Plastic surgery in the treatment of war casualties

PLASTIC SURGERY IN THE TREATMENT OF WAR CASUALTIES* LEON E. SUTTON, M.D. Professor

of Clinicd

Surgery,

Syracuse

University

(Xlege

of hlrdicinc

SYRACUSE,NEW YORK

T

HE term, pIastic surgery, is somewhat misleading but has become so well established that change is diffrcult. Since the first worId war the term, “ mnxillofacial surgery,” has been used in the medica services of the army and navy. This would suggest that pIastic surgery is limited to the jaws and face. Reconstructive surgery is a better term. Staige Davis, whom Sir HaroId GilIies recentIy described as the “grandfather of pIastic surgery in America,” defines pIastic surgery as that branch of general surgery which has to do with the reconstruction of injured, Iost or deformed parts all over the body, and is concerned primarily with restoration of function and secondariIy with improvement of appearance. At the close of the previous war pIastic surgery was being done for the most part by men with denta or ear, nose and throat training. Today it is generally recognized as a special branch of general surgery requiring thorough training in general surgery and a working knowredge of severa other speciarties. The American Board of PIastic Surgery was set up in 1939. A committee of this Board and the two plastic surgery societies, of which Dr. Gordon New of the Mayo Clinic is chairman, has completed a survey of existing facilities for the study of this subject. This survey shows that these facilities are inadequate for peace times. Now that al1 types of residencies have been sharpIy limited, training in plastic surgery will be almost nonexistent. This is a serious situation in view of the fact that onIy about 125 surgeons have been certified by the American Board of Plastic Surgery. To quote from the Manual of PIastic and Maxillofacial Surgery prepared by the * Prescntcd

at the \V:tr Session

of the American

NationaI Research Council and the MedicaI Department of the U. S. Army,’ “The CasuaIty from the field of battIe has a right to expect and demand the optimal result which can accrue from a highIy cooperative professiona service and a ski11 which results from the utilization of all that is best in the genera1 and specia1 experience reIated to his particular probIem. His future mental comfort and success in the competition of living wiII be materiaIIy influenced by his facia1 function and appearance.” The preliminary treatment of the casualtl determines to a large extent the outcome (;f Iater reconstruction. Prompt local hemostasis, pressure bandages, use of small hemostats and fine ligatures, conservation of bone fragments which are attached and soft tissue which is viable-all these points should be kept in mind as the casuaIt>p passes from the Battalion Aid Station through the CIearing Station and Evacuation Hospital. The medical of-fcer is often faced with medica or surgical situations with which he must deal without consultation or assistance. He should be acquainted with the principles of reconstructive surgery. He should know how to cIose wounds of the face and when to leave them open. A skin graft is often the best dressing for a wound. He should be able to cut and apply the simpler types of skin grafts and care for them. The early local treatment of a severe burn will determine to a Iarge extent the time required for hearing and the degree of permanent disability. After the casualty has been removed from the combat zone and has recovered from shock a complete examination can be made and treatment outlined. Fractures of

College

239

of Surgeons,

HuF:llo,

New \r’ork,

hIarch

I z, I ~14~.

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American

Journal

of Surgery

Sutton-PIastic

the facial bones with dispIacement can frequentIy be determined before x-ray examination if sweIIing and tenderness are not too great. BiIateraI paIpation of the face bones from above downward is heIpfu1. The order of frequency of fracture of the faciaI bones is: mandibIe, nose, zygoma, maxiIIa and multipIe fractures. Failure to reduce a fresh fracture requires extensive surgica1 measures Iater, but it can be reduced within the first two or possibIy three weeks. These fractures shouId not be manipuIated and the nose shouId not be packed in the presence of cerebra1 fIuid drainage. Delay reduction for at Ieast ten days after drainage ceases. The nose is the most prominent facial feature. Marked abnormaIities create a definite economic and psychic hazard. Reduce the fracture as soon as possible. X-ray is not very heIpfu1 in most cases. If uncertain as to diagnosis, wait unti1 the sweIIing has subsided. Examine both the inside and outside of the nose for dispIacement and movement. The mucosa is anesthetized with cocaine soIution IO per cent and epinephrine 1-2000 on cotton appIicators pIaced upward, backward and IateraIIy and aIso aIong the floor of the nose. The externa1 soft parts are injected with 0.5 per cent soIution of procaine and epinephrine (IO gtt. to the ox.) aIong the bases of the nasa1 processes. EIevate and straighten the nasa1 septum and return the cartilage to its groove in the vomer. Loosen fragments of the bony arch, eIevate and rotate them into position. Any thin strong instrument covered with thin rubber tubing can be used inside the nose. Light vaseIined gauze packing and an externa1 spIint may be appIied. Remove the packing in twentyfour hours. Fractures of the zygoma usualIy show depression of the arch of the cheek bone, flatness above and sweIIing beIow. Motion of the jaw may be Iimited. UniIateraI nasa1 hemorrhage, infra-orbita nerve anesthesia and dipIopia may be present. Most of these fractures can be reduced by one of the following methods: through the antrum (by

Surgery an intranasa1 opening or through the canine fossa); through the mouth by an incision above the Iast upper tooth, inserting an antrum trocar under the zygoma for manipuIation and eIevation; by the temporal route through an incision in the hairIine above and in front of the ear, passing a periostea1 eIevator through the tempora1 fascia, downward and forward beneath the zygoma. The skuI1 is used as a fuIcrum to Iever the fragments into pIace. Fractures of the maxilla and especiaIIy those of the mandible usuaIly require some type of permanent fixation after soft tissue wounds have been treated. AI1 compIeteIy detached pieces of bone or teeth shouId be removed but any fragments of bone stiIJ attached to the soft tissues shouId be preserved. It is better to Ieave a doubtfu1 bone fragment and remove it Iater if necessary. The co-operation of the denta surgeon wiI1 be required for inter- or intramaxiIIary wiring if needed. In some cases skeIeta1 reduction and fixation by interna wiring or modification of the Roger-Anderson method may be used. X-ray exaeination shouId be made for conceaIed foreign bodies. Later reconstruction of bony dejects of the face involves some type of camouflage procedure such as grafts of cartiIage, bone, dermo-fat, fascia. Peer2 has recentIy suggested what he terms, “diced cartilage,” for filling these bony defects ot the face. The patient’s own cartilage is cut into very smaI1 cubes and introduced into the defect through an incision beIow it. The excess is squeezed out and the cartiIage patted into the proper contour. Peer states that this type of cartiIage graft remains viable, does not change shape and in time becomes quite vascuIar. Soft tissue wounds of the face may be treated somewhat differentIy than wounds of the rest of the body. Because of the better bIood suppIy the tendency to infection is Iess and the heaIing more rapid. If the wound is seen within ten or tweIve hours and is not grossIy dirty, greatly contused or ragged, it may be sutured without

prcIiminar.\ treatment except irrigation with saline. If first seen after twelve hours, it shouId be left open, dusted with a sulfonamide powder and saline or bland ointment dressing apphed. If the wound is fresh but dirty and can be cleaned with soap and water foIlowed by saline, it may be dusted with sulfonamide powder and closed. Debridement should be less radical in the face than elsewhere. DoubtfuI flaps even with a small pedicle shouId be preserved if possibIe and sutured in place. Attached bone fragments shouId be preserved and replaced. If hemostasis is doubtfu1 a small rubber strip shouId be placed between the sutures and removed in and twenty-four hours. SmalI hemostats fine ligatures must be used. The use of deep sutures is desirable but this will depend upon the judgment and experience of the surgeon. If in doubt they shouId be Fine needIes and fine suture omitted. material are essentia1 and the sutures should not be left in more than three days. At the first sign of infection sutures should be removed and a wet dressing applied. Face wounds Iike a11 others should be immobiIized as much as possible; talking should be prohibited and feedings done b\: syringe or tube in the stomach. The early local treatment of burns under combat conditions wiI1 probably be more or less standardized by order. Some type of crust treatment may be used if time permits. The best crust methods are tannic acid, tannic acid and siIver nitrate, triple dye, and sulfadiazine in triethanolamine. The crust treatment reduces pain and fluid loss and simpIifies the earIy care of the The sulfadiazine-triethburned patient. anolamine and triple dye crusts form more slowly than the tannic crusts but they are more pliable and infection is less frequent. Crusts shouId never be used on the face, hands or genitalia. No crust should be Ieft on a third degree burn Ionger than three vveeks. It should then be removed and the defect grafted as soon as all necrotic tissue has disappeared and the granulations are pink, firm and reIativeIy IeveI. The derma-

tome may be used to cut large grafts which are sutured in place and frxed with elastic pressure (sponges or cotton waste). The safest graft to use, if one is not experienced, is the small deep graft of Dav.is. These grafts are small pieces of skin, full thickness in the center and thin at the edges. They are picked up on a needle held in ;I clamp and cut as described by Davis” with a knife or razor bIade heId in a clamp. They may be placed as cIose together as desired. These grafts should never be applied to exposed parts such as the hands or face. Whichever type of graft is used on a granulating surface, the first dressing should be done on the third day and the elastic pressure continued for a week to ten days. Other methods of treatment are the envelope method favored by the British,* the pressure method” and the saline bath method.‘j The envelope treatment employs an oiled silk sleeve with an inlet and outlet which fits snugly to an extremit),. Electrolytic sodium hypochorite tlows slowly. through the sleeve. Saline or a sulfa solution may be used instead of the sodium hypochlorite. The pressure method uses sulfonamide powder covered with vraseline gauze, cotton waste and a cast or elastic pressure bandage. Burns of the face may be sprayed with a fine sulfonamide powder and covered with one layer of \,aselined gauze and a saline pack. The saline bath method requires more nursing care than is avaiIable under wartime conditions. The treatment of the contracted scars, which so often follow severe burns, presents a major plastic problem. The degree of contracture is directIy proportional to the heahng time. The longer the time required for healing, the thicker the scar, and the thicker the scar the greater the contracture wiI1 be. Thick scar webs on the neck and face and across joints of the extremities are not onIy unsightIy but interfere greatly with function. Thick burn scars may continue to contract for weeks or months after surface healing is complete. This tendency varies greatIy in different individuals even to the point of true keloid formation.

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American Journal of Surgery

Sutton-Plastic

Surgery

undersurface, sutured accurateIy into its PIastic reconstruction shouId be delayed new site and dressed under erastic pressure until the scars have become reIativeIy soft for over two weeks. This graft requires a and most of the redness has faded. Four to firm, sterile bed. It can be used onIy on a ten months may be required to reach this fresh, surgica1 wound and in an area which stage. Flaps of scar tissue can then be can be compIeteIy immobiIized. Its “take ” shifted within reasonable Iimits so that is Iess certain than a part thickness graft, tension is removed and function restored, cut with knife or Dermatome, but if it frequentIy without the necessity of grafting takes compIeteIy gives a good functiona or moving ffaps from a distance. One of the and cosmetic resuIt. Part thickness or spIit best ways of doing this is by transposing the points of a z-shaped incision.’ Whatever grafts take more readiIy, and if cut through the deeper Iayers of the skin yield method of shifting flaps is used the new almost as good a result. They have the suture Iine shouId run at angIes to the former scar band. Contractures relieved by added advantage of Ieaving enough skin eIements for regeneration of the donor site. shifting flaps do not recur if the bIood The usefuIness of the smaI1 deep graft of suppIy of the Aaps has been accurateIy Davis in grafting Iarge, deep burns when appraised and they remain compIeteIy viabIe. When grafts are used instead of the condition of the patient is poor has been mentioned. flaps some degree of contraction of the Flaps differ from grafts in that they grafts foIIows and reIief of the contracture incIude both skin and fat and depend for is not compIete. However, if complete surviva1 on an intact bIood supply. One end reIaxation cannot be obtained by shifting of a fIap must remain attached and carry ffaps, the remaining defect must be covered the bIood suppIy whiIe the other end is with a graft. growing into its new site. After two to three What has just been said concerning the weeks the second end has acquired a new shifting of flaps instead of appIying grafts emphasizes one of the first principIes of bIood suppIy; then the first end may be pIastic surgery. This principIe is that a11 detached and the rest of the flap fitted into its new Iocation. FIaps may be brought avaiIabIe adjacent tissue should be utiIized from a distant part of the body by roIIing in the correction of a defect before bringing them into a tube and grafting one end temin tissue from a distance. With the advent porariIy into a movabIe part, usuaIIy the of new methods and new instruments there hand or wrist. FIaps are usefu1 in correcting is a tendency to forget that estabIished defects of contour and for covering exposed surgica1 principIes remain unchanged. The tendons and other deep structures but they Dermatome, invented by Ear1 Padgett, has require muItipIe operations and Iong hosmade the cutting of Iarge skin grafts of prepitaIization whiIe grafts usuaIJy need but determined thickness a reIativeIy simpIe one operation. FI aps retain their original matter. This instrument, properIy used, color fairIy we11 but grafts are prone to represents a rea1 technical advance in skin show increased pigmentation at times. grafting and if the principle mentioned above is folIowed, it wiI1 not be misused. Flaps contract scarceIy any after they are fitted to their new site but grafts may show The scope of this paper does not permit detaiIed discussion of types of grafts and over $0 per cent contraction if cut through the outer quarter of the skin. AI1 grafts Aaps which wiI1 be needed in the reconcontract somewhat but the thicker the struction of the defects produced by graft the Iess the contracture. It should be modern instruments of warfare. Skin grafts vary as to thickness and size. The fuI1 remembered that a graft is aIways a “patch,” and seIdom matches the surthickness graft is cut according to a pattern rounding skin perfectIy. A rotated or of the defect to be covered. It is carefuIIy shifted ffap of normal adjacent tissue is dissected so that no fat remains on its

if available. alw;i~ s more satisfactory Rather extensive scars may be removed by repeated, partial excisions. At times it is desirable to apply a temporary graft then later excise the graft in stages, with long intervals between them. It should be emphasized that grafts are a rather poor substitute for the- original skin but the) should be used without hesitation when indicated. is sometimes missed An opportunity because the surgeon does not think of the possibility of immediate grafting of a traumatic wound with loss of tissue. This rn:\y be important in getting a war casualty back into service quickly. If the wound is seen within six hours of the injury and is grossly clean or can be dkbrided satisfactoriI>., and the defect cannot be cIosed in a reasonable manner, immediate grafting should be considered. A graft of any desired thickness or length and up to one and three quarters of an inch in width can be cut with an ordinary safety razor blade held in a clamp. The graft is tacked at severa points Lvith interrupted sutures, trimmed to fit, and a running suture of “c” silk carried around the edge. Several small hoIes should be made in the graft for drainage of serum. The graft is then covered with one Iayer of \,aseIined gauze and one thickness of saIine gauze sponge. Over this is pIaced a rubber sponge, synthetic sponge, sea sponge or cotton waste and firmIy bandaged. The first dressing is done on the fifth day or earlier if an odor or other sign of infection is observed. Elastic pressure is continued for ten days to three weeks depending upon the thickness and condition of the graft. When the back of a hand is denuded, exposing tendons, the hand may be pIaced under an abdomina1 flap through two parallel incisions. When the skin and fat pad of a finger tip is lost the defect may

be attached to a lIap raised on the proximal part of the palm or to a similar Hap on the abdomen. The subsequent care of these flaps follows the principles of Maps elsewhere. SU.MMAKY

I. The war casualty should receive the benefit of modern methods of reconstruction. The preliminary treatment of the casualty may determine to a large extent the outcome of Iater reconstruction. 2. Facilities for postgraduate training in plastic surgery should be augmented to meet the demand for surgeons properI>, trained in this specialt)-. 3. Conservation of tissue is important in care of wounds and compound fractures of the face. 3. Early skin grafting is essential in the treatment of large deep burns. When possible a method of early local treatment should be used which will facilitate early grafting. 3. Contracted scars should be relaxed b? shifting flaps and skin grafts used only as an aIternative. 6. Immediate grafting of certain wounds should be considered as a means of preventing deformit? and shortening the period of disabiIity. KEFEKENCES

1. Ililktry Surgical \lanuaIs. Vol. I, 1’. 3, 1()+2. PEER, L. A. Unpublished data. 3. DAVIS, J. S. The small drcp graft. Ann. Sty<., XC,: 902, I929 _t. RUNY.AN, J. Envclopc method of treating l~rns. l’roc. Hq.. SW. Med., 34: 65, 1r)4.0. 5. ALIXN, ~~.+RwY S. Treatmrnt of superficial injuries and burns of the hand. J. A. M. A., I 16: IS;<,. 2.

l()L&I. 5.

BLAIR, V. P. et al. The

early care I)F burns and the rcpnir of their defects, J. A. M. A., 08: ,355, 1932. 7. DAVIS. J. S. and ~ITLOWSK1. It. S. The theorv and practical use of the z incision for the relief of scar contrxtures. Ann. Sura., IO<): IOOI, 1030.