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The preparation of superficial wounds for skin grafting by the local use of sulfanilamide and sulfanilamide-allantoin ointment
THE PREPARATION GRAFTING
OF SUPERFICIAL
WOUNDS
BY THE LOCAL USE OF SULFANILAMIDE
AND SULFANILAMIDEdALLANTOIN J.
Ross VEAL, M.D., ROY G. KLEPSER,
M.D.
WASHINGTON,
T
FOR SKIN
HERE are several methods of preparing superficia1 granmating wounds for the reception of skin grafts. The most
AND D.
many These matic
OINTMENT*
MICHAEL
P.
DEVITO,
M.D.
C.
cases require the use of skin grafts. incIude extensive body burns, trauwounds, postoperative skin defects,
6000 SULFANILAMIOE
ALLANTOIN OINTMENT (ALLANTOMIDE)
DAILY
SINGLE SPLIT-THICKNESS SKIN GRAFT
GRAFTING
0
I I
2
3
4
5
6 DAYS
7
8
9
IO
II
I2
I3
14
15
I6
I7
AFTER DEBRIDEMENT
FIG. I. Chart showing rapid controt of infected second and third degree burn of buttocks,
ment and the topica appIication of sulfaniIamide and sulfanilamide-allantoin grafted at one stage. Note position and size of lesion on buttocks.
amputation stumps and chronic Ieg ulcers. PracticaIIy al1 such Iesions are contaminated or grossIy infected. The chief aims of treatment shouId be the contro1 of the infection and the promotion of the natura1 processes of heaIing. The healing time of granulating wounds depends upon the size, depth, vascuIarity, Iocation and the activity of the infecting organisms. Many of the smaller superficial ulcers wiI1 heaI promptIy if they are kept clean and the growing epitheIium is protected. The heaIing time of the larger ulcers may be tremendousIy shortened by the use of autogenous skin in order to apply skin grafts. However, grafts successfuhy to such Iesions the fieId must be properly prepared. The bacterial
successfu1 has been continuous wet dressings or irrigations with norma saIine soIution and miId antiseptics. These measures require expert management and constant attention. In some parts of the body they are diffrcuIt to apply and are annoying to the patient. A more simpIe and effective method has long been needed. This need seems to have been fuIliIIed with the introduction of the suIfonamides. The resuIts obtained by the IocaI application of suIfaniIamide and suIfaniIamide-aIIantoin ointment in preparing some forty superficia1 uIcerations for skin grafting forms the basis for this report. In a large surgica1 service, such as we have at the Gallinger MunicipaI Hospital, * From the Department
following dtbridcointment. Entire lesion
of Surgery of Gallinger blunicipal 716
IiospitaI,
Washington,
D. C.
NEW SERIES VOL. LIV, No. 3
VeaI
et aI.-Skin
activity, or infection, must be inhibited and an adequate bIood supply of the granulating bed promoted. In a recent communica-
A
Grafting
AIller~c:tnJcjurn;rI d
surgery
717
troIIed. ProIonged IocaI use of the pure drug may sIow the healing process in granuIating wounds by inhibiting the
I3
C
FIG. 2. A, photomicrograph of granulation tissue of ulcer after controlling infection by the Iocal application of sulfanilamide. Note the scant number of blood vessels. n, same area of ulcer after ten days’ , . apphcatron of z per cent allantom. Note Increased vascularity and aIso the exacerbation of infection. c, same area after being treated by the local application of suIfanilamide-allantoin ointment for ten days. Note the marked decrease in infection with the maintenance of adequate bIood suppIy.
we outIined the technic used in tion’ combatting IocaI infection in pyogenic wounds by the topical application of suIfanilamide and SuIfaniIamide-aIIantoin ointment. The same routine has been highly effective in controIIing the infection in superficial granuIating wounds. After proper appIication of this form of treatment, these wounds have been found to be in an idea1 state for the reception of skin grafts. SuIfaniIamide, when applied directIy to an infected or contaminated wound, inhibits bacteria1 growth according to the degree of concentration of the drug. Its action is a direct one, and the drug must come into actual contact with the organisms to be effective.2 This means that the lesion to be treated must be adequately dkbrided and a11 parts made accessibIe. SuIfaniIamide inhibits the growth of a11 the common organisms found in surface wounds. Among these are the various strains of staphyIococci, streptococci, the coIon-dysentery group, diptheroids and BaciIIus pyocyaneus. A single appIication of the pure suIfanilamide does not steriIize the wound. A fresh suppIy must be added daiIy unti1 the infection is compIeteIy con-
vascuIarization of granuIation tissue and retarding the growth of new epitheIium.1,3 We have found that by substituting suIfaniIamide-allantoin ointment for the concentrated powder after the infection has been controIIed active heaIing wiI1 quickIy revive. Robinson4 has previously demonstrated that aIIantoin has a stimuIating effect upon epitheIization by increasing the vascuIarity of granuIation tissue. The suIfaniIamide-allantoin ointment (aIlantomide) contains IO per cent suIfaniIamide and 2 per cent aIIantoin in a specia1 base. This amount of suIfaniIamide prevents reactivation of the bacteria1 growth and yet does not produce a harmful effect on the deIicate new epithelial ceIIs. Two per cent aIIantoin has proved sufficient to promote rapid deveIopment of bIood vesseIs in the granujation tissue. The base5 of this ointment contains stearic acid, triethanoIamine and glycerine, which is greaseIess andflapparentIy insures compIete Iiberation of both the active ingredients. The foIIowing method has now been used in preparing more than forty cases of superficia1 uIcerating areas for skin grafts. It has proved highIy successful and quite
718
American Journal of Surgery
Veal et al.-Skin
simpIe in application. The first measure is that of making the entire surface of the Iesion accessibIe to the IocaI apphcation of
FIG. 3. Intractable furuncufosis of axillary pad. Entire area excised; control of infection with SuIfaniIamide powder; preparation of granulation tissue for skin graft with alIantoinsulfanilamide ointment; successful singIe spIit thickness graft. A, showing sulfanilamide powder applied to surface of lesion. B, heaIed graft.
the SuIfaniIamide powder. AI1 necrotic and nonviabIe tissue is removed and all pockets and undermined regions are adequateIy drained. In the more extensive lesions a suitabIe anesthesia should be used for this procedure. After hemostasis has been secured a sufficient quantity of the pure suIfaniIamide is appIied to cover compIeteIy the entire surface of the wound. The amount used, of course, varies with the size and character of the Iesion under treatment. From 2 to IO Gm. may be safeIy used in the grossIy infected wounds. The rate of absorption from such lesions is slow and the tota amount absorbed into the bIood stream is smaller than when the drug is given by mouth or parenteraIIy. We have
Grafting
D~cemm.
1~41
seen no evidence of any systemic toxic reaction foIIowing IocaI application of suIfaniIamide or suIfaniIamide-aIIantoin ointment in more than 300 cases of pyogenic wounds. After instiIIation of the powder the wound is simpIy covered with a dry gauze A new dressing with a fresh dressing. suppIy of sulfanilamide is applied daily unti1 the infection is completely controIIed. At this stage many of the smaI1 uIcerated areas wiI1 be found ready for the application of a skin graft. In the case of the larger uIcers and extensive burns, however, the granulation tissue is often paIe, anemic and poorIy vascuIarized. Such cases require correction of this dereterious action of the drug before a grafting operation is undertaken. The aIIantoin-suIfaniIamide ointment (allantomide) is very efficacious for this stage. (Fig. I .) The pure smfanilamide is discontinued and the granuIating surface is IightIy covered with the ointment. It may be spread directIy upon the surface or applied on a gauze dressing. These dressings are appIied daily. Within a few days after beginning the use of the ointment the granulation tissue begins to grow activeIy and becomes more heaIthy in appearance. Biopsies taken from such wounds actuahy show many smaI1 new blood vesseIs growing into the granuIation tissue. (Fig. 2.) The bacteria1 activity remains inhibited. As soon as the granuIation tissue becomes bright pink in coIor and bIeeds freeIy when traumatized, the uIcer is considered ready for grafting. (Figs. 3, 4, and 3.) We have empIoyed the same immediate operative preparation in a11 cases. The patients receive a suitabIe anesthetic. The recipient heId is scrubbed with green soap and water. The donor areas are prepared by ether, iodine and aIcoho1. The granuIation tissue is pared down with a sharp scaIpe1 and complete hemostasis secured. SeveraI types of skin grafts have been employed in the present series of cases. In the majority of instances, however, the spIit thickness skin graft has been used. The Padgett dermatome6 has simpIified the taking of this type of graft and has made it
NEW SERIESVOL. LIV, No. 3
VeaI et al.-Skin
the most practica1 of aII. By this technic a graft of aImost unbelievable size can be The postoperative used at one operation.
Grafting
American
Journal
of Surgery
719
stage we have applied suIfanilamide-alIantoin ointment dressings to the ungrafted area whiIe awaiting the next stage. (Fig. 6. j
Frc. 4. Extensive streptococcic and gas bacillus infection of leg with skin gangrene. Rapid control of infection by the topical application of sulfanilamide after dChridement; granulation tissue prepared hy sulfanilamidc-allnntoin ointment. A, granulation tissue ready for graft. n, successful graft in one stage.
FIG. 5. Carcinoma of face with gross infection; excision; control of infection by topical application of sulfanilamide and sulfanilamideallantoin ointment. A, carcinoma of face before excision. B, granulation ready for graft. c, healed graft.
care of the grafts has varied considerably, but in a11 cases the grafted part has been immobihzed. When the entire granuIating surface has been covered at one stage, we have used wet and dry dressings with equa1 success. In those cases in which onIy a portion of the Iesion was grafted at the first
This dressing has maintained contro1 of the infection and has not interfered with the “take” of the graft. SUMMARY
SuIfaniIamide has proved to be an exceIIent IocaI agent in combatting bacteria1
720
American Journal of Surgery
Veal
et A--Skin
growth in infected and contaminated surface wounds. The action of the drug is a direct one and must come into contact with the invading organisms. Prolonged use of
SULFANILAMIOE
0
5
IO
I5 DAYS
DELLMULI~, ,<)_b,
We wish to thank The National Drug Corn-pany, of Philaddphia, Pennsylvania, for l‘urnishing us with the allantomide used in this study.
ALLANTOIN (ALLANTOMIDE)
20 AFTER
Grafting
25
OINTMENT
30
32
DAILY
35
40
42
DEERIDEMENT
FIG. 6. Chart showing rapid control of infection by suIfaniIamide locally in extensive second and third degree burn of back folIowine dhbridement. Preoaration of granulation tissue for skin graft by topicat appIication of sulfanilamide-alkmoin ointment. Note size of graft used and the healthy appearance of granulation tissue.
the pure drug may retard heaIing. Complete removal may aIIow a reactivation of the infection. Both of these disadvantages may be averted by substituting sulfaniL amide-aIIantoin ointment for the pure powder after the infection has been controlled. The aIIantoin promotes active VascuIarization of the granuration tissue thereby creating a favorabIe state for the reception of skin grafts. The excelIent resuIts obtained by preparing some forty superficial wounds for skin grafting by the IocaI use of suIfaniIamide and suIfaniIamide-allantoin ointment (aIIantomide) has been most encouraging. The method is simpIe and appIicabIe to a11 areas of the body.
REFERENCES I.
2.
3.
4.
5.
5.
J. R. and KLEPSER, R. G. The treatment of pyogenicalIy infected wounds by the topica application of powdered sulfanilamide and sulfaniIamide-aIIantoin ointment. Med. Ann. District of Columbia, IO: 61, 1941. LOCKWOOD,J. S. Sulfonamide therapy as an aid to surgery. Surg., Gynec. FYObst., 72: 307, 1941. BRICKER, E. M. and GRAHAM, E. A. Inhibitory effects of suIfaniIamide on wound heating. J. A.M. A., I 12: 2593, 1939. ROBINSON,WM. StimuIation of healing in nonhealing wounds by alIantoin occurring in maggot secretions and of wide biologica distribution. J. Bone IV Joint Surg., 17: 267, 1935. GREEP~BAUM,F. R. Allantoin, a new granulation tissue stimulating substance with especial emphasis on alIantoin in ointment form. Am. J. Surg. 34: 259, ‘937. PADGETT, E. C. CaIibrated intermediate skin grafts. Surg., G_vnec. c~ Obst., 69: 779, 1939.
VEAL,
OF SUPERFICIAL
WOUNDS
BY THE LOCAL USE OF SULFANILAMIDE
AND SULFANILAMIDEdALLANTOIN J.
Ross VEAL, M.D., ROY G. KLEPSER,
M.D.
WASHINGTON,
T
FOR SKIN
HERE are several methods of preparing superficia1 granmating wounds for the reception of skin grafts. The most
AND D.
many These matic
OINTMENT*
MICHAEL
P.
DEVITO,
M.D.
C.
cases require the use of skin grafts. incIude extensive body burns, trauwounds, postoperative skin defects,
6000 SULFANILAMIOE
ALLANTOIN OINTMENT (ALLANTOMIDE)
DAILY
SINGLE SPLIT-THICKNESS SKIN GRAFT
GRAFTING
0
I I
2
3
4
5
6 DAYS
7
8
9
IO
II
I2
I3
14
15
I6
I7
AFTER DEBRIDEMENT
FIG. I. Chart showing rapid controt of infected second and third degree burn of buttocks,
ment and the topica appIication of sulfaniIamide and sulfanilamide-allantoin grafted at one stage. Note position and size of lesion on buttocks.
amputation stumps and chronic Ieg ulcers. PracticaIIy al1 such Iesions are contaminated or grossIy infected. The chief aims of treatment shouId be the contro1 of the infection and the promotion of the natura1 processes of heaIing. The healing time of granulating wounds depends upon the size, depth, vascuIarity, Iocation and the activity of the infecting organisms. Many of the smaller superficial ulcers wiI1 heaI promptIy if they are kept clean and the growing epitheIium is protected. The heaIing time of the larger ulcers may be tremendousIy shortened by the use of autogenous skin in order to apply skin grafts. However, grafts successfuhy to such Iesions the fieId must be properly prepared. The bacterial
successfu1 has been continuous wet dressings or irrigations with norma saIine soIution and miId antiseptics. These measures require expert management and constant attention. In some parts of the body they are diffrcuIt to apply and are annoying to the patient. A more simpIe and effective method has long been needed. This need seems to have been fuIliIIed with the introduction of the suIfonamides. The resuIts obtained by the IocaI application of suIfaniIamide and suIfaniIamide-aIIantoin ointment in preparing some forty superficia1 uIcerations for skin grafting forms the basis for this report. In a large surgica1 service, such as we have at the Gallinger MunicipaI Hospital, * From the Department
following dtbridcointment. Entire lesion
of Surgery of Gallinger blunicipal 716
IiospitaI,
Washington,
D. C.
NEW SERIES VOL. LIV, No. 3
VeaI
et aI.-Skin
activity, or infection, must be inhibited and an adequate bIood supply of the granulating bed promoted. In a recent communica-
A
Grafting
AIller~c:tnJcjurn;rI d
surgery
717
troIIed. ProIonged IocaI use of the pure drug may sIow the healing process in granuIating wounds by inhibiting the
I3
C
FIG. 2. A, photomicrograph of granulation tissue of ulcer after controlling infection by the Iocal application of sulfanilamide. Note the scant number of blood vessels. n, same area of ulcer after ten days’ , . apphcatron of z per cent allantom. Note Increased vascularity and aIso the exacerbation of infection. c, same area after being treated by the local application of suIfanilamide-allantoin ointment for ten days. Note the marked decrease in infection with the maintenance of adequate bIood suppIy.
we outIined the technic used in tion’ combatting IocaI infection in pyogenic wounds by the topical application of suIfanilamide and SuIfaniIamide-aIIantoin ointment. The same routine has been highly effective in controIIing the infection in superficial granuIating wounds. After proper appIication of this form of treatment, these wounds have been found to be in an idea1 state for the reception of skin grafts. SuIfaniIamide, when applied directIy to an infected or contaminated wound, inhibits bacteria1 growth according to the degree of concentration of the drug. Its action is a direct one, and the drug must come into actual contact with the organisms to be effective.2 This means that the lesion to be treated must be adequately dkbrided and a11 parts made accessibIe. SuIfaniIamide inhibits the growth of a11 the common organisms found in surface wounds. Among these are the various strains of staphyIococci, streptococci, the coIon-dysentery group, diptheroids and BaciIIus pyocyaneus. A single appIication of the pure suIfanilamide does not steriIize the wound. A fresh suppIy must be added daiIy unti1 the infection is compIeteIy con-
vascuIarization of granuIation tissue and retarding the growth of new epitheIium.1,3 We have found that by substituting suIfaniIamide-allantoin ointment for the concentrated powder after the infection has been controIIed active heaIing wiI1 quickIy revive. Robinson4 has previously demonstrated that aIIantoin has a stimuIating effect upon epitheIization by increasing the vascuIarity of granuIation tissue. The suIfaniIamide-allantoin ointment (aIlantomide) contains IO per cent suIfaniIamide and 2 per cent aIIantoin in a specia1 base. This amount of suIfaniIamide prevents reactivation of the bacteria1 growth and yet does not produce a harmful effect on the deIicate new epithelial ceIIs. Two per cent aIIantoin has proved sufficient to promote rapid deveIopment of bIood vesseIs in the granujation tissue. The base5 of this ointment contains stearic acid, triethanoIamine and glycerine, which is greaseIess andflapparentIy insures compIete Iiberation of both the active ingredients. The foIIowing method has now been used in preparing more than forty cases of superficia1 uIcerating areas for skin grafts. It has proved highIy successful and quite
718
American Journal of Surgery
Veal et al.-Skin
simpIe in application. The first measure is that of making the entire surface of the Iesion accessibIe to the IocaI apphcation of
FIG. 3. Intractable furuncufosis of axillary pad. Entire area excised; control of infection with SuIfaniIamide powder; preparation of granulation tissue for skin graft with alIantoinsulfanilamide ointment; successful singIe spIit thickness graft. A, showing sulfanilamide powder applied to surface of lesion. B, heaIed graft.
the SuIfaniIamide powder. AI1 necrotic and nonviabIe tissue is removed and all pockets and undermined regions are adequateIy drained. In the more extensive lesions a suitabIe anesthesia should be used for this procedure. After hemostasis has been secured a sufficient quantity of the pure suIfaniIamide is appIied to cover compIeteIy the entire surface of the wound. The amount used, of course, varies with the size and character of the Iesion under treatment. From 2 to IO Gm. may be safeIy used in the grossIy infected wounds. The rate of absorption from such lesions is slow and the tota amount absorbed into the bIood stream is smaller than when the drug is given by mouth or parenteraIIy. We have
Grafting
D~cemm.
1~41
seen no evidence of any systemic toxic reaction foIIowing IocaI application of suIfaniIamide or suIfaniIamide-aIIantoin ointment in more than 300 cases of pyogenic wounds. After instiIIation of the powder the wound is simpIy covered with a dry gauze A new dressing with a fresh dressing. suppIy of sulfanilamide is applied daily unti1 the infection is completely controIIed. At this stage many of the smaI1 uIcerated areas wiI1 be found ready for the application of a skin graft. In the case of the larger uIcers and extensive burns, however, the granulation tissue is often paIe, anemic and poorIy vascuIarized. Such cases require correction of this dereterious action of the drug before a grafting operation is undertaken. The aIIantoin-suIfaniIamide ointment (allantomide) is very efficacious for this stage. (Fig. I .) The pure smfanilamide is discontinued and the granuIating surface is IightIy covered with the ointment. It may be spread directIy upon the surface or applied on a gauze dressing. These dressings are appIied daily. Within a few days after beginning the use of the ointment the granulation tissue begins to grow activeIy and becomes more heaIthy in appearance. Biopsies taken from such wounds actuahy show many smaI1 new blood vesseIs growing into the granuIation tissue. (Fig. 2.) The bacteria1 activity remains inhibited. As soon as the granuIation tissue becomes bright pink in coIor and bIeeds freeIy when traumatized, the uIcer is considered ready for grafting. (Figs. 3, 4, and 3.) We have empIoyed the same immediate operative preparation in a11 cases. The patients receive a suitabIe anesthetic. The recipient heId is scrubbed with green soap and water. The donor areas are prepared by ether, iodine and aIcoho1. The granuIation tissue is pared down with a sharp scaIpe1 and complete hemostasis secured. SeveraI types of skin grafts have been employed in the present series of cases. In the majority of instances, however, the spIit thickness skin graft has been used. The Padgett dermatome6 has simpIified the taking of this type of graft and has made it
NEW SERIESVOL. LIV, No. 3
VeaI et al.-Skin
the most practica1 of aII. By this technic a graft of aImost unbelievable size can be The postoperative used at one operation.
Grafting
American
Journal
of Surgery
719
stage we have applied suIfanilamide-alIantoin ointment dressings to the ungrafted area whiIe awaiting the next stage. (Fig. 6. j
Frc. 4. Extensive streptococcic and gas bacillus infection of leg with skin gangrene. Rapid control of infection by the topical application of sulfanilamide after dChridement; granulation tissue prepared hy sulfanilamidc-allnntoin ointment. A, granulation tissue ready for graft. n, successful graft in one stage.
FIG. 5. Carcinoma of face with gross infection; excision; control of infection by topical application of sulfanilamide and sulfanilamideallantoin ointment. A, carcinoma of face before excision. B, granulation ready for graft. c, healed graft.
care of the grafts has varied considerably, but in a11 cases the grafted part has been immobihzed. When the entire granuIating surface has been covered at one stage, we have used wet and dry dressings with equa1 success. In those cases in which onIy a portion of the Iesion was grafted at the first
This dressing has maintained contro1 of the infection and has not interfered with the “take” of the graft. SUMMARY
SuIfaniIamide has proved to be an exceIIent IocaI agent in combatting bacteria1
720
American Journal of Surgery
Veal
et A--Skin
growth in infected and contaminated surface wounds. The action of the drug is a direct one and must come into contact with the invading organisms. Prolonged use of
SULFANILAMIOE
0
5
IO
I5 DAYS
DELLMULI~, ,<)_b,
We wish to thank The National Drug Corn-pany, of Philaddphia, Pennsylvania, for l‘urnishing us with the allantomide used in this study.
ALLANTOIN (ALLANTOMIDE)
20 AFTER
Grafting
25
OINTMENT
30
32
DAILY
35
40
42
DEERIDEMENT
FIG. 6. Chart showing rapid control of infection by suIfaniIamide locally in extensive second and third degree burn of back folIowine dhbridement. Preoaration of granulation tissue for skin graft by topicat appIication of sulfanilamide-alkmoin ointment. Note size of graft used and the healthy appearance of granulation tissue.
the pure drug may retard heaIing. Complete removal may aIIow a reactivation of the infection. Both of these disadvantages may be averted by substituting sulfaniL amide-aIIantoin ointment for the pure powder after the infection has been controlled. The aIIantoin promotes active VascuIarization of the granuration tissue thereby creating a favorabIe state for the reception of skin grafts. The excelIent resuIts obtained by preparing some forty superficial wounds for skin grafting by the IocaI use of suIfaniIamide and suIfaniIamide-allantoin ointment (aIIantomide) has been most encouraging. The method is simpIe and appIicabIe to a11 areas of the body.
REFERENCES I.
2.
3.
4.
5.
5.
J. R. and KLEPSER, R. G. The treatment of pyogenicalIy infected wounds by the topica application of powdered sulfanilamide and sulfaniIamide-aIIantoin ointment. Med. Ann. District of Columbia, IO: 61, 1941. LOCKWOOD,J. S. Sulfonamide therapy as an aid to surgery. Surg., Gynec. FYObst., 72: 307, 1941. BRICKER, E. M. and GRAHAM, E. A. Inhibitory effects of suIfaniIamide on wound heating. J. A.M. A., I 12: 2593, 1939. ROBINSON,WM. StimuIation of healing in nonhealing wounds by alIantoin occurring in maggot secretions and of wide biologica distribution. J. Bone IV Joint Surg., 17: 267, 1935. GREEP~BAUM,F. R. Allantoin, a new granulation tissue stimulating substance with especial emphasis on alIantoin in ointment form. Am. J. Surg. 34: 259, ‘937. PADGETT, E. C. CaIibrated intermediate skin grafts. Surg., G_vnec. c~ Obst., 69: 779, 1939.
VEAL,