PRINCIPLES OF PLASTIC SURGERY
Plastic surgery is resorted to in covering defects of the skin due to
congenital or traumatic malformation, injuries, burns, the removal of
neoplasms, or the ulcerative processes of disease. Furthermore, it can be
employed cosmetically for the rebuilding of organs, whole or in part, or
for their reduction when abnormally developed. This applies particularly
to the nose, ears, and lips, wherein it may involve either the skin alone
or the mucous membranes, or all the tissue making up the parts operated
on.
=Incisions.=—The incisions in plastic surgery are to be made obliquely
into the skin rather than at right angles to the surface, the former
permitting of better apposition, and undoubtedly causing less epidermal
scar. The incisions include the skin only, except when otherwise stated.
=Sutures.=—Sutures should be placed not more than ¼ of an inch apart and
be made to include the skin only, unless it is deemed advisable to employ
deeper ones to relieve undue traction, which often results in suture
scars and ofttimes tissue loss, necessitating further operation. The
latter may be obviated by placing every other stitch at greater distance
from the free edge of the skin, that is, into the undissected border.
Intracutaneous sutures may also be employed, but these are rarely, if
ever, necessary if the apposition has been properly accomplished. To
relieve tension, harelip pins are also used, as later described. Catgut
of such size as would be suitable because of its ready absorption is not
to be employed for skin suturing, fine twisted silk or selected horsehair
being the best material.
Formaldehyd catgut can be used if it is desirable; its fine strands
withstand absorption to a greater degree than the ordinary.
[Illustration: FIG. 37.—⅝ CIRCLE HAAGEDORN NEEDLES.]
[Illustration: FIG. 38.—CRESCENT CURVE HAAGEDORN NEEDLES.]
_Needles._—Very fine, flat, round-eye needles, such as Haagedorn’s,
Nos. 12 to 15, ½ or ⅝ circle, are the most serviceable in skin work, as
they incise the skin in penetrating and leave an elongated slit, which
heals readily, rarely leaving a needle scar. The selection of needles,
however, must be left to the operator, many preferring the one variety to
the other. Split-eye needles are quite convenient, but they break more
readily, and while they work best with fine silk, this is more readily
withdrawn from the eye at undesirable times. For very delicate work the
needles mentioned are the best.
_Needle Holders._—Inasmuch as the needles used in plastic operations are
very small and fine, proper needle holders must be used. The requisitions
are that the jaw be long, narrow, of soft copper, and that they have an
automatic lock attachment. Plain needle holders may be used, but at times
the locking device is very necessary and saves time. The most serviceable
of this class are the Kersten modification of Mathieu, an uncomplicated
holder of merit (Fig. 39), and the small Haagedorn, five-inch narrow-jaw
holder (Fig. 40), or the holders taking similar needles, as shown
in Figs. 41 and 42, known as Pozzi’s and Weber’s modifications,
respectively.
[Illustration: FIG. 39.—KERSTEN-MATHIEU NEEDLE HOLDER.]
[Illustration: FIG. 40.—HAAGEDORN NEEDLE HOLDER.]
[Illustration: FIG. 41.—POZZI-HAAGEDORN NEEDLE HOLDER, 5 IN.]
[Illustration: FIG. 42.—WEBER-HAAGEDORN NEEDLE HOLDER, 6 IN.]
[Illustration: FIG. 43.—NEEDLE WITH SUTURE CARRIER.]
Holders with cup jaws serrated at different angles are of no value,
unless other needles are used with them, as they invariably break the
flat ones.
To overcome the necessity of rethreading or the use of many needles,
the very ingenious holder with ligature carrier can be used, especially
where the surgeon does not care to sew with a long, free thread. The silk
can be sterilized on the metal spool separately and inserted within the
handle of the holder, as shown in Fig. 43.
METHODS IN PLASTIC OPERATIONS
THERE ARE FIVE DISTINCTIVE METHODS EMPLOYED IN PERFORMING PLASTIC
OPERATIONS:
I. Stretching of the margins of the skin.
II. Sliding flaps of adjacent skin.
III. Twisting pedunculated flaps.
IV. Implantation of pedunculated flaps by bridging.
V. Transplantation of nonpedunculated flaps or skin grafting.
This classification differs from that heretofore generally given in the
meager literature on the subject, but the author believes his arrangement
to be more scientifically exact as well as simpler for recording and
history purposes.
I. STRETCHING METHOD
In the stretching method the defect is neatly excised, so as to freshen
the margins to be brought together. It may be necessary, if the defect
is too large for free apposition, to dissect the skin away from the
underlying tissue to render it more movable and to overcome tension. The
shape of the incision depends largely upon the nature of the defect and
must be made with a view of leaving as little scar as possible. Where the
defect is somewhat _linear_, or elongated, an elliptical incision (_A_)
is made, as in Fig. 44, and, if necessary because of too great tension,
the skin is undermined sufficiently to allow the parts to come together;
if this cannot be done readily, two semilunar incisions (_b_, _b_) must
be added. This will allow of ready coaptation. The wound is then brought
together with an interrupted suture, appearing as in Fig. 44_a_, the
semilunar spaces being allowed to heal by granulation.
[Illustration: FIG. 44.
CELSUS INCISIONS.]
[Illustration: FIG. 44_a_.
CELSUS RELIEVING INCISIONS.]
In excisions in small rhomboidal form, the skin is merely dissected up
and around the wound, the same as in Fig. 45, and the wound is sutured in
linear form, as shown in Fig. 46.
[Illustration: FIG. 45.
RHOMBOID EXCISION.]
[Illustration: FIG. 46.
UNION OF RHOMBOID EXCISION.]
If the defect is oblong in form, the angles are brought together wholly,
leaving a small surface to granulate, as in Fig. 47, or they are drawn
toward the center, leaving the remainder of the parallel lines to be
sutured, as shown in Fig. 48.
[Illustration: FIG. 47.
OBLONG EXCISION.]
[Illustration: FIG. 48.
COAPTATION OF SAME.]
Another method of overcoming a smaller defect of similar form is to
excise a small triangular portion of skin at either side of the oblong,
as in Fig. 49, and then with or without dissection bringing the margins
together in linear form, as in Fig. 50.
[Illustration: FIG. 49.
BITRIANGULAR EXCISION.]
[Illustration: FIG. 50.
LINEAR COAPTATION.]
Likewise can a triangular fault be brought together by sewing in the
greater angles and making a linear wound of the remaining part, as in
Figs. 51 and 52.
[Illustration: FIG. 51.
TRIANGULAR EXCISION.]
[Illustration: FIG. 52.
COAPTATION OF WOUND.]
Again, a triangular defect may be remedied by adding a smaller triangle
at each end involving healthy skin, utilizing, if need be, the relieving
incisions, as in Figs. 53 and 54.
[Illustration: FIG. 53.
TRIANGULAR EXCISION WITH RELIEVING INCISION.]
[Illustration: FIG. 54.
COAPTATION OF WOUND.]
II. SLIDING METHOD
Following the principle of Celsus, as mentioned on page 8, defects can be
overcome in various ways. The incisions may be straight or curved, and
one or more flaps of skin are raised, slid, and sutured over the part to
be covered. The simplest form is the covering of a square, as shown in
Figs. 55 and 56.
[Illustration: FIG. 55.
SQUARE EXCISION.]
[Illustration: FIG. 56.
COAPTATION OF WOUND.]
If the square be too large for the above method, the incisions can be
carried to the other side and above or below the defect, as shown in
Figs. 57 and 58.
[Illustration: FIG. 57.
SQUARE EXCISION.]
[Illustration: FIG. 58.
COAPTATION OF FLAPS.]
For triangular areas the curved incisions can be made, as in Fig. 59,
rotating the flap into place, as shown in Fig. 60.
[Illustration: FIG. 59.
TRIANGULAR EXCISION.]
[Illustration: FIG. 60.
COAPTATION OF FLAP.]
Or bilateral flaps may be utilized by straight incisions, stretched and
sewn, as in Figs. 61 and 62.
[Illustration: FIG. 61.
TRIANGULAR EXCISION.]
[Illustration: FIG. 62.
COAPTATION OF FLAPS.]
Again, two curved incisions are made to obtain rotating flaps, Fig. 63,
and sewn, as shown in Fig. 64.
[Illustration: FIG. 63.
TRIANGULAR EXCISION.]
[Illustration: FIG. 64.
ARRANGEMENT OF FLAPS.]
Bürow introduced a method for closing over defects by sliding flaps
in which he utilized the mobility of skin obtained by the excision
of triangles of healthy skin. The results are exceedingly good, but,
unfortunately, the sacrifice of skin affects its general use, inasmuch as
patients can afford but little loss of healthy skin; besides, there is
the objection of added scarring. The closing of a triangular defect by
this method is shown in Figs. 65 and 66, in which _a_ is the triangular
defect and _b_ the triangle of healthy skin excised. The skin about the
incisions is dissected up and the flaps are sutured into position, as
shown in Fig. 66.
[Illustration: FIG. 65.
DOUBLE TRIANGULAR EXCISION.]
[Illustration: FIG. 66.
COAPTATION OF WOUND.]
Where the triangular defect has a wide base, bilateral triangular
sections of skin are removed (Fig. 67), and the flaps are coapted, as in
Fig. 68.
[Illustration: FIG. 67.
TRI-TRIANGULAR EXCISION.]
[Illustration: FIG. 68.
COAPTATION OF WOUND.]
Through the sacrifice of two triangles a large oblong or square defect
may be covered, the excisions being shown in Fig. 69 and the suturing in
Fig. 70.
[Illustration: FIG. 69.
RECTANGULAR-BITRIANGULAR EXCISION.]
[Illustration: FIG. 70.
COAPTATION OF WOUND.]
III. TWISTING METHOD
Although in several of the above methods the flaps are rotated and
slightly twisted, the following are only classified with those under this
division.
Where an elliptical defect is to be obliterated the curved incision shown
in Fig. 71 can be satisfactorily employed, leaving but a small area to
granulate over. The suturing is depicted in Fig. 72.
[Illustration: FIG. 71.
WEBER METHOD.]
[Illustration: FIG. 72.
COAPTATION OF FLAPS.]
In this the twisting of the flaps is but little, while in the following,
in which the defect is of similar shape, the twisting is more apparent;
so much so, that a fold at the root of the flap may be induced to some
extent. The excision and incisions are shown in Fig. 73, and the method
of bringing the parts together in Fig. 74, leaving a small area for
granulation.
[Illustration: FIG. 73.
ELLIPTICAL EXCISION.]
[Illustration: FIG. 74.
COAPTATION OF FLAPS.]
Considerable twisting of flaps is shown in covering triangular parts in
Figs. 75 and 76.
[Illustration: FIG. 75.
TRIANGULAR EXCISION.]
[Illustration: FIG. 76.
COAPTATION OF FLAPS.]
In this only a small surface is left to granulate over, while in the
following the parts are entirely covered. The excision and incisions are
shown in Fig. 77, and the method of approximation and suturing in Fig. 78.
[Illustration: FIG. 77.
TRIANGULAR EXCISION.]
[Illustration: FIG. 78.
COAPTATION OF FLAPS.]
In covering a square area considerable twisting must be resorted to, as
shown in Figs. 79 and 80, leaving a portion to granulate.
[Illustration: FIG. 79.
LENTENNER METHOD.]
[Illustration: FIG. 80.
COAPTATION OF FLAP.]
Where the area is irregular and formed somewhat as in Fig. 81, bilateral
incisions are made and the flaps twisted into place and sewn, as in Fig.
82.
[Illustration: FIG. 81.
BURNS METHOD.]
[Illustration: FIG. 82.
COAPTATION OF FLAPS.]
IV. IMPLANTATION OF PEDUNCULATED FLAPS BY BRIDGING
In this method the flap to be utilized in covering a defect is taken from
a distant part of the body, as, for instance, from the arm. The flap
thus taken at first remains attached at its distal end to the tissue of
the arm by a pedicle, which is not severed until a circulation has been
established between the flap and the part of the human economy to which
its free end has been attached by suture, the arm being held in position
in the meantime by a suitable contrivance, as shown in Fig. 83.
[Illustration: FIG. 83.—TAGLIACOZZA HARNESS.]
These pedunculated flaps, bridging over space, may likewise be taken from
the forearm, the hand, or the thoracic region.
When thoracic flaps are used they may be directly sewn at their free ends
to the part to be covered, as, for instance, in the forearm or arm, or
they are stitched to the forearm to be later transferred to another part
of the body after their circulation had become established.
The various methods of the employment of these bridging flaps will be
taken up individually in their respective places farther on.
V. TRANSPLANTATION OF NONPEDUNCULATED FLAPS OR SKIN-GRAFTING
Where there is loss of skin due to injury or operative procedure the
parts may heal by granulation, but as this requires much time, and the
consequent cicatrice causes considerable deformity, the granulating or
freshly made wounds are covered with so-called detached skin flaps or
grafts, when the former methods of plastic surgery cannot be followed.
The methods employed in skin-grafting may be classified as: 1,
autodermic; 2, heterodermic; 3, zoödermic.
1. _Autodermic_, when the grafts are taken from the tissue of
the patient.
2. _Heterodermic_, when the grafts for the patient are taken
from other persons.
3. _Zoödermic_, when the grafts for the patient are taken from
the lower species.
The former two classes may for convenience be again subdivided into
1. (_a_) Auto-epidermic.
(_b_) Autodermic.
2. (_c_) Hetero-epidermic.
(_d_) Heterodermic.
The third class will permit of a great many subdivisions, too numerous to
mention, each taking its name from the source of the graft.
_1. Autodermic Skin-grafting_
=a. Auto-epidermic Skin-grafting.=—The method of covering granulation
areas with small circular pieces of detached skin, pin grafts, was first
advocated by J. Reverdin in 1870. The Reverdin method is applicable to
healthy granulating surfaces only. The small lentil-form skin grafts
are obtained from the arm or other suitable part of the body by raising
the superficial layer of the skin with a tenaculum hook and cutting the
conelike elevation off with delicate scissors. The grafts thus obtained
contain the epiderm and corium and a slight base of the Malpighian layer.
They are immediately transferred, without handling, to the granulating
surface and fixed by the gentle pressure of the hook point.
The skin may be transfixed with an ordinary sewing needle and the
graft cut away with a delicate flat knife or razor blade, or scissors
especially designed for the purpose may be used. (See Fig. 84.)
[Illustration: FIG. 84.—SMITH SKIN GRAFTING SCISSORS.]
A number of these grafts are often needed to cover a defect, in which
case they are placed side by side upon the surface with a little space
between their borders. Several such operations may be necessary, as many
of the grafts are liable to die from malnutrition, pressure, or defective
cutting.
The granulating surface to be covered in this manner must first be
cleansed with a weak sublimate solution, followed by a sterilized
normal salt solution. When an ulcerated or denuded surface requires
skin-grafting, the best time to begin is as soon as there is evidence
of the formation of new skin at the edges of the wound; in other words,
when reparative action is becoming established. This does not apply to
surfaces just denuded over healthy areas for plastic purposes, which
should be grafted immediately.
The grafts, having been placed, are covered with a layer of very thin
protective silk, or gutta percha, over which a soft gauze or cotton
dressing may be applied, borated absorbent cotton being most suitable.
_Thiersch_ recommends the use of gauze compresses saturated in the normal
salt solution, which are changed each day.
Another method of covering the grafts is to use perforated silk or small
strips of the same material, which permit the dressings to absorb the
excretions from the wound and also allow of the free use of either weak
antiseptic or sterile salt solutions.
The use of silk or rubber prevents the adhesion of the grafts, which
would otherwise be torn away by the removal of dressings, although
iodoform gauze answers the purpose very well. It can be safely lifted by
first thoroughly wetting it with the normal salt solution.
Strips of tinfoil, first rendered aseptic by immersion in a 1-1,000
sublimate solution and then dipped into sterilized oil or two-per-cent
salicylized oil, have been recommended by _Socin_. Goldbeaters’ skin has
also been advocated.
A method that has proved of great value in America is that of
skin-grafting in blood. In this method the grafted site is covered with
perforated protective silk or rubber tissue, covered with a thin layer of
absorbent cotton, or, better, several folds of sterilized gauze, which is
kept wet constantly with bovinine. The latter undoubtedly is the means of
keeping life in the grafts by supplying the necessary nutrition until the
grafts have formed vascular connection, have become firmly adherent, and
begin to spread or grow out at their edges.
The living grafts remain as pale islets of skin, which throw out thin
epidermal films that meet and grow thicker, until finally the interjoined
grafts assume all the functions of normal skin.
It is often necessary to reduce or scarify the edges of the healthy skin
that has become thickened where the grafts meet it. This is permissible
only when the grafts have become firm and thrive, and may be accomplished
by the careful and intelligent use of pure carbolic acid applied with a
wooden pick, or by the employment of a stick of fused nitrate of silver,
care being taken not to come in contact or to allow the cauterant to
touch directly or in solution the new skin.
=b. Autodermic Skin-grafting.=—Larger pieces of skin may be excised from
selected parts of the body, preferably the outer side of the arm, and
utilized to cover the entire defect. The piece of skin is cut about one
third larger than the size and shape of the area to be covered. This
method was first introduced by _R. Wolfe_ in 1876, and gives splendid
results. He advises removing all subcutaneous adipose tissue from the
graft by gently cutting it away with fine scissors or the razor, and then
loosely suturing the flap to the skin surrounding the denuded defect.
Granulating surfaces must first be freed of their loose superficial
layers with a sharp curette and the bleeding controlled by
sponge-pressure before the flaps are placed. The edges of the wound made
by the excision of the flap are simply sewn together, or one of the
plastic methods may be used to accomplish the same. Unfortunately these
flaps, if they thrive, contract, leaving uncovered spaces, which must be
treated separately or allowed to granulate. The dressing in this case is
the same as in the Reverdin process.
_F. Krause_, of Altoona (1896), advocates the use of freed flaps from
which the subcutaneous adipose tissue has not been removed, holding that
in the healing of such there is less contraction to follow. The success
in both of the above methods depends upon an early vascular connection,
as considerable nutrition is necessary to supply their want. The blood
dressing has aided much in bringing about a happy result. The latter is
continued in the manner described for about ten or twelve days, when the
grafts may be allowed to depend upon their own circulatory supply. The
parts must, in the meantime, be kept at rest and all undue pressure is to
be avoided.
These grafts, while becoming organized, change in color more or less from
a light gray to a bluish gray and shed off their epitheliar layers, while
the _cutis vera_ remains, rebuilding its squamous covering eventually and
leaving the surface quite normal.
At times small points of the flap, where subjected to undue pressure or
interference, will turn dark and break down, sloughing away and leaving
the granulating surface exposed. These areas are, however, soon recovered
by skin cells being thrown out from the infral edges of the graft. Often
the use of the nitrate-of-silver stick, applied gently at various tardy
points, will hasten the process of repair.
The most satisfactory results in skin-grafting are those obtained by
the method introduced by _Ollier_, of Lyons, in 1872, and perfected by
_Thiersch_, of Leipzig, 1874. His method is now almost entirely used
for covering large defects. The grafts can be applied over connective
tissue, periosteum, bone, and even adipose tissue. The grafts consist of
very thin strips of skin taken from the extensor surface of the arm or
the anterior region of the thigh, after thorough antiseptic preparation.
They should be taken from the patient in preference to those of other
individuals or the new-dead or freshly amputated parts.
Granulating surfaces are scraped clean of their superficial or loose
layer, while fresh wounds may be covered at once or a few days after
having been made, antiseptic compresses being used in the meantime.
Hemorrhage is controlled at the time of grafting by sponge-pressure or
torsion of the small vessels.
In this, as in the former method, it is desirable that the surface to be
covered be free from loose tissue and dry (_Garre_).
For the removal of the strips the Thiersch razor is to be used. It is
concave on its upper side and plane below, the blade being bent at an
angle to the handle (Fig. 85). Folding razors of the same type can be
procured; their advantage lies in having a protecting case when not in
use.
[Illustration: FIG. 85.—THIERSCH RAZOR.]
Slide fixation locks are a valuable addition to the latter, as they hold
the blade in place when open. See Fig. 86.
[Illustration: FIG. 86.—FOLDING RAZOR.]
The site from which the graft is to be taken is first thoroughly scrubbed
and washed, then cleansed with an antiseptic solution. The skin of the
anterior surface of the arm or upper thigh is usually chosen. The skin of
the part is made tense with the left hand, while the point of beginning
is slightly raised by the assistant with the aid of a tenaculum hook. The
razor, dipped into sterile salt solution, is now taken in the right hand
and by quick sawing movements, the plane side being placed next to the
limb, a strip of skin is detached (Fig. 87), which, as it is cut, glides
in folds upon the concave side of the razor.
[Illustration: FIG. 87.—METHOD OF CUTTING THIERSCH GRAFT.]
The uppermost layer of the skin is removed, including epidermis, the
Malpighian and papillary layers, as well as a small portion of the
stroma. _Hübscher_ includes only the epidermis and the upper portion of
the papillary layer, with equal success.
The length and width of the strips so removed must be made according to
the defect to be covered. Their width may be made as much as two inches
and their length not to exceed four inches.
The collected strip of skin, still on the razor, is now brought to the
place of grafting and, with the point of a needle placed at its farther
end, is slid off upon the part to be covered and allowed to fall in place
by the gentle backward withdrawal of the razor blade, as shown in Fig.
88.
[Illustration: FIG. 88.—METHOD OF PLACING THIERSCH GRAFTS.]
The graft may be smoothed out with the needle held flatwise or be stroked
down gently, so that its fresh surface makes contact with every portion
of the part covered, a precaution the author considers important to
obtain the best results.
If the defect is large, and where several grafts are needed, the second
flap thus obtained is made to slightly overlap the one already placed,
and so on. The free, or distal, ends of the flaps are made to slightly
overlap the skin or that of a graft placed endwise to it. Every part of
the wound should be covered.
As soon as this has been accomplished the strips are powdered over
with iodol or aristol or protected with some antiseptic gauze (boric
or iodoform), or covered with strips of lint smeared with borated
petrolatum, over which light, teased-out pieces of sterilized cotton are
placed. A gauze bandage may be utilized to hold all in place.
It is quite necessary to have the part kept at rest so as not to displace
the skin-graft arrangement. If the antiseptic powder has been used
the dressings need not be disturbed for a week or ten days, but the
petrolatum dressing must be changed every third day, care being observed
not to disturb the grafts.
Perhaps the best success is obtained by the aid of perforated rubber
tissue, covered with gauze dressing, constantly kept wet with bovinine
for ten days.
In healing, parts of the grafts may die, leaving small areas to
granulate over, but ordinarily the cicatrization resulting therefrom
is indeed slight. From the observations of E. Fisher, it seems that
the most successful results are obtained when the grafts are taken and
transplanted under the bloodless method of Von Esmarch.
_2. Heterodermic Skin-grafting_
=c. Hetero-epidermic Skin-grafting.=—A novel method of covering wounds
with skin is advocated by Z. J. Lusk, of Warsaw, N. Y., 1895, in which
small squares of epithelium, previously prepared, are placed upon the
granulating surface, over which a dressing of sterilized gauze is placed,
saturated with a mixture of balsam of Peru, ʒj, and ol. Ricini, ℥j, and
covered with several layers of sterilized absorbent cotton. The dressing
is allowed to remain undisturbed until the tenth or twelfth day, unless
there is an accumulation of pus.
The advantage of this method is that the epidermal layers can be
collected at random from various patients who present themselves with
blistered surfaces—the result of burns—or where the skin has been raised
by some blistering process for counterirritative reasons.
This loose skin is collected and spread upon a glass plate and sterilized
in warm boric-acid solution, then allowed to dry in this position to
prevent curling, and, when dry, cut into desirable sizes and laid away
for future use.
=d. Heterodermic Skin-grafting.=—In this mode of skin-grafting the
pieces of skin are taken from freshly amputated limbs of one patient or
from any selected part of the body of the newly dead, and placed upon
the defects to be covered in another patient. These grafts have been
successfully employed even after ninety-six hours had elapsed between
the time of amputation or the death of a person and the taking of the
skin-grafts.
The method employed is as follows: The site of the amputated member or
dead body from which the skin is to be taken is thoroughly cleansed, as
in the Thiersch method. Pieces of the skin, including the subcutaneous
tissue, but no fat, are cut from the cleansed parts. These sections are
cut into smaller pieces, about one inch square (_Hartman_ and _Weirick_),
and placed upon the granulating surface to be covered, leaving
one-half-inch wide interval between each piece.
The grafts are then covered with overlapping narrow strips of rubber
tissue, over which a normal saline dressing is applied. The outer
dressing is composed of gauze saturated with the same solution. These
dressings are changed every twenty-four hours.
The grafts will soon be found to adhere, showing a pinkish color in about
six days; those showing a tendency to undergo gangrene or a laziness of
attachment at this time are removed.
In about two weeks the epitheliar surfaces of these grafts are thrown
off, as with other grafts already mentioned, and shortly thereafter a
new, deep-pink epithelium is formed, the ends of the grafts throw out
epitheliar cells, which soon coalesce with those of the neighboring
grafts, eventually taking on the normal appearance and vitality of skin.
_3. Zoödermic Skin-grafting_
The advantage of using zoödermic grafts is that the patient is saved the
ordeal of general anesthesia and the secondary wound occasioned by the
removal of the graft, which necessarily leaves more or less of a scar.
The grafts for this purpose may be taken from freshly killed animals,
such as dogs, rabbits, frogs, kittens, etc.
The best results, in the estimation of the author, are obtained by the
use of the skin taken from the abdominal region of dogs.
The method for preparing these grafts is to kill a healthy animal,
thoroughly cleansing the skin of the abdomen, as already described in the
taking of any graft.
The entire abdominal surface is neatly shaved under antiseptic
precautions and the skin is dissected off in one piece, leaving the
subcutaneous tissue. It is then placed in a warm boric-acid solution and
cut into small pieces, say one or two inches square, according to the
size of the defect to be covered.
These pieces are placed upon the granulating surface and firmly pressed
into place, so that they are in close contact throughout their area.
Other pieces are placed quite near or even in contact with the edge of
the first, and so on, until the space is entirely covered. Boric-acid
dressing of any desired form is placed over them and superimposed by
loose gauze and bandage.
The dressing should be left undisturbed for at least forty-eight
hours, and then be gently removed and renewed. The utmost care should
be exercised with the dressings, since here lies the success of the
whole result. The blood dressings have given excellent results in cases
undertaken by the author, and should be resorted to whenever practicable.
The method has already been fully described, and does not differ in the
event of employing zoödermic grafts.
When boric-acid dressings are used, they should be changed every day
after the first dressing has been removed, so that the behavior of the
grafts can be closely watched.
Lazy grafts and those showing signs of sloughing should be removed at
once, and granulations crowding through the grafts should be snipped off
with a fine scissors, as they are liable to destroy the life of a graft
by pressure or by crowding it away from its bed of nourishment.
As in dermic grafts, the upper layers of these plaques will be thrown
off, giving at times the appearance of total sloughing, yet on
interference the deeper layers will be found to be intact and healthy.
The dressings should be continued until the grafts have not only
established their circulation, but until their edges have firmly united
and the surface has taken on a dull reddish color, which eventually fades
to a shade somewhat paler than the normal skin. The hairs that have been
carried over with the grafts at first seem to thrive, but eventually drop
out, leaving the surface bare. Spots of color so often observed in the
skin of the bellies of dogs also disappear from the grafts, leaving their
color uniform.
Amat, in 1895, claims that good results in skin-grafting are obtained by
substituting the epidermal pin grafts with the film or inner-shell lining
membrane of the fresh hen’s egg. For this purpose as fresh an egg as can
be obtained is used. It is broken along the horizontal axis. A delicate
forceps is now made to grasp the free membrane found at the air chamber
of the enlarged end of the egg. The inner lining is drawn away from the
shell in pieces four or five millimeters long; these pieces are cut with
a fine scissors into equal lengths and placed with the point of the
scissors to the granulating surface to be covered, in the same way as the
Reverdin grafts. Amat covered the grafts with tinfoil, over which were
placed several lays of carbolized gauze. The dressings were changed every
three or four days.
The skin of the frog has successfully been implanted upon granulating
surfaces by Baratoux and Dobousquet-Laborderie. They observed that the
peculiar pigmented mottling of the skin disappeared about the tenth day,
and that the grafts gradually took on the appearance of human skin
thereafter.
The best results in this method are obtained with the skin taken from the
back of the frog in preference to that of the belly or legs. This skin is
cut into pieces about one fourth inch square, which are placed upon the
granulating surface in rows, each graft being separate from its neighbor
by a space of half an inch.
At the end of forty-eight hours the plaques of skin will have adhered to
the granulating surface. At the end of five days they lose their original
color and send out cells of epithelium to each neighboring square.
The dressing to be applied over the flaps should consist of borated
vaselin, one dram to the ounce, which is smeared upon strips of sterile
gauze, over which loose gauze is placed, held in place by a roller
bandage.
The skin, once organized, is very thin, as a rule, and requires more or
less care for some time after.
_General Remarks_
The skin of the grafted area will always present a different appearance
from that of the healthy skin, both as to color, which is always paler,
and in texture. The grafted portion is usually slightly elevated above
the healthy skin, giving it an edematous look.
It has been found that skin grafts taken from the negro take more
successfully than those from the white race. White skin flaps placed upon
the negro do not meet with much success. In this event, however, the
newly grafted skin soon takes on the color peculiar to the negro and vice
versa (Thiersch).
The investigations of Karg seem to show that the pigmentation of skin is
not secreted in the rete, but is carried to it by wandering cells arising
from the deeper layer. Von Altmann has discovered certain cell granules,
termed by him bioblasts, which he believes are responsible for the
production of the pigmentary deposits under peculiar influences of the
blood.
MUCOUS-MEMBRANE-GRAFTING
The grafting of mucous membrane, both from the animal and man, has been
accomplished by Wölfler. His methods are particularly applicable to the
restoration of the conjunctiva, mucous membrane of the cheek, etc. Under
certain circumstances pedunculated skin flaps have been folded inward to
serve as the mucous membrane by Gersuny. When mucous-membrane flaps were
taken from the animal, the conjunctiva of the rabbit has been preferred.
Under peculiar circumstances, though rarely, mucous-membrane flaps may be
utilized to cover denuded skin areas. The mucous membrane, in such cases,
in about ten days takes on the appearance of the skin.
Ofttimes, when it is impossible to obtain foreign mucous membrane, grafts
may be taken from the inner surface of the lips of the patient. These
grafts answer exceedingly well for conjunctival restorations, while the
wound occasioned by their removal is closed by suture or allowed to heal
by itself, if not too large, under boric-acid antisepsis.
BONE-GRAFTING
Bone-grafting, as followed by MacEwen, Ollier, Poncet, and Adamkierwicz,
has been more or less successful. Their methods have been often employed
in plastic facial surgery, as will be shown later. Their methods were
later improved by Senn, who advocated chips of decalcified bone in place
of bone taken from young or new-born animals, from which the bones under
ossification have been utilized.
Glück’s method of introducing pieces of ivory into bone defects may be of
interest, but is applicable only to long bone implantations. The success
of his method has yet to be practically demonstrated. Zahn and Fisher
have used various foreign substances to overcome bone defects, but these
do not interest the cosmetic surgeon to any extent, since other methods
have been proved to give better results. These, however, belong to the
subject of subcutaneous prothesis, and must be considered separately
thereunder.
HAIR-TRANSPLANTATION
It may be of interest to know that Schweininger and v. Nussbaum have
attempted to graft hairs upon granulating tissue by sprinkling the hairs,
with their attached roots, upon the surface to be covered. If any of
these lived and attached themselves the root sheath formed a scar center,
and the hair dropped out after several days.