CHAPTER VIIIPRINCIPLES 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, harelippins 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.

Fig. 37.—⅝ Circle Haagedorn Needles.Fig. 38.—Crescent Curve Haagedorn Needles.

Fig. 37.—⅝ Circle Haagedorn Needles.

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are quite convenient, but they break more readily, and while they work best with fine silk, this is more readily withdrawn from the eye at undesirable times.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 inFigs. 41 and 42, known as Pozzi’s and Weber’s modifications, respectively.

Fig. 39.—Kersten-Mathieu Needle Holder.Fig. 40.—Haagedorn Needle Holder.Fig. 41.—Pozzi-Haagedorn Needle Holder, 5 in.Fig. 42.—Weber-Haagedorn Needle Holder, 6 in.Fig. 43.—Needle with Suture Carrier.

Fig. 39.—Kersten-Mathieu Needle Holder.

Fig. 40.—Haagedorn Needle Holder.

Fig. 41.—Pozzi-Haagedorn Needle Holder, 5 in.

Fig. 42.—Weber-Haagedorn Needle Holder, 6 in.

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 inFig. 43.

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.

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.

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 somewhatlinear, or elongated, an elliptical incision (A) is made, as inFig. 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 inFig. 44a, the semilunar spaces being allowed to heal by granulation.

Fig. 44.Celsus Incisions.Fig. 44a.Celsus Relieving Incisions.

Fig. 44.Celsus Incisions.

Fig. 44.

Celsus Incisions.

Fig. 44a.Celsus Relieving Incisions.

Fig. 44a.

Celsus Relieving Incisions.

In excisions in small rhomboidal form, the skin is merely dissected up and around the wound, the same as inFig. 45, and the wound is sutured in linear form, as shown inFig. 46.

Fig. 45.Rhomboid Excision.Fig. 46.Union of Rhomboid Excision.

Fig. 45.Rhomboid Excision.

Fig. 45.

Rhomboid Excision.

Fig. 46.Union of Rhomboid Excision.

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 inFig. 47, or they are drawn toward the center, leaving the remainder of the parallel lines to be sutured, as shown inFig. 48.

Fig. 47.Oblong Excision.Fig. 48.Coaptation of Same.

Fig. 47.Oblong Excision.

Fig. 47.

Oblong Excision.

Fig. 48.Coaptation of Same.

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 inFig. 49, and then with or without dissection bringing the margins together in linear form, as inFig. 50.

Fig. 49.Bitriangular Excision.Fig. 50.Linear Coaptation.

Fig. 49.Bitriangular Excision.

Fig. 49.

Bitriangular Excision.

Fig. 50.Linear Coaptation.

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 inFigs. 51 and 52.

Fig. 51.Triangular Excision.Fig. 52.Coaptation of Wound.

Fig. 51.Triangular Excision.

Fig. 51.

Triangular Excision.

Fig. 52.Coaptation of Wound.

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 inFigs. 53 and 54.

Fig. 53.Triangular Excision with Relieving Incision.Fig. 54.Coaptation of Wound.

Fig. 53.Triangular Excision with Relieving Incision.

Fig. 53.

Triangular Excision with Relieving Incision.

Fig. 54.Coaptation of Wound.

Fig. 54.

Coaptation of Wound.

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 inFigs. 55 and 56.

Fig. 55.Square Excision.Fig. 56.Coaptation of Wound.

Fig. 55.Square Excision.

Fig. 55.

Square Excision.

Fig. 56.Coaptation of Wound.

Fig. 56.

Coaptation of Wound.

If the square be too large for the above method, theincisions can be carried to the other side and above or below the defect, as shown inFigs. 57 and 58.

Fig. 57.Square Excision.Fig. 58.Coaptation of Flaps.

Fig. 57.Square Excision.

Fig. 57.

Square Excision.

Fig. 58.Coaptation of Flaps.

Fig. 58.

Coaptation of Flaps.

For triangular areas the curved incisions can be made, as inFig. 59, rotating the flap into place, as shown inFig. 60.

Fig. 59.Triangular Excision.Fig. 60.Coaptation of Flap.

Fig. 59.Triangular Excision.

Fig. 59.

Triangular Excision.

Fig. 60.Coaptation of Flap.

Fig. 60.

Coaptation of Flap.

Or bilateral flaps may be utilized by straight incisions, stretched and sewn, as inFigs. 61 and 62.

Fig. 61.Triangular Excision.Fig. 62.Coaptation of Flaps.

Fig. 61.Triangular Excision.

Fig. 61.

Triangular Excision.

Fig. 62.Coaptation of Flaps.

Fig. 62.

Coaptation of Flaps.

Again, two curved incisions are made to obtain rotating flaps,Fig. 63, and sewn, as shown inFig. 64.

Fig. 63.Triangular Excision.Fig. 64.Arrangement of Flaps.

Fig. 63.Triangular Excision.

Fig. 63.

Triangular Excision.

Fig. 64.Arrangement of Flaps.

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 ofa triangular defect by this method is shown inFigs. 65 and 66, in whichais the triangular defect andbthe triangle of healthy skin excised. The skin about the incisions is dissected up and the flaps are sutured into position, as shown inFig. 66.

Fig. 65.Double Triangular Excision.Fig. 66.Coaptation of Wound.

Fig. 65.Double Triangular Excision.

Fig. 65.

Double Triangular Excision.

Fig. 66.Coaptation of Wound.

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 inFig. 68.

Fig. 67.Tri-triangular Excision.Fig. 68.Coaptation of Wound.

Fig. 67.Tri-triangular Excision.

Fig. 67.

Tri-triangular Excision.

Fig. 68.Coaptation of Wound.

Fig. 68.

Coaptation of Wound.

Through the sacrifice of two triangles a large oblong or square defect may be covered, the excisions being shown inFig. 69and the suturing inFig. 70.

Fig. 69.Rectangular-Bitriangular Excision.Fig. 70.Coaptation of Wound.

Fig. 69.Rectangular-Bitriangular Excision.

Fig. 69.

Rectangular-Bitriangular Excision.

Fig. 70.Coaptation of Wound.

Fig. 70.

Coaptation of Wound.

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 inFig. 71can be satisfactorily employed, leaving but a small area to granulate over. The suturing is depicted inFig. 72.

Fig. 71.Weber Method.Fig. 72.Coaptation of Flaps.

Fig. 71.Weber Method.

Fig. 71.

Weber Method.

Fig. 72.Coaptation of Flaps.

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 inFig. 73, and the method of bringing the parts together inFig. 74, leaving a small area for granulation.

Fig. 73.Elliptical Excision.Fig. 74.Coaptation of Flaps.

Fig. 73.Elliptical Excision.

Fig. 73.

Elliptical Excision.

Fig. 74.Coaptation of Flaps.

Fig. 74.

Coaptation of Flaps.

Considerable twisting of flaps is shown in covering triangular parts inFigs. 75 and 76.

Fig. 75.Triangular Excision.Fig. 76.Coaptation of Flaps.

Fig. 75.Triangular Excision.

Fig. 75.

Triangular Excision.

Fig. 76.Coaptation of Flaps.

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 inFig. 77, and the method of approximation and suturing inFig. 78.

Fig. 77.Triangular Excision.Fig. 78.Coaptation of Flaps.

Fig. 77.Triangular Excision.

Fig. 77.

Triangular Excision.

Fig. 78.Coaptation of Flaps.

Fig. 78.

Coaptation of Flaps.

In covering a square area considerable twisting must be resorted to, as shown inFigs. 79 and 80, leaving a portion to granulate.

Fig. 79.Lentenner Method.Fig. 80.Coaptation of Flap.

Fig. 79.Lentenner Method.

Fig. 79.

Lentenner Method.

Fig. 80.Coaptation of Flap.

Fig. 80.

Coaptation of Flap.

Where the area is irregular and formed somewhat as inFig. 81, bilateral incisions are made and the flaps twisted into place and sewn, as inFig. 82.

Fig. 81.Burns Method.Fig. 82.Coaptation of Flaps.

Fig. 81.Burns Method.

Fig. 81.

Burns Method.

Fig. 82.Coaptation of Flaps.

Fig. 82.

Coaptation of Flaps.

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 inFig. 83.

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.

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.

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.

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.

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. (SeeFig. 84.)

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 ulceratedor 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.

Thierschrecommends 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 bySocin. 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 formedvascular 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 byR. Wolfein 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 offreed 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 thecutis veraremains, 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 byOllier, of Lyons, in 1872, and perfected byThiersch, 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.

Fig. 85.—Thiersch Razor.

Slide fixation locks are a valuable addition to the latter, as they hold the blade in place when open. SeeFig. 86.

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 quicksawing 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.

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.Hübscherincludes 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 inFig. 88.

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 theantiseptic 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.

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 amputatedlimbs 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 (HartmanandWeirick), 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.

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 crowdingthrough 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, andthat 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.

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 responsiblefor the production of the pigmentary deposits under peculiar influences of the blood.

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, 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 tolong 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.

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.

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