The role of general surgeon in Canada continues to evolve. Where once the rise of specialist surgery eroded the requirement for services provided by general surgeons, the current lack of access to certain types of care has increased the burden on general surgeons, who are now ill-equipped to meet these demands. In this issue of the Canadian Journal of Surgery, 2 new textbooks of plastic surgery are reviewed. The second book, which deals with a topic likely to remain the preserve of the specialist, is reviewed because of its significant Canadian content. The subject of the first book, has so far found no surgical specialty champion.
PERFORATOR FLAPS: ANATOMY, TECHNIQUE & CLINICAL APPLICATIONS. P.N. Blondeel, G.G. Hallock, S.F. Morris, P.C. Neligan, editors. St. Louis (MO): Quality Medical Publishing, Inc; 2006. 1096 pages and DVD; CDN $500. ISBN 1576261786
Perforator flaps: anatomy, technique & clinical applications masterfully provides the current level of knowledge in a relatively new phase of flap surgery. The text is organized into 4 parts. Part 1 outlines the fundamental concepts in perforator flap surgery. These introductory chapters provide the history of flap surgery; the vascular anatomic basis of flaps; an important and well-explained overview of nomenclature, plus reviews of injection techniques (laboratory); flap physiology; use of colour Doppler for preoperative planning; and advice on how to avoid complications. The chapters on anatomy and nomenclature crystalize various terms and classifications that have been used over the last 3 decades into a classification that makes practical sense. The text brings together information provided by many different authors and provides a unified classification that is easier to understand and use.
In part 2 of the text, flap anatomy and surgical techniques are reviewed by region, with sections on the head and neck, the upper extremity, the trunk and the lower extremity. The injection studies are impressive. The simplified illustrations are excellent and support the written material. Most skin flaps described are reviewed, classified and illustrated. The clinical photographs are well chosen and tidy. The references are extensive and often include brief summaries of the articles for those who wish to read further. A few of the chapters overuse the abbreviations provided in the chapter on classification, making it more difficult to follow the flow of the text; however, inside the front cover of each volume there is a complete list of flaps and abbreviations.
Part 3 provides clinical applications of various flaps by region. Once again, the use of high-quality photographs helps to illustrate the case examples. The clinical cases often demonstrate situations where flaps other than perforator flaps might be used to deal with the defect. Some of the flaps chosen by the authors might be more difficult than flaps the average microsurgeon or plastic surgeon would chose to close the same defect. However, the cases chosen do illustrate the versatility and availability of flaps not commonly used in a typical plastic surgery practice. The authors cause the plastic surgeon readers to think a little more about blood supply to the skin rather than set flap designs, which we sometimes do with too little thought about the vasculature. Conversely, the cases sometimes provide simpler solutions to cases that we have all struggled with and used microsurgical techniques to solve; the authors show the value of pedicled perforator flaps in many settings.
Part 4 discusses controversies and future directions of perforator flap surgery. The concept of “freestyle” local perforator flaps is nicely reviewed, and clinical cases are provided for the nonbelievers. Freestyle free flaps are also described and lead to a chapter on supermicrosurgery and perforator-to-perforator free flaps. The ultimate technical challenge is presented with chapters on ultrathin perforator flaps and microvascular augmented superthin flaps. Nonmuscle perforator flaps, in particular neurocutaneous perforator flaps, are also discussed in this section.
This book is written for all flap surgeons. General surgeons will learn from the descriptions of the vascular basis for skin flaps and from the refined approach to how skin flaps should be designed and elevated. The average microsurgeons will think differently about flap anatomy after reading this book and might want to step further into the exciting field of supermicrosurgery. The editors' enthusiasm is obvious, and they have produced a state-of-the-art text that is well organized, well written and beautifully illustrated (including a DVD illustrating 4 flaps). They state their hope that the book will be a “modest contribution to the further development of medical science and, what is most important, to the improved care of our patients.” There is no doubt that this text will accomplish both goals. It should be part of any flap surgeon's library.
Brian Evans, MD Division of Plastic Surgery Department of Surgery University of Western Ontario London, Ont.
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Competing interests: None declared.