Making Decisions and Avoiding Complications in Skin Flaps PDF

Preface

Most skin surgery textbooks focus on the fundamentals with lengthy discussions and illustrations on technique, but are limited on demonstrative clinical photographs. We have found that when we are pondering the options on how to repair a defect in a particular anatomical location that an atlas with a large number of clinical photographs showing how various flaps would look in repairing that particular defect would be extremely helpful in our decision-making process. The purpose of this atlas is to fill that gap. This atlas is intended for the surgeon who already has a grasp of the fundamentals and mechanics of flap repair, but may need additional ideas on selecting an appropriate flap for a given defect. Each example will have a photograph showing the defect and a second showing the repair. When available and/or of educational value, illustrations of the flap or long-term follow-up photos may be used. Throughout the text, we've highlighted in bold text surgical pearls which can help optimize a particular flap's success rate and/or aesthetic outcome and have also compiled these pearls into an addendum at the end of the book. We have elected to publish clinical photographs of flaps only and leave those of primary closure, secondary intention closure, and graft closure to other sources.

This atlas is divided into three sections. The first section contains repairs organized by location. Therefore, if the surgeon has a defect on the nasal tip, lip, or eyelid, etc. he/she can go to that chapter and review the various options that can be used for repairing the defect. Our atlas does not contain an exhaustive list of all flaps ever used, but the ones we have successfully used on a routine basis. In some instances we may express a preference for a particular flap in a particular location, but we have found over the years that excellent aesthetic results depend not only on the flap chosen, but also the surgeon's technique. Where one surgeon may obtain superb results with a bilobed flap another surgeon may not be able to obtain such excellent results with the same flap, but obtain equally excellent aesthetic results with a different flap such as an island pedicle flap for the same type of defect. We all seem to have our favorite or workhorse flaps, but another purpose of this atlas is to help expand the surgeon's armamentarium so that he/she does not force the flap they are most familiar with to work in a given defect, but is able to choose a different flap that will give a better aesthetic result.

The second section contains repairs organized by flap type. We suspect most of us have seen or read about a flap we have never used and are excited to try it out. In that case the surgeon can choose the flap they would like to try and then see clinical photographs of how it has been used successfully in various types of defects. For simplicity's sake we do not differentiate between the various types of rhombic flaps. We just call them all rhombic flaps.

For those of us who teach it is tempting to show only our best results. Our best results show how flaps can be put to best use. However, over the years we have found that discussing and showing suboptimal results may be equally or even more helpful. Therefore, the third section contains clinical photographs of suboptimal results with a discussion of what we think went wrong and what could have been done differently to obtain a better result.

Some defects are complex and involve several cosmetic units making them difficult to categorize by anatomic location. In such instances, instead of repeating these photos in multiple chapters (e.g.: tip, ala, and sidewall), we've placed them in the chapter which contains the cosmetic unit that posed the greatest challenge in closing the defect.

Lastly, the intention of this text is not to showcase results but to present flap options for different defects and anatomic sites. Most of our photos are taken by medical assistants who do not have any photography experience and neither of us has a photo studio or professional equipment. As such, the quality and reproducibility of the photos can vary from picture to picture. In addition, follow-up dates are approximate.