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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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Fig. 8.3
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Fig. 8.4
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Duplicate Patient Information
The patient is first given comprehensive information about the objectives and risks ofthe procedure on the day of the first cons ultation.
A written record is kept of this.
One day before the surgical procedure, the patient is again given comprehensive information on two separate occasions: once by the surgeon
and once by the surgical resident. All the risks are set down in writing
at this time.
Preliminary Examinations
Current preoperative rou tine laboratory examinations, ECG, chest X-ray,
clinical examination.
Photographic Documentation
Borders: Proximal: tip of the shoulder
Medial: anterior and posterior axillary line
Distal part of the elbow
Surgical Planning
The procedure is carried out under tumescent local anesthesia or under
general anesthesia with endotracheal intubation. On the day before the
operation, the surgeon discusses in detail with the patient which
changes he or she wants and how the surgeon can achieve this.
The patient must be warned about unrealistic expectations and must be
fully informed about postoperative behavior, in particular about how to
care for the scar.
Intraoperative single-shot injection proph ylaxiswith cefaclor 2 g.
Compression dressing, patient is monitored for 24 h.
Preliminary Marking of Incision Lines (Fig. 8.5)
䊏
Before the operation, the areas of surplus skin are marked with the
patient standing with his/her arms slightly abducted and bent at the
elbow joint to 70°. Optimum preoperative marking is extremely important for brachioplasty. The surgeon must take his/her time and position
the incision in such a way that it cannot be seen either from the front or
the back when the patient’s upper arm is hanging down. In order to do
this, the surgeon holds the surplus skin together between the thumb
and index finger of his/her left hand and marks the outer resection bor-
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Fig. 8.5
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der with a pen. In general, markings are made for the upper longitudinal incision about two finger widths above the sulcus bicipitalis medialis. The exact course of the lower incision is only defined during the
operation. To achieve a symmetrical result, however , the incision is
marked approximately before the operation.
If appropriate, the spindlelike resection in the axilla can be extended in
an axillary direction by Z-plasty or a vertical ellipse.
In all aesthetic resections of cutaneous/fatty flaps in the head, neck, or
body the final resection is carried out in stages in order to ensure that
neither too much nor too little is removed, as in both these cases the
result would be unsatisfactory . The skill of the aesthetic surgeon is to
have a feeling for the tissue, to be able to think in three dimensions,
andtobeabletofulfillthepatient’swisheswitharigorousexplanation
of the procedure. An aesthetic surgeon can only be successful in the
long term if he or she does this.
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Mang’s Fish-Mouth Technique (Fig. 8.6)
In appro p riate cases, i.e., when the folds of skin do not extend a long
way into the elbow region, a variation of the incision, without extension
beyond the cranial third of the upper arm, can be successful. With this
incision, not only vertical tightening in the upper arm area is achieved,
but also tangential tightening in the axilla. The advantage of this incision is that the scar is barely visible, and skin folds in the axilla and
upper third of the upper arm can be eliminated very effectively. The
scar can hardly be seen at all when sleeveless clothes are worn.
Positioning, Disinfection
䊏
The patient’s arms are abducted by 90° before the operation. Care
should be taken to position them correctly so that there is no pressure
or traction in order avoid damaging the brachial plexus. Disinfection
with Cutasept® is carried out to the edges and to the breast region.
Tumescence (Fig. 8.7)
䊏
Tumescence is then performed without blurring the marked borders.
App roximately 200 ml of tumescence solution without the addition of
triamcinolone acetonide is injected manually per side (0.9% NaCl,
500 ml, 1% prilocaine 250 mg = 25 ml, epinephrine 0.5 mg, 8.4%
NaHCO35mEq).
䊏
Tumescence is carried out in the layer where dissection will lat er be
done, i.e., on the fascia of the upper arm, so that the skin/fat flap is
separated from the fascia by the injection itself. During tumescence, the
surgeon can feel the thickness of the flap and can therefore carry out
dissection quickly and with almost no bleeding. The tumescence also
predetermines the level of dissection, so that no deeper vessels or
nerves are damaged.
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Fig. 8.6
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Fig. 8.7
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Incision (Fig. 8.8)
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The incision starts at the marked line above the sulcus bicipitalis medialis. The incision made with a size 15 scalpel should be wedge-shaped
(30°), so that when the wound is closed later (equilateral triangle with
the deepest point on the upper arm fascia), an inverted scar is not
produced.
Superficial Dissection (Fig. 8.9)
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After the upper, tangential (30°) incision has been made, the assistant
insertsasharpretractorandpullsitforwardgentlysothatdissection
can be done more easily with a scalpel. It should be ensured that the
medial brachial cutaneous nerve is not damaged.
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Fig. 8.8
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Fig. 8.9
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Deep Dissection, Hemostasis (Fig. 8.10)
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Theskinflapisbestdissectedbypullingitupwardwithtwofourpronged retractors. During this procedure the assistant should ensure
that the retractors are pulled forward gently. A t the same time, the
assistant can carry out hemostasis with bipolar tweezers. As a result of
thetumescenceinfiltration,thesurgicalareaisclearlyvisibleandnot
covered with blood. This enables dissection from the fascia of the
upper arm to be carried out quickly. The surgeon can do this with
either scissors or a scalpel.
Incision of the Dissected Dermofat Flap in Stages (Fig. 8.11)
䊏
Once the skin/fat flap along the fascia of the upper arm has been dissected to deep within the marked resection border, Backhaus clamps
are attached to both ends and rotated gently in a cranial direction.
Resection of surplus fatty tissue, in particular at the cranial and caudal
incision borders, is carried out approp riatel y. Incision of the dermofat
flap at marked sites is then done while monitoring the tension. When
doing this, it is important that the incisions are made under slight
tension stage by stage in line with the cranial incision line to prevent
toolittleskinfrombeingexcised,resultinginanunsatisfactoryresult,
or too much skin being excised, resulting in the scar being placed
under too much tension (risk of hypotrophic scarring).
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Fig. 8.10
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Fig. 8.11
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