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A model for training in elevation of local skin flaps in the hand
A MODEL
FOR TRAINING FLAPS
IN ELEVATION IN THE HAND
OF LOCAL
SKIN
H. D. SKOFF From the Departments
of Orthopaedic and Plastic Surgery, Harvard Medical School, Beth Israel Hospital, Boston, USA
Appropriate skin flap design is crucial for success in surgery of the hand. Practice models are useful in acquiring surgical experience. The author describes a three-dimensional model composed of readily available materials which has been useful for practice in elevation of local skin flaps in the hand.
Journal of Hand Surgery (British and European Volume, 1994) 19B: 6: 794-795 Skin flaps are an important component of surgery of the hand (Lister, 1993; Smith and Walton, 1992; Tubiana, 1985). Proper skin flap design is necessary, and expertise in the geometry and vascularity of skin flaps is the result of much experience. Three-dimensional models may help surgeons to improve their psychomotor skills in the design and elevation of skin flaps.
Fig 2
Equal-sized
MATERIAL
Fig 1
A simple 60” z-plasty
drawn
z-plasty
flaps raised.
AND METHODS
The materials required are sand, latex surgical gloves (light and dark), wire twists, a marking pen, clear adhesive tape, scissors and forceps. A dark surgical glove is placed upon the surgeons hand, a light surgical glove of equal size is placed over the dark glove. Both are then removed together. The sand is poured into the inner glove until all digits and the hand are filled. The glove opening at the wrist is
in the first web space. 194
FLAP TRAINING
MODEL
195
multiple and four flap), VY advancement flaps, rotation flaps, and transposition flaps to resurface the hand and digits. A simple Z-plasty for a hypothetical first web space contracture is shown in Figures 1,2 and 3 (Furnas, 1985). Gains in length along the contractual diagonal are at the expense of shortening along the transverse diagonal. For the most common angle size of 60”, a theoretical lengthening of 75% is anticipated (McGregor, 1980). DISCUSSION In hand surgery, three-dimensional models for skin flap design have been slow to develop. Static models of patients’ hands have been constructed from plaster and alginate (Flatt, 1993, personal communication). Once formed, however, their shape cannot be altered. A single surgical glove applied to a human hand (Lane and Kuschner, 1992) has also been described as a hand model, but requires the presence of an assistant and may be impractical. The technique presented in this article is inexpensive and convenient. This model accurately simulates the plasticity of human skin while retaining the shape and contour of the hand. I have found it to be valuable in visualizing and practicing the design and technique of local skin flaps. References
Fig 3
Z-plasty flaps rotated contracture is redirected
and inset. The and lengthened.
hypothetical
linear
then closed with a wire twist. Skin flaps are drawn onto the hand model and the flaps are raised with scissors and forceps. The flaps can be held in place with clear tape. Utilizing this technique, the author has created a variety of common hand flaps, including Z-plasty (single,
FURNAS, D. W. (1985). Z-p&ties and related procedures for the hand and upper limb. Hand Clinics, 1: 4: 649-665. LANE, C. S. and KUSCHNER, S. H. (1992). A technique for planning skin flaps in the hand. Journal of Hand Surgery, 17A: 6: 116Zm1 163. LISTER, G. D. Skin Flaps. In: Green, D.P. (Ed). Operative Hand Surgery, 3rd Edn. New York, Churchill Livingstone, 1993: 1741-1822. MCGREGOR, I. A. Fundamental Techniques of Plastic Surgwy, 7th Edn. Edinburgh, Churchill Livingstone, 1980: 35-55. SMITH, P. J. and WALTON, J. Local Skin Flaps in the Hand. In: Evans, D. M. (Ed). Skin Cover in the Injured Hand. Edinburgh, Churchill Livingstone, 1992: 27-45. TUBIANA, R. Skin Flaps. In: Tubiana, R. (Ed). Tlze Hand, Vo12. Philadelphia, Saunders, 1985: 257-286.
Accepted: 15 April 1994 H. D. Skoff, M D, 330 Brookline Avenue, Boston, MA 02215, USA. 0 1994 The British Society for Surgery of the Hand
FOR TRAINING FLAPS
IN ELEVATION IN THE HAND
OF LOCAL
SKIN
H. D. SKOFF From the Departments
of Orthopaedic and Plastic Surgery, Harvard Medical School, Beth Israel Hospital, Boston, USA
Appropriate skin flap design is crucial for success in surgery of the hand. Practice models are useful in acquiring surgical experience. The author describes a three-dimensional model composed of readily available materials which has been useful for practice in elevation of local skin flaps in the hand.
Journal of Hand Surgery (British and European Volume, 1994) 19B: 6: 794-795 Skin flaps are an important component of surgery of the hand (Lister, 1993; Smith and Walton, 1992; Tubiana, 1985). Proper skin flap design is necessary, and expertise in the geometry and vascularity of skin flaps is the result of much experience. Three-dimensional models may help surgeons to improve their psychomotor skills in the design and elevation of skin flaps.
Fig 2
Equal-sized
MATERIAL
Fig 1
A simple 60” z-plasty
drawn
z-plasty
flaps raised.
AND METHODS
The materials required are sand, latex surgical gloves (light and dark), wire twists, a marking pen, clear adhesive tape, scissors and forceps. A dark surgical glove is placed upon the surgeons hand, a light surgical glove of equal size is placed over the dark glove. Both are then removed together. The sand is poured into the inner glove until all digits and the hand are filled. The glove opening at the wrist is
in the first web space. 194
FLAP TRAINING
MODEL
195
multiple and four flap), VY advancement flaps, rotation flaps, and transposition flaps to resurface the hand and digits. A simple Z-plasty for a hypothetical first web space contracture is shown in Figures 1,2 and 3 (Furnas, 1985). Gains in length along the contractual diagonal are at the expense of shortening along the transverse diagonal. For the most common angle size of 60”, a theoretical lengthening of 75% is anticipated (McGregor, 1980). DISCUSSION In hand surgery, three-dimensional models for skin flap design have been slow to develop. Static models of patients’ hands have been constructed from plaster and alginate (Flatt, 1993, personal communication). Once formed, however, their shape cannot be altered. A single surgical glove applied to a human hand (Lane and Kuschner, 1992) has also been described as a hand model, but requires the presence of an assistant and may be impractical. The technique presented in this article is inexpensive and convenient. This model accurately simulates the plasticity of human skin while retaining the shape and contour of the hand. I have found it to be valuable in visualizing and practicing the design and technique of local skin flaps. References
Fig 3
Z-plasty flaps rotated contracture is redirected
and inset. The and lengthened.
hypothetical
linear
then closed with a wire twist. Skin flaps are drawn onto the hand model and the flaps are raised with scissors and forceps. The flaps can be held in place with clear tape. Utilizing this technique, the author has created a variety of common hand flaps, including Z-plasty (single,
FURNAS, D. W. (1985). Z-p&ties and related procedures for the hand and upper limb. Hand Clinics, 1: 4: 649-665. LANE, C. S. and KUSCHNER, S. H. (1992). A technique for planning skin flaps in the hand. Journal of Hand Surgery, 17A: 6: 116Zm1 163. LISTER, G. D. Skin Flaps. In: Green, D.P. (Ed). Operative Hand Surgery, 3rd Edn. New York, Churchill Livingstone, 1993: 1741-1822. MCGREGOR, I. A. Fundamental Techniques of Plastic Surgwy, 7th Edn. Edinburgh, Churchill Livingstone, 1980: 35-55. SMITH, P. J. and WALTON, J. Local Skin Flaps in the Hand. In: Evans, D. M. (Ed). Skin Cover in the Injured Hand. Edinburgh, Churchill Livingstone, 1992: 27-45. TUBIANA, R. Skin Flaps. In: Tubiana, R. (Ed). Tlze Hand, Vo12. Philadelphia, Saunders, 1985: 257-286.
Accepted: 15 April 1994 H. D. Skoff, M D, 330 Brookline Avenue, Boston, MA 02215, USA. 0 1994 The British Society for Surgery of the Hand