Getting Started: Planning and Drawing

Abstract

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.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

The wide range of local flaps described in this book may seem overwhelming to the novice. The best approach initially is to familiarize yourself with the classification of local flaps and their broad defining groups. The understanding of how the individual local flaps either advance, transpose, rotate around a pivot point or move by a combination of rotation and advancement is essential. With experience, you will begin to appreciate which flaps work best in different anatomical regions.

Drawing and visualizing what you are planning to do is an essential plastic surgical skill. Not everyone is a natural artist, but with some simple tips and practice, you can improve your drawing skills quite quickly. One approach is to take a digital image and then make a simple line drawing of the image. Onto this, you can outline the edge of the tumour/wound, the resection margins/debridement and the options for local flap repair. A full thickness skin graft may be an alternative repair option or you could let the wound heal by secondary intention (this is commonly the case with forehead flap donor sites).

Fig. 2.1

Simple drawing tools (a), plan for biwinged excision large BCC on the chin (b) and glabellar V-Y transposition/advancement flap for similar infiltrating BCC right medial canthus (c). 5 mm margins of resection and triangulation of the medial canthal defect. Blood supply from the left paranasal contralateral side. A full thickness preauricular skin graft is a good alternative

Fig. 2.2

‘Make a plan and a pattern’—surgical plan and drawings of Captain Harold Gillies FRCS, Queen’s Hospital, Sidcup, Kent (1919) for Private Bell, referred to him by Dr. Charles Valadier from France, following gunshot injury to midface. Glass slide collection shows final result circa 1920. Images courtesy of Dr. Andrew Bamji (former rheumatologist and Gillies Archivist at Sidcup Hospital, Kent, UK and from the Archives of The Royal College of Surgeons of England)

Fig. 2.3

My current camera, Nikon D3100 with a 60 mm F/2 Tamron macro lens. A number of cameras are useful. Woodrow Wilson of www.clinicalimaging.com.au recommends consumer grade DSLR with lens between 60 and 100 mm

Fig. 2.4

Plan for resection and reconstruction of a large infiltrating BCC of the lateral canthal/eyelids periorbital region in a 91-year-old gentleman. Large right lateral periorbital defect anticipated after wide margins of excision, so combination of local flaps planned (see result in Chap. 18)

Planning with Flint’s Circles

These are particularly useful on the trunk and limbs.

Fig. 2.5

(a, b) Flint’s circles changed to ovoid shape to reveal the Relaxed Skin Tension Lines (RSTL) for wide excision of nodular BCC on the right scapular region of a 77-year-old woman. Initial stamps applied with the patient bent over in the flexed foetal position to put the back skin under tension (a). Similar Flint’s circles for a 50-year-old man with BCC same region (b)

Fig.2.6

Flint’s circles used to plan the optimum scar lines for the wide excision of an infiltrating BCC on the presternum of a 65-year-old man and repair with a keystone perforator island local flap