advancement flap

LaceyCanon

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Conway, AR
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Can anyone help with this procedure, I asked the doc if the raising of the skin flaps was an advancement flap and all he did was do an addendum to his note stating it was a complex repair.

lOPERATIVE FINDINGS:
A 3 cm leg cyst was excised and closed primarily. A 2 cm left shoulder cyst was excised and closed primarily and a 3 cm back skin cyst was excised and closed primarily. The back wound was a 15 x 5 x 3 cm lesion, which involved the underlying fascia and latissimus muscle. This was completely excised. Skin flaps were raised and then a complex 15 cm closure performed.

HISTORY:
The patient is a 43-year-old male who presents with initially an infected sebaceous cyst on his back. He underwent an I and D. Initially, wet to dry dressings were started. He eventually required debridement in clinic. Pathology from this showed a benign proliferating epidermal cyst, which is more likely to develop carcinomatous changes. We discussed close monitoring as we allowed this wound to heal. However, an adjacent sebaceous cyst has become infected and also turned into an abscess and ruptured into the initial wound creating a much larger complex wound. He has another adjacent back cyst as well as a cyst on his shoulder and left knee that he would like excised at the same setting.

DESCRIPTION OF PROCEDURE:
Written informed consent was obtained. All planned lesions were marked with the patient awake, he was then taken from the preop staging area to the operating suite. General endotracheal anesthesia was introduced. He was then transferred to the operating room table in the prone position. All pressure points were padded appropriately. The left shoulder, back and left leg about the lateral portion of the knee were prepped and draped in normal sterile fashion. Time-out was called. I started with the left leg excision and a longitudinal ellipse was made with a 15 blade scalpel over the lesion. The lesion was then excised with a scalpel. Hemostasis was obtained at the base with electrocautery. The wound was then irrigated with peroxide followed by saline. Hemostasis ensured and then closed with interrupted 3-0 Vicryl sutures followed by Mastisol, Steri-Strips and Medipore dressing. We turned our attention next to the left shoulder and local anesthetic was used and then a 3 cm x 1 cm ellipse of skin incised with a 15 blade scalpel. A 2 cm skin cyst was then completely excised using a scalpel and electrocautery. I then irrigated the wound thoroughly with peroxide followed by saline. Hemostasis ensured with cautery and then the wound closed with interrupted 3-0 Vicryl sutures. The wound was dressed with Mastisol, Steri-Strips, and a Medipore dressing. We then turned our attention to the final back skin cyst. This was excised again with a 3 cm x 1 cm ellipse after first anesthetizing the skin. The incision was made as above and the cyst excised in total. The wound was irrigated with peroxide and saline followed by hemostasis using cautery and then closed with interrupted 3-0 Vicryl sutures, Mastisol, and Medipore dressing. We finally turned our attention to the largest wound, a 15 x 5 cm ellipse was incised for complete excision of the infected and sebaceous cyst. This was performed with a 10 blade scalpel. I then used cautery to deepen the incision to the underlying fascia as we excised the mass. The midportion mass that had ruptured below the fascia and into the latissimus muscle. This was taken with the specimen. Once the specimen was completely excised, it was marked with a short stitch superior and a long stitch lateral. I then used skin rakes to raise superior and inferior skin flaps approximately 5 cm to close the wound under no tension. I then irrigated the wound thoroughly with peroxide. We then irrigated with saline and then ensured hemostasis with electrocautery. We then closed in layers 1st with interrupted 3-0 Vicryl sutures for the subcutaneous tissues and deep dermis. The skin was then closed with interrupted 2-0 nylon vertical mattress sutures. This gave a 15 cm complex transverse closure. We did use approximately 30 mL of local anesthetic for the wound. The wound was then dressed with a Medipore dressing. The patient was transferred back to the supine position, awoken from anesthesia and taken to the recovery room in stable condition. All lap, sponge, instrument, and needle counts were correct prior to completion of our case
 
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It reads to me like the raising of the skin was necessary to repair the tissue underneath after the cyst was removed. The skin was then sutured back together from the original incision. Basically a layered closure, which is probably why the additional info was simply "complex repair".
 
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