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New method for transfer of full-thickness skin: Grille graft
NEW METHOD FOR TRANSFER OF FULL#THICKNESS SKIN: GRILLE GRAFT* G. FRANK SAMMIS, M.D., F.A.C.S. Senior Surgeon, St. John’s HospitaI, Brooklyn; HOLLIS,
T
Frc.
Plastic Surgeon, Queens Genera1 HospitaI, Jamaica NEW
HE plastic surgeon is often confronted with conditions demanding the use of fuII thickness skin for reconstructive
I.
YORK
writer’s experience but the donor site is large and sIow to heal and the dissection, Ieaving the isIands of intact skin on the donor site, is tedious, sIow and difficult. No undermining of adjacent skin is practica1, as it would resuIt in covering the isIands and defeat the object for which they were intended. Of course, it might be practical to Ieave a Iarger area of intact skin at the free edges of the graft, thereby making fewer isIands and then undercut the donor site edges and partiahy cIose the wound. It wouId stiI1 be tedious and take much time to dissect around these severa isIands. So, in a effort to overcome these diffrcuIties and objections, the author presents an origina method and has caIIed it the GriIIe graft. It consists of Ieaving one, two or more narrow paraIIe1 strips of skin on the donor site undisturbed to act as islands, estabIishing centers from which healing begins to take pIace very earIy postoperativeIy. Very Iittle, if any, allowance need be made for “shrinkage” of the graft during its appIication to the recipient site, in contrast to the “sieve graft” where it is recommended that the graft be about 25 per cent oversized. This, of course, means the area from which the skin is taken, is larger and slower in heahng. Surrounding edges of the donor site may be undermined to varying degrees, drawn toward the isIands and sutured to them, thereby effacing a Iarge area of the defect Ieft by the removal of the graft. The recipient site is prepared in the usua1 exuberant granmations removing way, when necessary, applying hot pads and pressure to obtain as nearly complete hemostasis as possibIe. A pattern or
Condition before GriIle graft was appIied.
and corrective purposes. Free grafts are not always successfu1 and they Ieave unsightIy scars on donor sites. The tubed pedicIe of GiIIies is aImost uniformly successfu1 but requires two or more operations, Iong hospitalization, uncomfortabIe immobilization and return to society is Iong deterred. It has been the practice of the writer, when the tube shah have served its purpose, to discard the proxima1 unused segment instead of replacing it in its original bed. In this way, a singIe longitudina1 scar resuIts, where repIacement necessitates two and this aIso avoids an additiona operative procedure. ResuIts of pinch grafts are not pIeasing cosmeticaIIy, on either donor or recipient sites. Douglas has devised the “sieve graft,” which has been very satisfactory in the
* Read before the Brooklyn Surgical Society, December, 46
1936.
Sammis-GrilIe template may be made, after the recipient site shaI1 have been prepared and apphed to the donor site as an outline, then transfer
Graft
Amencan
Journal
of Surgrry
-47
A. S. age six years, colored male, was admitted to St. John’s HospitaI, Brooklyn, with extensive
burns
of the
arms,
abdomen
and
FIG, z. Diagram showing strips of skin left intact on donor site; A, graft; B, skin Ieft intact on donor site.
the fulI thickness skin and suture it carefuIIy in place, accurately apposing the edges. This leaves one, two or more
FIG. 4. Diagram showing undermined skin edges sutured to islands of skin on donor site; A, adjacent skin undermined, slid and sutured to itseIf and to intact skin; s, skin Ieft intact on donor site.
“ventilated” areas, according to the size of the graft, to aIIow the escape of serum and air bubbles, when sea-sponge shaI1 have been appbed. Following is a typical case report
FOG. 3. Donor site after removal of graft technique shown in Figure 2.
following
The surfaces were tanned early and fairly good results were obtained except for two
chest.
FIG. 5. Undermined skin edges sutured to islands on donor site, as shown in Figure 1.
areas on the extensor surfaces of the left elbow, about 3 by 3 cm., which resisted treatment and skin grafting was erected. On May 29, 1936, GriIle grafts were raised from the anterior surfaces of both thighs and transferred to the Ieft elbow. UsuaI sea-sponge
48
American
Journal
of Surgery
Sammis-GrilIe
dressing was appIied to the recipient site and vaseIine gauze to the donor sites. HeaIing progressed, the grafts having “taken” to such an extent that an oIder pa-
FIG. 6. “Ventilated” areas of skin having been left on donor site; G, grilled graft sutured into recipient site; showing VA, “ventilated areas.”
tient might have Ieft the hospita1 at the end of the fourteenth day. The wounds were
FIG. 8. Recipient
site heaIed, twenty-two
days.
firmIy heaIed and a11 dressings removed at the end of twenty-one days. CONCLUSIONS
The advantages are as foIIows:
cIaimed
for this method
Graft I. The ease with which the graft is raised; ten minutes is the usuaI time necessary to dissect a moderate sized graft with two openings;
FIG. 7. Two GriIle grafts sutured in place, as shown in diagram in Figure 6.
PartiaI cIosure of the donor site; 3. “VentiIation” of the recipient site;
2.
FIG. g. Donor site healed, fourteen days.
4. Rapid heaIing and presentabIe scars at both sites; 5. Less restriction of the parts by immobiIization, and shorter hospitalization; together with the advantages of the sieve, the tube and other fuI1 thickness skin
NEW SERIES
VOL.
XXXVI,
No.
Sammis-GriIIe
I
transfers, namely, prevention of subsequent contractures, as in flexor surfaces such as the popIitea1 and axiIlary spaces;
A
Graft
American
Journal
of Surgery
49
where skin and superficial fascia are not pIentifu1; 7. The restoration of denuded areas on
B
FIG. LO. A, Complete excision of all the scar tissue could not be accomplished because of its density and its ertent from the forearm to the chest, hence the grafts were sutured to the surrounding areas of abnorma1 skin; R, end-result four months postoperativeIy, showing aImost complete extension and healed areas of donor site.
and 6. Prevention of desquamation “cracking” on extensor surfaces, such as the eIbow, knee and other locations
scaIp or skin, following the deep removal of maIignant growths; and 8. In indoIent varicose uIcers.
T
Frc.
Plastic Surgeon, Queens Genera1 HospitaI, Jamaica NEW
HE plastic surgeon is often confronted with conditions demanding the use of fuII thickness skin for reconstructive
I.
YORK
writer’s experience but the donor site is large and sIow to heal and the dissection, Ieaving the isIands of intact skin on the donor site, is tedious, sIow and difficult. No undermining of adjacent skin is practica1, as it would resuIt in covering the isIands and defeat the object for which they were intended. Of course, it might be practical to Ieave a Iarger area of intact skin at the free edges of the graft, thereby making fewer isIands and then undercut the donor site edges and partiahy cIose the wound. It wouId stiI1 be tedious and take much time to dissect around these severa isIands. So, in a effort to overcome these diffrcuIties and objections, the author presents an origina method and has caIIed it the GriIIe graft. It consists of Ieaving one, two or more narrow paraIIe1 strips of skin on the donor site undisturbed to act as islands, estabIishing centers from which healing begins to take pIace very earIy postoperativeIy. Very Iittle, if any, allowance need be made for “shrinkage” of the graft during its appIication to the recipient site, in contrast to the “sieve graft” where it is recommended that the graft be about 25 per cent oversized. This, of course, means the area from which the skin is taken, is larger and slower in heahng. Surrounding edges of the donor site may be undermined to varying degrees, drawn toward the isIands and sutured to them, thereby effacing a Iarge area of the defect Ieft by the removal of the graft. The recipient site is prepared in the usua1 exuberant granmations removing way, when necessary, applying hot pads and pressure to obtain as nearly complete hemostasis as possibIe. A pattern or
Condition before GriIle graft was appIied.
and corrective purposes. Free grafts are not always successfu1 and they Ieave unsightIy scars on donor sites. The tubed pedicIe of GiIIies is aImost uniformly successfu1 but requires two or more operations, Iong hospitalization, uncomfortabIe immobilization and return to society is Iong deterred. It has been the practice of the writer, when the tube shah have served its purpose, to discard the proxima1 unused segment instead of replacing it in its original bed. In this way, a singIe longitudina1 scar resuIts, where repIacement necessitates two and this aIso avoids an additiona operative procedure. ResuIts of pinch grafts are not pIeasing cosmeticaIIy, on either donor or recipient sites. Douglas has devised the “sieve graft,” which has been very satisfactory in the
* Read before the Brooklyn Surgical Society, December, 46
1936.
Sammis-GrilIe template may be made, after the recipient site shaI1 have been prepared and apphed to the donor site as an outline, then transfer
Graft
Amencan
Journal
of Surgrry
-47
A. S. age six years, colored male, was admitted to St. John’s HospitaI, Brooklyn, with extensive
burns
of the
arms,
abdomen
and
FIG, z. Diagram showing strips of skin left intact on donor site; A, graft; B, skin Ieft intact on donor site.
the fulI thickness skin and suture it carefuIIy in place, accurately apposing the edges. This leaves one, two or more
FIG. 4. Diagram showing undermined skin edges sutured to islands of skin on donor site; A, adjacent skin undermined, slid and sutured to itseIf and to intact skin; s, skin Ieft intact on donor site.
“ventilated” areas, according to the size of the graft, to aIIow the escape of serum and air bubbles, when sea-sponge shaI1 have been appbed. Following is a typical case report
FOG. 3. Donor site after removal of graft technique shown in Figure 2.
following
The surfaces were tanned early and fairly good results were obtained except for two
chest.
FIG. 5. Undermined skin edges sutured to islands on donor site, as shown in Figure 1.
areas on the extensor surfaces of the left elbow, about 3 by 3 cm., which resisted treatment and skin grafting was erected. On May 29, 1936, GriIle grafts were raised from the anterior surfaces of both thighs and transferred to the Ieft elbow. UsuaI sea-sponge
48
American
Journal
of Surgery
Sammis-GrilIe
dressing was appIied to the recipient site and vaseIine gauze to the donor sites. HeaIing progressed, the grafts having “taken” to such an extent that an oIder pa-
FIG. 6. “Ventilated” areas of skin having been left on donor site; G, grilled graft sutured into recipient site; showing VA, “ventilated areas.”
tient might have Ieft the hospita1 at the end of the fourteenth day. The wounds were
FIG. 8. Recipient
site heaIed, twenty-two
days.
firmIy heaIed and a11 dressings removed at the end of twenty-one days. CONCLUSIONS
The advantages are as foIIows:
cIaimed
for this method
Graft I. The ease with which the graft is raised; ten minutes is the usuaI time necessary to dissect a moderate sized graft with two openings;
FIG. 7. Two GriIle grafts sutured in place, as shown in diagram in Figure 6.
PartiaI cIosure of the donor site; 3. “VentiIation” of the recipient site;
2.
FIG. g. Donor site healed, fourteen days.
4. Rapid heaIing and presentabIe scars at both sites; 5. Less restriction of the parts by immobiIization, and shorter hospitalization; together with the advantages of the sieve, the tube and other fuI1 thickness skin
NEW SERIES
VOL.
XXXVI,
No.
Sammis-GriIIe
I
transfers, namely, prevention of subsequent contractures, as in flexor surfaces such as the popIitea1 and axiIlary spaces;
A
Graft
American
Journal
of Surgery
49
where skin and superficial fascia are not pIentifu1; 7. The restoration of denuded areas on
B
FIG. LO. A, Complete excision of all the scar tissue could not be accomplished because of its density and its ertent from the forearm to the chest, hence the grafts were sutured to the surrounding areas of abnorma1 skin; R, end-result four months postoperativeIy, showing aImost complete extension and healed areas of donor site.
and 6. Prevention of desquamation “cracking” on extensor surfaces, such as the eIbow, knee and other locations
scaIp or skin, following the deep removal of maIignant growths; and 8. In indoIent varicose uIcers.