Plastic and cosmetic surgery

by Frederick Strange Kolle

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.