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. The surface of this roll drain is powdered well with aristol or iodol and it is gently placed beneath the flap so that it rests easily upon the same. 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.
This dressing may be changed the second day, when the flap will appear anemic. Signs of discoloration indicate gangrene, which is difficult to overcome. In a short time the skin takes on a pale pink color, which indicates a reëstablishment of circulation, and granulations begin to show themselves on the reverse side, which, as they multiply, soon thicken the flap sufficiently for the purpose desired.
The dressings are continued, as begun, if there be no indication for interference, although the granulations may be stimulated if too inactive. Gently irritating the granular surface with a 1-3,000 sublimate solution, although rarely permitted by most surgeons, does no harm; in fact, it is to be recommended before reapplying the dry dressing.
In removing the dressings the edges of the flap will be found to adhere to the gauze; this may be gently lifted with the tenaculum, after previous softening with a weak solution of hydrogen peroxid.
Pus (laudable) is the natural secretion from these flaps. 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. This must be cauterized along the edge with the caustic pencil, keeping the granulations within the desired limit until the opposite layer of skin has either cicatrized with it or has been grafted near it for the same purpose. The surface is then antiseptically treated, as any granulating surface, except as otherwise indicated.
Foreign Bodies.—Especial care must be exercised with wounds into which foreign bodies have been implanted. Under favorable conditions many are kindly received by the tissues, but often these rebel and even with the greatest of care in dressing such wounds will often result in the necessity for removal of the substance. Individual cases of such nature are fully referred to later.