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.
Fig. 85.—Thiersch Razor.