It turns out he was eager to help out in any way he could! And he did! Charlot became one of our complicated patients who, to this day, I have no idea how he survived without proper nutrition. We re-repaired him (#3). Tried a J tube via his nose, which Charlot ripped out some during the night, so it was no longer a J-tube. We put in a proper J-tube for a while, but it didn’t seem to be working properly. Finally on his 5th and final repair, Charlot was surely lacking nutrition, which makes healing anything a nightmare, Dr. Bill re-closed his perforation and made an abdominal wall flap to cover his stomach perforation. He made it 7 days after this 5th and final surgery NPO. There is no TPN here. We pulled his NG tube and advanced his diet VERY slowly. It worked! Abdominal wall flap to reinforce the gastric perforation’s 5th repair. All of this with the minimal supplies, labs (no chemistry here yet), and nursing care. Charlot is a walking miracle. The miracle is that he is walking and eating and very much alive.
Koumakang was also a case we did together early on. He is a young boy who developed a bad scalp infection. All of his scalp was dead from the infection. He underwent a debridement for dead skin and infection on this head. (Essentially, scrubbing his scalp with soap and water removed most of the skin.) After a few days, Bill and I grafted and flapped his head! His whole head, well, at least the part that grows hair. He had a large portion of his skull showing. Bill showed me that you can split the scalp into a few layers to make flaps. (I hadn’t heard the word ‘Galea’ since medical school.) This allows the skull to have a layer of tissue over it, onto which you can graft skin from other parts of the body. So we grafted his whole head.
So many cool flap cases. The list goes on.
Suzanne. Suzanne was the victim of domestic violence. Her husband, who she’s been separated from for four years, used a machete to cut her left forearm almost entirely in two. He had been waiting for her and followed her home from the market one night and hacked hard at her as she was entering her compound. She went to the hospital in Lai, and we aren’t certain what they did there, but there isn’t really any evidence they did anything. Her family isn’t super supportive either. She ended up at home with an open fracture of her radius and ulna and all of her extensor tendons exposed to the world.
When she first arrived late one evening, Olen saw her at the door to the operating room and smelled something unpleasant. So he sat her down on the step outside the OR and took down the old, smelly, rudimentary bandage she had over her arm. She very literally had 2cm of radius and 2cm of ulna sticking out of her skin proximally and 2cm of radius and 2cm of ulna sticking out of her skin distally. I don’t know how that hand didn’t rot off on it’s own. Sometimes they do here. She was fortunate.
Bill wanted an X-ray of the arm before surgery, which is no small feat to accomplish, as it would involve traveling 25 miles by motorcycle over rutted dirt road, only to then have to take a Corolla filled with seven people for two hours to the next big town, then walk across town to the hospital, then repeat the trip in reverse. The family refused. Not because it would be too painful for the patient. Because they just wanted the arm chopped off. Olen tried to explain until he was blue in the face that we wanted to try to save this poor woman’s arm. They tried every excuse. Then they said they didn’t have money for the trip. So Bill and Laura actually gave them $50 so they didn’t have any more excuses and had to go get the X-ray.
Remember my hippo patient who I didn’t know how to do an ex-fix on? Well, now I do. We did an ex-fix on Suzanne’s radius. We tried to do one on her ulna, but it wouldn’t quite work, so we had to put a small rod in (to be removed later). After a few days... THE FLAP. This one is the ultimate flap. The one Olen’s wanted to do for years. The one where your mouth drops open in amazement that it can actually work. And not just work. Work in dusty, rural Africa. Because there certainly is a difference. But this surgeon has been in Africa for 20 years! He knows Africa and knows how to improvise! That is the key. We didn’t have the right parts for the ex-fix, so he used casting plaster to weave in between the pins and the rod to keep the radius fixed to the rod. Improvising. That’s the key. Along with flaps. The second key perhaps. To the same door.
Suzanne had a large open wound with exposed bone on her posterior forearm. So... flap from her abdomen of course. We created a flap (well, Bill really, but I assisted) from her inferior abdomen. Then sutured her arm to her abdomen! It’s still sutured to her abdomen by the way.
Ada is a little one-year-old who had a bad infection in her right groin. It was debrided and then developed into a hip contracture. She had a granulated (not skin-covered) area of about 8x8cm on her groin and abdomen. So... careful de-contracturing of her hip and then tensor fascia lata (TFL) flap! And graft her abdomen and leg, and voila. Another child saved from not being able to walk! And with a flap!
Odette had a large nose tumor. Take the tumor off and... you guessed it, flap! Pulled a flap from the side of her mouth! Leave for a month and then carefully cut if off. It’s still brewing!
Zachee, our ex-cook, had a tumor on the bottom of his heel. It was most likely a type of pre- melanoma or maybe even melanoma by now. He needed a wide excision of the tumor. So... you guessed it again! Flap for the win. This was so cool. A lollipop flap. A flap from his mid calf. He has an extra large skin pedicle for a month to bring blood supply to the flap.
Of course, nothing here is without challenges and complications. At some point during the three weeks of cleft lips and cleft palates and insane tumor resections and flaps and... our dermatome went for a swim. And dermatomes are not meant to swim. (A dermatome is a machine, ours is run on compressed gas, that vibrates a blade to take a thin slice of skin from one place in the body and put it onto another place that needs skin. The host site loses such a thin layer, that it heals quite quickly with minimal intervention. Without a dermatome, one must take a ‘full-thickness’ skin graft from a donor site, which means the original host site needs extra work to heal, and the graft itself is a much more painful process for both surgeon and patient, not to mention drastically more time-consuming.) Some exceedingly helpful and overworked nurse in the operating room was trying to do a great job and clean our instruments really well... and didn’t speak English... so didn’t read the ‘Do Not Submerge’ warning on the dermatome. So bleach water got into all manner of places where it shouldn’t have. And now we don’t have a working dermatome, which is a losing situation for Danae, who now has to spend copious time carefully removing full-thickness grafts and then treating the place she took the graft from, and a losing situation for the patient, who now has to heal up where they lost a thick hunk of skin.
So... if anybody has a spare dermatome lying around and collecting dust...
