Local flap cover (rotation / transposition / advancement)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• partial or complete loss of the flap
• dark, swollen flap from poor venous drainage, which may need release of sutures
• bleeding and haematoma under the flap
• wound infection and wound breakdown
• visible, thick or keloid scar, longer than the lesion itself
• skin puckering (dog ear) needing trimming later
• donor area may need a skin graft
• further surgery if the histology shows the tumour is not fully removed

Pre-operative details for this operation

1. Cause of the defectExcision of skin tumourExcision of benign lesionTraumaChronic wound or pressure sorebiopsy result if known
2. Site and sizeexact site, side, lesion size in mm, planned margin
3. Wound readiness (non-tumour defects)debrided, no active infection, healthy bed
4. Patient factorsdiabetes, smoking, anticoagulants or antiplatelets and whether stopped, previous radiotherapy or scars at the site
5. Skin tension lines and lax skin markedYes
6. Photograph before surgeryTaken with consentNot taken

Anaesthesia and position

1. AnaesthesiaLocal infiltrationRegional blockGeneralfor local: drug, strength, with or without adrenaline, total volume and mg/kg
2. IV lineSecured before infiltration
3. Positionprone / supine / lateral, part supported

Operative findings

1. Defect after excisionlength x width x depth in mm, deepest layer exposed
2. Structures exposed in baseSubcutaneous fatDeep fasciaMuscleBone, tendon or vessel (flap needed, not graft)
3. Laxity of surrounding skinGoodModeratePoor
4. Flap perfusion at endPink, good capillary refill, bleeds bright red from edgePaleDusky or congested
5. Tension on closureNoneMildHigh: action taken

Procedure (steps)

1. Markinglesion, margin, skin tension lines, flap outline marked before infiltration; measurements
2. Flap type chosenRotationTransposition: rhomboid (Limberg)Transposition: bilobedTransposition: Z-plastyAdvancement: V-YAdvancement: bipedicled / keystonebase width and length (length to base ratio; random flaps traditionally not longer than 3 times the base)
3. Local infiltrationdrug, strength, volume
4. Excisionmargin taken, depth, specimen oriented with a marking suture
5. Haemostasis of the bedBipolar cauteryMonopolar cauteryLigatures
6. Flap raisedplane: below deep fascia on trunk and limbs, subgaleal on scalp, sub-SMAS on face; perforators preserved where possible
7. Undermining of surrounding skinextent, same plane
8. Back cutNot neededMade to reduce tension
9. Flap moved and insetkey suture first, then inset
10. Donor (secondary) defectClosed directlySplit-skin graft (site)
11. Dog earNoneTrimmed
12. Perfusion check before dressingcolour, capillary refill; sutures released if congested

Closure, drains and dressing

1. Deep layerabsorbable suture (material, size), dead space closed
2. SkinInterrupted monofilament nylon or polypropyleneVertical mattress for eversionSubcuticularmaterial and size
3. DrainNoneSuction drain under flap
4. Dressingcontact layer, absorbent layer, light binding; no pressure on the flap base

Specimens and implants

1. Excised lesion for HPEorientation suture (e.g. long = superior, short = medial), margins to report
2. Tissue discarded (dog ear, trimmed skin)DiscardedSent with main specimen

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Flap checkscolour, warmth, capillary refill at set intervals; report pale or dark flap at once
2. If flap dark and congestedsurgeon to see; release of some sutures
3. Positionno lying or pressure on the flap; limb elevated if on a limb
4. Analgesiadrug, dose, frequency
5. Dressingfirst dressing day
6. Suture removalface about day 5; most of the body after at least a week; back and lower leg day 10 to 14
7. HPE follow upmargins; re-excision if involved
8. Scar care adviceto return if wound opens or scar becomes thick

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery