Flap

“ If followed, he opens a flap in his forehead from under which an extraordinary brilliant and dazzling light issues, proceeding from a precious stone; any foolhardy person who ventures to grasp at it is blinded, the flap is let down under the long black hair and the animal disappears into darkness. ”

“ Where the loss of substance is not too great and along the helix of the ear, a flap can be taken from the back of the ear, leaving it attached at its cicatrized union with the primary wound, and sliding this flap upward or outward until the defect of the helix is overcorrected to allow for contraction and suturing the flap in its new position. ”

“ Pedunculated Flaps.—When pedunculated flaps are left free of other attachment, for reasons later mentioned, they must be dressed as granulating wounds. Here it becomes necessary to support the loose piece of skin in such a way as to overcome circulatory obliteration. Unnecessary handling is always to be avoided. The following method has been used with the best results by the author.
The flap is not dressed until all hemorrhage has ceased. A small pad of sterilized or borated absorbent cotton is covered lightly with ten-per-cent iodoform gauze—cigarette fashion. ”

“ Whatever remains on the surface is easily removed by an antiseptic solution, whereupon the powder is again dusted upon the part. When the flap has thickened sufficiently it may be covered by skin grafts, but this is rarely done until it has been properly implanted into the area for which it was intended and only then when union between its sutured borders has taken place. Ofttimes one part of a flap is left unattached, as, for instance, the outer border of the ear, with the object of developing a greater thickness. ”

“ A flap bears weight badly when the muscles have retracted around the bone, over which there is then nothing but skin. It is the same when the flap is stretched tightly across the end of the bone, the soft parts must remain soft and free.
Among the hundreds of cases of amputation of the leg or thigh that have passed before us in being fitted at the Fédération des Mutilés, there were many in which the presence of a terminal scar rendered the fitting of an apparatus difficult ”

“ The long anterior flap, not like Teale's to fold upon itself, but like Spence's and Carden's to hang over and shield the end of the bones, and the face of a transversely-cut short posterior flap, seems to be now the typical method for successful amputations. There may be exceptions, as when the anterior skin is more injured than the posterior, or where an anterior flap would demand too great sacrifice of length of limb, but as a rule it will be found the best method for the patient. ”

“ Some authors recommend a semilunar anterior flap; this is quite unnecessary, increases bagging and delays union. It can be required only in cases where the heel flap has been destroyed or lessened by disease, or by operators in whose hands the heel flaps occasionally slough.
(6.) It is not impossible that a careless operator may (by cutting a little too low) miss the joint and get into the hollow of the neck of the astragalus, where he may cut away for a long time without making much progress. ”

“ Flaps are usually to be preferred if the surgeon desires to have the widest possible view of the brain surface. In the formation of the flap, advantage should be taken of the vessels that minister to its vitality. Thus, in the lateral region of the head, the base lies below, the middle meningeal artery supplying the flap. Under special circumstances, the blood-supply may be disregarded; the flap never sloughs, so far as my experience goes.
Sewing up the dura mater. Considerable difficulty may be experienced in sewing up the dura—by reason of the bulging of the brain. ”

“ With undermining it is usually easy to bring the edges of the gap in the abdominal wall together, even in children; the skin flap on the dorsum of the hand appears rather thick and prominent--almost like the pad of a boxing-glove--for some time, but the restoration of function in the capacity to flex the fingers is gratifying in the extreme.
[Illustration: FIG. 1.--Ulcer of back of Hand covered by flap of skin raised from anterior abdominal wall. The lateral edges of the flap are divided after the graft has adhered.] ”

“ When the parts are sound, a flap may be made in front by introducing a straight, double-edged knife over the outer condyle, and carrying it across and through the soft parts over the opposite or inner condyle, when by cutting downward and outward a flap is to be formed of from three to four fingers’ breadth in length. ”

“ The epidermal surface of such flap is made to form the inner or mucous surface of the repaired cheek (see Fig. 265) , while its external surface and the secondary wound are covered with Thiersch grafts, at one and the same sitting.
The only difficulty experienced in the case with men is that the bearded surface of this inturned flap offers considerable discomfort to the patient, although in the majority of cases the skin thus inverted soon takes on the appearance of the mucosa, the objectionable hairs falling out and the hair follicles becoming obliterated. ”

“ In dissecting the long flap from below upwards, the tissues of which it is composed must be separated close to the periosteum and interosseous membrane. The short flap is made by a transverse incision through all the structures down to the bones, care being taken to separate the parts upwards close to the periosteum and membrane." The stump must be placed in the prone position, "to allow the long dorsal flap to be the superior when the patient is recumbent, and thus fall over the ends of the bones." ”

“ A second and somewhat larger pad or roll of like construction is placed next to the skin surface of the flap. This is held in position by silk protective plaster or several layers of gauze bandage, gently, though snugly, applied.
The flap thus dressed should not be subjected to pressure, often requiring considerable care on the part of the patient, especially during the night. Undue pressure will induce sloughing and must be avoided, even at the expense of comfort to the patient. ”

“ He must, especially in total rhinoplastic cases, prepare a paper or oiled silk model of the flap or flaps he has decided upon to take from the forehead or cheek, and to fold and bend this model into the place of the deformity to be overcome, to make sure of the result to be attained, allowing for the loss, if any, of mass by reason of the torsion of the flap at its pedicle. ”

“ The knife is again entered at the same point, carried behind the bone, and brought out at the same angle, and an exactly corresponding flap cut from the other side of the limb, the flaps are then retracted, the bone cleared by circular incision and sawn through as high up as it is exposed. In primary cases, where the muscles are firm and developed, the flaps should be cut a little concave. ”

“ Each carries a fly-flap, which is his badge of office, and consists of a long bunch of fine brown fibre, very like a horse's tail, sometimes plaited into a multitude of the finest braids, and all attached to a carved handle about a foot in length. ”

“ A flap is put on each sleeve, 61⁄2 inches deep and 2 inches wide between the point; it is made of scarlet cloth embroidered in gold.
Sword flaps are placed at the back of each skirt, 1⁄2 inch shorter than the skirt itself. The width at the bottom point being 3 inches. The number of buttons down the front is 8; 2 are placed behind and three on each flap; an edging of white cloth 3/16 wide is put down the front round the collar, cuffs and flaps. The shoulder cords are gold plaited wire basket cord 3/16 inch in diameter, with a small gold gimp down the centre. ”

“ Furthermore, the secondary wound is more extensive; the bone exposed requires about a month’s time to granulate over before skin grafts can be successfully applied over it.
With the employment of a cheek-flap lining there is [405] the added objection of cicatrization. The use of a flap from the arm is complicated and requires considerable time for the completion of the operation, and there is always the added danger of infection and consequent death of the osseous plate. ”

“ Flannelette′, a cotton fabric, made in imitation of flannel.—adjs. Flann′elled; Flann′elly. [Orig. flannen, acc. to Skeat, from W. gwlanen—gwlan, wool; acc. to Diez, the equivalent Fr. flanelle is from the O. Fr. flaine, a pillow-case.]
Flap, flap, n. the blow or motion of a broad loose object: anything broad and flexible hanging loose, as the tail of a coat: a portion of skin or flesh detached from the underlying part for covering and growing over the end of an amputated limb.—v.t. to beat or move with a flap.—v.i. to move, as wings: to hang like a flap:—pr.p. ”

“ The reason of this may be found in the nature of the flap itself, originally intended to bear the weight of the body, there being no cicatrix at the part on which pressure is borne. I have noticed that perfection in walking on an ankle-joint stump has a certain relation to the freedom of movement which the pad has over the face of the bone. This ought to be pretty considerable. It is explained by the new attachments formed by the tendons, and is under the control of the patient, being elicited when he is told to move his toes. ”

“ The dissection of the flap must be carefully conducted in order to avoid injury to the digital nerves. The result is usually good and permanent. In some cases it might be permissible to carry the plastic principle still further by the transplantation of a flap on the Tagliacotian principle from the chest or upper arm or any other convenient point; or the more simple resource of grafting, after the manner of Thiersch, may be employed with advantage, [40] as it has been proved to have a remarkable effect in lessening cicatricial contraction. ”

“ The surgeon in making flaps should use the greatest gentleness in handling them to prevent pressure gangrene. His finger tips are far better than fixation forceps. Sharp tenaculi may be employed with gentle traction only. Never permit the use of serrated forceps in autoplasty.
In cutting, employ the rules laid down under the principles of plastic surgery, and in dressing flap operations such methods as have been heretofore described. ”

“ These were opened; the redness of the skin rapidly disappeared after this. The line of incision is now entirely healed at the outer part; the inner is not so far advanced, but is doing well. The flap is becoming a firm, round cushion; and the pressure, when he walks, will fall upon the skin taken from the sole of the foot. The advantages which this operation appears to possess are, that the flap is not so large and baggy as in the early stage after Syme’s amputation; it is performed with greater facility and rapidity, and there is less chance of wounding the posterior tibial artery. ”

“ Cartilaginous Support of Flap
The methods just described in which an osseous plate of various size and form is included with skin flaps for the restoration of the nose give undoubtedly the best rhinoplastic results. The new nose is given not only better shape, but a permanency of such form that skin flaps of themselves could never give.
The unfortunate factors in these osteo-cutaneous operations are the many difficulties experienced.
The cutting or making of the bony plate is no simple task. ”

“ The women have not only such a flap, even higher than that used by the men, but also a broad strip of leather over the forward part of the foot, leaving the toes peeping out in front; between the heel flap and the toe covering, the foot is quite as well enclosed, excepting for the toes, as in a white man's shoe. ”

“ Excision of Metatarsal Bone of Great Toe.—For this operation a quadrilateral flap has been recommended, but this is quite unnecessary. A single straight incision along the inner border of the foot, extending the whole length of the bone, renders it very easy to remove the whole bone from joint to joint. ”

“ The skin of the forehead is without hair, is well nourished, and has little adipose tissue underlying it, facts that make it especially useful for these operations. The skin surface he turns into the mouth cavity, while the outer or raw surface is covered with a pedunculated skin flap taken from the region of the intramaxillary region. ”

“ The second has to manage the limb, and on the manner in which he performs his duty much of the success and nearly all the celerity of the operation depend. While the surgeon is transfixing the anterior flap, this assistant is to support the limb in a slightly flexed position, so as to relax the muscles; the instant the flap is cut he is to extend the limb forcibly, and at the same time be careful not to abduct it in the least, but to turn the toes inward so as to bring the great trochanter well forwards on a level with the joint ”

“ The first flap is made posteriorly to the bone, by transfixing the limb, for which purpose the knife is entered at the mid-point between the anterior and posterior surfaces, carried transversely across the limb, and made to cut toward the posterior surface, in an oblique direction, until all the soft structures are divided. It is necessary, in entering the knife, to bear in mind that the bone lies opposite to the mid-point, and that, in carrying the knife across the limb, it would strike against the surface of the bone, unless means were adopted for its prevention. ”

“ Schimmelbusch Method.—The principle herein is to give an osseous wall to the whole length of the restored nose, covering well the skin inside and outside, and, if possible, to fix the new nose solidly at the pyriform opening.
[395]
“I cut an osteo-cutaneous flap from the middle of the forehead, of a size proportional to the size and shape of the nose. Its pedicle between the eyebrows is two or three centimeters wide; it widens out superiorly to form seven to nine centimeters. ”