Skin graft

“ 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 [91] vascular connection, have become firmly adherent, and begin to spread or grow out at their edges. ”

“ 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 [90] 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. ”

“ 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. ”

“ Skin-grafting is a subject which has long been more or less familiar to medical men, but which has only recently been developed to a practically successful operation. The older surgeons knew that it was possible to reunite a resected nose or an amputated finger, and in Hunter's time tooth-replantation was quite well known. Smellie has recorded an instance in which, after avulsion of a nipple in suckling, restitution was effected. It is not alone to the skin that grafting is applicable; it is used in the cornea, nerves, muscles, bones, tendons, and teeth. ”

“ 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. ”

“ Skin grafting of granulating surfaces is chiefly employed to promote healing in the large defects of skin caused by severe burns; the grafting is carried out when the surface is covered by a uniform layer of healthy granulations and before the inevitable contraction of scar tissue makes itself manifest. Before applying the grafts it is usual to scrape away the granulations until the young fibrous tissue underneath is exposed, but, if the granulations are healthy and can be rendered aseptic, the grafts may be placed on them directly. ”

“ The doctor incised the edges of the granulating surface and then led the granulations on by what is known in the medical profession as the 'sponge graft.' He grew a new finger-tip.
"The sponge graft consists in using portions of a fine Turkish surgical sponge, such I have here. I found these pieces in a desk at Riverwood. The patient is anaesthetised. An incision is made from side to side in the stump of the finger and flaps of skin are sliced off and turned up for the new end of the finger to develop in—a sort of shell of living skin. ”

“ Irving proved to be correct in his prophecy of the probable attitude of the superintendent toward the proposition. Mr. Herrmann objected strenuously for the reason suggested by the spy and he took it on himself to find a person who would supply the skin to be grafted. Two days later he reported success and preparations for the operation were begun.
But everybody connected with these preliminaries had an important lesson to learn regarding the proper method for a layman to approach a matter of science. None of them, of course, knew anything, except in a very general way, about skin grafting. ”

“ The various kinds of oil once so greatly advocated in treating burns are now largely abandoned since they have no antiseptic properties. The deeper burns can only be attended to by a surgeon, whose aim will be first to bring septic absorption to a minimum, and later to hasten the healing process. Skin grafting has great value after extensive burns, not because it hastens healing, which it probably does not do, but because it has a marked influence in lessening cicatricial contraction. When a limb is hopelessly charred, amputation is the only course. ”

“ Hemorrhage was profuse from the temporal, occipital, and posterior auricular arteries, which were tied. The patient was seen three-quarters of an hour after the injury, and the mangled scalp was thoroughly washed in warm carbolized water, and stitched back in position, after the hair was cut from the outer surface. Six weeks after the injury suppuration was still free, and skin-grafting was commenced. In all, 4800 grafts were used, the patient supplying at different times 1800 small grafts. Her own skin invariably did better than foreign grafts. ”

“ Furthermore, the secondary wound is more extensive; the bone exposed requires about a month’s time to granulate over before skin grafts can be successfully applied over it.
With the employment of a cheek-flap lining there is [405] the added objection of cicatrization. The use of a flap from the arm is complicated and requires considerable time for the completion of the operation, and there is always the added danger of infection and consequent death of the osseous plate. ”

“ T85.623 Displacement of artificial skin graft and decellularized allodermis Dislodgement of artificial skin graft and decellularized allodermis Displacement of artificial skin graft and decellularized allodermis T85.624 Displacement of insulin pump T85.628 Displacement of other specified internal prosthetic devices, implants and grafts T85. ”

“ Stripping of large areas of skin is not in itself a reason for removing a limb, as much can be done by skin grafting, but when it is associated with other lesions it favours amputation. In considering these points, it must be borne in mind that the damage to the deeper tissues is always more extensive than appears on the surface, and that in many cases it is only possible to estimate the real extent of the injury by administering an anaesthetic and exploring the wound. ”

“ If it is more desirable to cover the granulating area by means of skin grafts it may be accomplished readily, as later described. This is usually resorted to when there has been loss of tissue from the result of sloughing, although a sliding-flap operation may overcome the defect to a nicety; this is especially true of wounds about the anterior nasal border.
If the resulting cicatrice is no larger than the gaping wound it may be excised, the skin at either side is undermined and the edges are brought together, as was originally intended. ”

“ Even the patient found out the error, and Murphy, who was a good-hearted fellow, wished he had known more about skin-grafting before he had punished him so. It was some weeks ere the victims arms healed, and the scars remain now, and even the operator is still sore when the subject is referred to.
It was wonderful how they managed to get the patients to take all the new remedies that were tested upon them. Folks are usually very careful as to the physic they swallow. ”

“ Your ideas of skin grafting are a good deal like a child's. In the first place we shan't need anybody to supply any skin. Sorry to disappoint the young patriot with really commendable spirit of loyalty. ”

“ 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) . ”

“ When the joints are not destroyed, the utility of the member may generally be restored by well-devised plastic measures, the new material being either an epidermic graft, or a skin flap taken from a convenient portion of the surface ”

“ And, of course, peg legs and hooks for persons who had lost their hands might be called replacive surgery, though they were very crude. Later on came more refined dentures, artificial limbs, corrective lenses, skull plates, hearing aids, plastic or cosmetic surgery, blood transfusions, all types of skin grafts, et cetera.
"The 1950s saw the beginning of bone and corneal transplants, use of plastics in arteries, those huge heart-lung and kidney machines, implantation of electrodes in the heart to steady its beat—many things which were mostly emergency or stop-gap measures. ”

“ If the ulcer is of limited extent and situated on an exposed part of the body, the most satisfactory method is complete removal, by means of the knife, scissors, or sharp spoon, of the ulcerated surface and of all the infected area around it, so as to leave a healthy surface from which granulations may spring up. Should the raw surface left be likely to result in an unsightly scar or in cicatricial contraction, skin-grafting should be employed. ”

“ Puzey, of Liverpool, has found it of extreme value, and even unequaled by any other part of the body, for furnishing skin-grafts, [81] these grafts showing a vitality that is simply phenomenal, considering the laxity of its tissues and its seemingly adipose character. There is no doubt, however, that for skin-transplanting there is nothing superior to the plants offered by the prepuce of a boy, and where any large surface is to be covered this should undoubtedly be chosen, as offering [208] the greatest and quickest success and the least chances of failure. ”

“ 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. ”

“ These grafts may be placed either on a fresh raw surface or on healthy granulations. It is sometimes an advantage to stitch them in position, especially on the face. The dressing and the after-treatment are the same as in epidermis grafting.
There is a degree of uncertainty about the graft retaining its vitality long enough to permit of its deriving the necessary nourishment from its new surroundings; in a certain number of cases the flap dies and is thrown off as a slough—moist or dry according to the presence or absence of septic infection. ”

“ A cellulitis following such an injection is exceedingly troublesome, the injected mass being thrown off usually at the base of the furrow, which is followed by a low type of inflammation with a protracted oozing of serous exudate. Should such a case come under the care of the surgeon, thorough cleansing of the affected site under scrupulous antisepsis should be done at once, and wet antiseptic dressings be applied daily until the wound is entirely healed.
A plastic skin operation must be done in most of these cases to overcome the ragged cicatrix formed upon healing of the wound. ”

“ 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. ”

“ Eventually the depression of contour may be corrected by hydrocarbon protheses introduced subcutaneously following subcutaneous dissection, if deemed necessary.
Small pits, where discrete, are best removed with a fine knife and brought together by a fine suture which is to be removed on the fifth day.
Confluent pittings, as after variola, must be removed by decortication or peeling methods.
The pits, if spread about the face promiscuously, may be treated separately by the peeling method, but when [489] they lie less than one inch apart, it is best to treat the skin of the whole face. ”

“ To assure the operator of a thorough dissection he may inject the site with sterile water through the opening made with the knife, squeezing it out before injecting the nose.
If the skin has had to be freed by surgical means the mass injected should be sufficient to overcome the defect almost entirely, to prevent the reformation of the bands of connective tissue which have been severed. ”