Alternative Free Flaps (Extracorporeal Tissue Transfer).By Ashok Govila and Anshul Govila. Pp. 147. Medad Printing and Packaging, Sharjah, United Arab Emirates, 2003.
Dr. Ashok Govila and co-author Dr. Anshul Govila have summarized many years of experience performing difficult reconstructive procedures using creative alternatives to microvascular surgery. The senior author, Ashok Govila, introduced his ideas in a letter to this Journal in 1989. He subsequently published a number of individual cases, followed by a comprehensive report in 1997 (“An Alternative Free-Flap Technique and 12-Year Follow-Up.” J. Reconstr. Microsurg. 13: 111, 1997). He is an innovative surgeon and must be commended for adapting modern principles of reconstructive surgery to his practice in India and the Middle East, areas with overwhelming medical needs and limited resources. Dr. Govila’s techniques have merit, and studying his previous publications is beneficial. Nevertheless, I am not enthusiastic about this textbook.
It appears to be a family project, with various members serving as authors, editors, producers, illustrators, and publisher, and thereby avoids a more rigorous peer review and editing process. The authors’ profiles seem exaggerated (I wonder who wrote them). The preface contains a colorful and entertaining account of difficulties trying to establish a new microsurgical unit, but I sense a tone of resentment. In chapter 1, Dr. Govila discusses the unequal distribution of “health, wealth, and prosperity on our planet.” He then calls microsurgery a “luxury of the West,” stating that his interest in it has been “extinguished.” He writes of “red tapism,” apparently a reference to prejudice that he believes prevents people who practice in developing countries from receiving recognition for their contributions. These points might deserve discussion, but they seem out of place and distracting in a textbook devoted to techniques in reconstructive surgery.
This text would prove an inadequate guide to an inexperienced surgeon. Chapters entitled “Flaps in the Upper Extremity” and “Flaps in the Leg” contain condensed summaries of anatomy without describing any surgical flaps. The drawings in these chapters show limited detail and do not highlight the key points relevant to performing surgery. Other chapters are devoted to showing these techniques applied throughout the body. The case presentations are fascinating and include good color photographs, but the quality of the drawings is inconsistent. Generally, I do not think they would be helpful to one unfamiliar with these techniques. Missing in previous publications and in this text is a thorough discussion of how to avoid morbidity associated with the prolonged immobilization required for these staged techniques (e.g., joint immobility), particularly in elderly or lower extremity patients.
Finally, Dr. Govila and his co-author do not appear to appreciate that their methods are essentially staged tissue transfers using modern surgical flaps instead of random skin tubes. They invent terminology (e.g., “extracorporeal tissue transfer” and “alternative free flap”) which sounds novel, but these are staged pedicle flaps and should be referred to as such. Their contribution is in combining a time-honored principle with contemporary flap designs.
The shortcomings of this textbook should not obscure the value of these methods. We are indebted to these authors for demonstrating the utility of these techniques. We would do well to consider this option for selected patients no matter where in the world we practice.
Michael J. Miller, M.D.
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