Michael F. Klaassen

How to Think Like a Plastic Surgeon

This final chapter is an attempt to demonstrate the thinking behind the many questions and challenges that are faced by the modern plastic surgeon. It begins with the patient and the history, examination, diagnosis and surgical plan for that patient.

Keystone Flap Concepts

This chapter summarises the concepts of the keystone flap including the anatomy, physiology and design principles pioneered by Associate Professor Felix C. Behan of Melbourne, Australia. This is the modern local flap and is now a preferred option for the lead author. It is simple, versatile and reliable and can be used from head to toe, for small, medium or large surgical defects. The lead author’s 5-year experience with this modern local flap is reviewed.

Where Skin Grafts Are Better

There are times in reconstructive practice where a skin graft will be the preferred option. Using actual clinical cases, from the lead author’s practice over the past 5 years, the use of both full thickness and split skin grafts is illustrated. It is important to appreciate the long-term appearance of skin grafts for facial defect reconstruction. Although they are generally a better option in the elderly patient (and the term elderly is defined rather loosely), they can also be applied as the best option in any given individual patient.

Getting Started: Planning and Drawing

The young plastic surgeon trainee is motivated by many factors, but intrinsic to the learning of the art and craft of plastic surgery is the fundamental skill of vision and creativity. We are the modern wound care specialists and the troubleshooters for challenging and complex surgical problems. Not everyone is an artist, but the good plastic surgeon needs to develop the skills of an artist—vision, 3D appreciation and creativity. Photography and simple drawings help to turn almost overwhelming surgical problems into clinical possibilities.

Knowledge Is Power, Experience Is Key

The only source of knowledge is experience. n n(Albert Einstein) nSenior plastic surgery trainees presenting for the final fellowship examination have probably more knowledge about the scope and theory of plastic and reconstructive surgery than at any other stage of their surgical careers. They may be limited in their knowledge of aesthetic surgery and some other subspecialties of the discipline but what they really lack is experience, i.e., the experience of thinking, planning and operating at a consultant level of competence. This is inevitable given that the previous 4–5 years have largely been a professional working life as a junior team member, with a supervising consultant or mentor above them. The final professional exams are predominantly about demonstrating through a series of confrontational interactions with experienced surgeon examiners that they are ready to make the step up to be a junior consultant. Dr. Sean Hamilton FRACS a former senior examiner for the Court of Examiners (RACS) used to emphasise that from his perspective ‘If the situation presented it, could this candidate he was examining be capable of taking over his practice for the next six weeks if he was temporarily out of action through illness, absence or other unexpected circumstance.’ In other words, could the candidate step into his shoes.

Long Clinical Cases

The good physician treats the disease; the great physician treats the patient who has the disease. (William Osler)

Elliptical Excision and Sliding Flap Repair

The elliptical excision of a tumour and repair of the wound directly is the basis of all other local flap techniques. The sliding flaps advanced bilaterally are inherently double advancement flaps. The biwinged excision and other variants of this are presented. The principles of adequate excision margins, gentle tissue handling and knowledge of the resting skin tension lines remain the same. Variants such as crescentic, asymmetrical, unilateral, wedge excision, M-plasty and halving technique are covered. Dog-ears and their management are also mentioned.

Favoured Keystone Flap Applications

The diagrams illustrating the designs of the various keystone flaps produce an irresistible challenge to trainee plastic surgeons. We believe that clinical experience is the key, with a good knowledge of basic flap principles and surgical skills required, before embarking on the keystone flap. I have selected ten keystone flaps covering the whole body, from scalp to foot, including my first and my most recent cases. Although tentative at the beginning, I soon gained confidence, and the keystone perforator island flap is now my preferred option. Photographs of all stages of this flap have served as a data record, from which I have been able to refine the procedure and avoid problems.

Technical Tips for Local Flap Surgery

Surgeons work with their heads and their hands. This chapter considers the important practical aspects of the environment we work in, the operating theatre and the universal precautions and safety standards that keep our patients protected and safe. Local anaesthetic doses, sterile technique, visual and lighting aids, instruments, surgical technique, post-operative care and scar management are considered, so too the increasing number of patients who are anticoagulated.

The Failed Candidate

Success is not final, failure is not fatal: n nIt is the courage to continue that counts. n n(Winston Churchill)