The early and late treatment of burns in children

THE EARLY AND LATE TREATMENT OF BURNS IN CHILDREN* DONALD

W.

MACCOLLUM,

Associate Vrsiting Surgeon, The ChiIdren’s HospitaI; BOSTON,

in Surgery,

Harvard

Medical SchooI

MASSACHUSETTS

INTRODUCTION

Iiterature is fiIIed with articIes on the treatment of burns. As a ruIe each paper champions one particuIar form of treatment. This paper, however, attempts to evaIuate the majority of these methods in reference to their specific appIication to infants and chiIdren. In addition, it attempts to evaIuate the various means of preventing and repairing the unsightIy scars, contractures, and deformities resuIting from burns in this age group. In The ChiIdren’s HospitaI of Boston, during the seven years from January I, 1930 to January I, 1937, 461 patients were seen with either fresh burns or deformities caused by burns. Of these patients, 302, whose burns were not suffIcientIy severe to necessitate their admission to the hospita1, were treated in the out-patient department. The remaining 159 patients were admitted to the wards. In this Iatter group, I 15 were suffering from fresh, severe burns. OnIy two patients of this group died whiIe under treatment. This gives a mortaIity rate of I.7 per cent for patients with fresh, severe burns, and is evidence of the efhcacy of the principles of treatment outIined in this paper. There was no mortaIity in the group of cases receiving operative treatment for repair of scars or burn deformities. Of the 159 patients admitted to the hospita1, the agents causing the burns were as shown in the tabIe in the opposite coIumn. ChiIdren are usuaIIy not exposed to the factors causing the majority of the

M

Instructor

M.D.

EDICAL

Cause I. Fire........................... 2. Hot liquids.. . 3. Contacts with hot surfaces. 4, Electric appliances. 5. ChemicaI agents.. 6.Sun . . . . . . . .._............... 7. Unknown agents.. ... ..

55 13 10 IO

. . .

I 3

burns in aduIts, such as ‘the industrial hazards of moIten metaIs, hot oil or acids, acetyIene torches, eIectrica1 instruments, high voItage wires, etc. They are more frequentIy exposed to those hazards that exist in or about the home, such as matches, bonfires, hot Iiquids in the kitchen, eIectrica1 househoId appIiances, fire-crackers, and inAammabIe Iiquids. Because of his smaI1 stature, a comparativeIy Iarge area of the chiId’_s body may be burned. Their heIpIess fright, which renders them unabIe to aid themseIves in removing or extinguishing the causa1 agent may resuIt in the burn becoming more extensive in depth. In this way, a bow1 of hot soup overturned upon a chiId may be more serious than many of the industria1 accidents of the aduIt. At the first examination, estimation of the depth of the burn is diffIcuIt. Experience with many cases is required, before a reasonabIy correct determination can be made. A first degree burn is designated as one showing a marked erythema with or without edema of the part, but without bIister formation. The most frequent causa1 agent of this type of burn in children is over-exposure to the sun. A second degree burn, theoreticaIIy, penetrates to, but not through the dermis. BIebs are formed, which upon breaking expose. a shiny pink Iayer of uninjured dermis. A third degree

* From the SurgicaI Service of The Children’s Hospital, Boston, Mass., and the Department University Medical School. 275

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burn extends through the dermis into the subcutaneous tissue. This type is diffIcuIt to differentiate from a second degree burn unIess the subcutaneous Iayers have been exposed. If the burned surface has rapidIy formed a bIeb which has broken, and the surface beneath the bIeb appears gray that the rather than pink, it indicates dermis has been destroyed. A fourth degree burn penetrates the skin and subcutaneous tissue into the muscIe and fascia1 pIanes. A burn of this severity is generaIIy not recognized unIess charring occurs. A fifth degree burn extends to bone and invoIves destruction of the periosteum. Of the 159 patients admitted to The ChiIdren’s HospitaI for treatment, fiftynine showed areas of first and second degree burn onIy, sixty-seven showed areas of third degree, and thirty-three showed areas of fourth degree. There were none of fifth degree. Ninety of these 159 patients required secondary operations for covering the unheaIed areas or for repair of unsightIy or deforming scars. Therefore, evaIuation of the depth of the burn is of some aid in the prognosis and in the estimation of the time required for compIete heaIing. An estimation of the body surface which has been burned is aIso of prognostic importance. The foIIowing division of body surfaces in a chiId wiI1 aid in such evaIuation: in children, the trunk forms 40 per cent of the body surface; the upper extremities form 16 per cent, of which the hands form one-fourth (4 per cent) and the arms three-fourth (12 per cent). Estimation of the surface area of the head is important in that the head of the chiId is reIativeIy larger than it is in the aduIt. To compute this, the age of the chiId in years is subtracted from twelve. This figure is then added to the figure expressing the aduIt estimation, which is 6 per cent. The Iower extremities are reIativeIy smaIIer in a chiId. To compute this the age in years is subtracted from tweIve and this figure subtracted from the estimation of the Iower extremities of the aduIt which is 38 per cent. The feet count approximateIy

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one-sixth (6 per cent), the Iegs one-third (13 per cent) and the thighs one-haIf (19 per cent). Using this index, it has been stated that if 3355 per cent of the body surface of an aduIt is burned, death wiI1 ensue. In chiIdren the percentage of surface area predisposing to a fataIity is thought to be somewhat smaIIer if the same index is empIoyed. I. TREATMENT

OF

FRESH

BURNS

ChiIdren with a fresh burn invariabIy show some degree of stock. This immediate shock resuIts from the fright of the accident as we11 as the pain of the burn itseIf. UnIess the burn is extensive in area and depth, this initia1 shock is transient, and may have IargeIy disappeared by the time the patient is seen by the doctor. When the burn is extensive, however, this initia1 shock may progress to a deeper and fata stage unIess immediate efforts are made to combat it. This deeper stage of shock is caused by pain insuffIcientIy reIieved, by exposure, and perhaps by a compensatory diIatation of the viscera1 bIood system in an effort to prevent the concentration of body ffuid which wiI1 soon occur in the region of the burn. This shock is simiIar to any surgica1 shock and shouId be treated by sedatives, warmth, and, if necessary, cardiac stimuIants. Transfusion is contraindicated at this time except in those cases in which a vesse1 has been eroded and there has been an appreciabIe Ioss of bIood, but the giving of intravenous saIine and gIucose is advocated. After twenty-four hours the bIebs which are formed, break and discharge Iarge amounts of body fluid from the burned area. With this fluid Ioss the temperature becomes markedIy eIevated, the puIse becomes rapid, and the patient becomes restIess, then comatose and finaIIy moribund. His bIood at this time wiI1 show an anhydremia. Intravenous infusion of Iarge amounts of saIine and gIucose rather than bIood is therefore advocated earIy in the

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shock treatment, in an effort to prevent this fluid imbaIance and subsequent coIIapse. If, after a few days of this treatment with intravenous saIine and gIucose, the patient becomes edematous or shows a Iowered serum protein, transfusions of bIood or bIood serum are advisabIe. After the shock has been combated, the IocaI treatment of the burn is instituted. When the patient is first seen, the area invoIved has aImost invariabIy been covered with some type of househoId grease (butter, Iard, oIive oi1) in an effort to coat the burn and thereby reIieve the pain. It is necessary that these oiIs be removed if infection of the area and generaIized sepsis are to be avoided. In the aduIt who has had sufficient medication, such as morphia, nembuta1 and scopoIamine, it is possibIe to cIeanse this area adequateIy without a genera1 anesthetic. In the child, however, it has been found that if the burn is to be properIy cIeansed and the devitaIized tissue removed, it is of utmost importance that the patient be compIeteIy anesthetized. If insuffIcient pre-operative medication is given and a Iight nitrous oxide anesthesia administered, this cIeansing process may send the chiId back into a stage of shock which may be rapidIy fatai. The routine at The ChiIdren’s HospitaI after the patient is compIeteIy recovered from his initia1 shock, is to administer nitrous oxide-ether unti1 the patient is in the third stage of surgica1 anesthesia. The burn is then scrubbed from five to seven minutes with sponges soaked in green soap and hydrogen peroxide. This is foIIowed by Iavages of aIcoho1 and hexyIresorcino1. AI1 of the bIisters are broken and the superficia1 dead skin removed. At the end of this procedure a surgicaIIy steriIe wound shouId have been produced. This dkbridement shouId be carried out rapidIy so as to avoid Iengthy exposure and chiIIing of the patient from the use of the soIutions. The type of medication and protection to dressing, be empIoyed whiIe the burn is heaIing, are now to be considered.

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Greases and ointments form the Iargest and most commonIy used group of medicaments. To state that ointments are outdated is to err, but in Iarge hospita1 practice other methods have been found to be more effective. Ointments cover the burn and thus heIp to Iessen the pain. Some contain anesthetic properties so that the pain is stiI1 more effectiveIy reIieved. Because of their greasy state, these dressings do not adhere to the painfu1, raw area. There are two important requisites that the majority of ointments do not meet: first, they do not prevent the escape of tissue ffuid from the burned area; and second, they do not have enough antiseptic properties to prevent infection entireIy in the burned site. In a severe burn this Iack of protection against anhydremia and sepsis becomes fundamenta1 in preventing the Ioss of Iife. If, however, a compIete surgica1 d&bridement of the burn is done and if a sterile ointment with antibacterial properties is appIied, the danger of sepsis is extremeIy sIight. NevertheIess, within twenty-four to forty-eight hours the dressings wiI1 have become saturated with fluid exuded from the part. By retrograde action the burn must therefore be regarded as contaminated. Changing this dressing may be painfu1. If the burn covers a Iarge area, it is very apt to become further contaminated during the changing. An ointment containing a coaguIant, such as tannic acid, wiI1 form an eschar, thereby meeting one requisite in preventing the Ioss of Auid from the raw area. This eschar formation, however, is proIonged if there is an appreciabIe amount of exudation taking pIace. With this deIay, infection may occur in the burned site and Iater be masked by the eschar. The gauze impregnated with the ointment often becomes so adherent that it forms an integra1 part of the eschar, and is therefore diffIcuIt and painfu1 to remove. The use of ointments generaIIy is indicated on burns covering onIy smaI1 areas, on burns which are of first degree, and on

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burns around any body orifice (eyes, ears, mouth, nose, genitaha, and anus). In these sites it is aImost impossibIe to keep the burned area continuousIy cIean, so that frequent Iavages and reappIication of some type of dressing are necessary. In fat, chubby babies with many redundant foIds of skin, it is often advantageous to use ointments on the fingers, hands, toes, feet and groins, mereIy because it is diffrcuIt to immobiIize these parts s&cientIy and prevent an eschar from cracking. In extensive burns invoIving areas other than those just mentioned, ointments are Iess desirabIe than other methods stiI1 to be discussed. GeneraIIy, ointments are superior to these other methods, if the latter are not correctIy empIoyed. The wet pack and the intermittent or continuous bath are other types of treatment. A burned part becomes extremeIy painfu1 if put under water and then removed from it. If it is kept immersed, however, the pain is quickIy relieved. In most cIinics wet dressings are used onIy on those patients whose untreated burn is covered by a weeping, infected crust. An operative debridement at this time is not advisabIe because of the danger of producing generalized sepsis. NevertheIess, it is necessary to remove the crust before the infection can be treated effectiveIy. Wet packs of saIine or boric acid are frequentIy empIoyed, but in some cIinics soIutions with more antibacteria properties, such as eusoI,* Dakin’s, hexyIresorcino1 or merthioIate are preferred. Wet packs may aIso be used in fresh burns when they involve the areas in the immediate vicinity of the genitaIia and rectum to insure mechanica cIeanIiness. A wet pack of I : 50,000 adrenaIin soIution is occasionaIIy appIied over a fresh burn, By contracting the capiIIary bed, it effects a reduction in the amount of tissue Auid 10s~. It is thought that the absorption of any toxic products formed in the burned area is thereby kept at a minimum. The amount of adrenaIin absorbed is aIso very *

See page 282 for method of preparation.

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FEBRUARY, 1938

smaI1 because of the IocaI constriction of the vesseIs. This method has not become popuIar in America, but is used in severa European cIinics. Continuous baths of saIine or boric acid have been advocated for the fresh burn. The chiId is compIeteIy immersed, in his cIothes if necessary, but as soon as he is comfortable the cIothes are cut away. He is aIIowed to defecate or urinate in the tub, reIying on the constant ffow and drain of the water to keep the burns cIean. There are, however, severa objections to the use of continuous baths for chiIdren. The ffuid Ioss from the burn is not checked. If intravenous infusion shouId be necessary, it is diffrcuIt to carry out with the patient in the tub. Constant attendance is necessary for the child. As tubs designed for constant baths do not generaIIy form a reguIar part of hospita1 equipment, the substitution of the ordinary tub frequentIy occurs. One encounters here many mechanicaI diffrcuIties in reguIating the constant suppIy and drainage of water at an even temperature and in devising equipment for supporting the patient. Instead of using boric acid, saIine, or pIain tap water, a tannic acid soIution may be used in the bath. Tanning wiI1 not take pIace over grease, so it is necessary to remove it or other foreign materiaIs before immersion. This type of bath is continued unti1 a good eschar is formed. Depending on the concentration of the tannic acid in the tub this may require a few hours or severa days. This method of tanning is not thought to be superior to the spray, except that it may take Iess time. It has the one important disadvantage of contracting a11 the pores in the norma skin. As the excretory power of the burned portion of the body surface has aIready been aboIished, it wouId seem unwise to reduce that of the remaining norma skin. The third main principIe of burn treatment constitutes covering the burn with a firm protective coating. This coating either takes the form of an eschar (coaguIum) or a coating of paraffin or wax.

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A coaguIum or crust wiI1 form over any Iarge raw surface from the simpIe cIotting and accumuIation of dried tissue fluid. Various agents have been used to hasten the formation of this coaguIum and in some instances to impregnate it with materia1 having antibacteria or antiseptic properties. Eschars are formed principaIIy by tannic acid, by tannic acid combined with siIver nitrate, by gentian vioIet, by gentian vioIet in combination with acri vioIet and briIIiant green, or by ferric chloride. UnIess one has treated many cases with each agent, it is diffIcuIt to decide which is the best to use. A “burn team” is usuaIIy trained to acquaint itseIf in the use of one or perhaps two types of eschars. In the hands of each group, the chosen form of treatment becomes effective. So far, no one cIinic has been abIe to produce equaIIy good resuIts with a11 methods, yet one cIinic wiI1 achieve remarkabIe resuIts with a method discarded by another. Tannic acid forms a coagulum over any area in which the epidermis is destroyed, exposing the dermis or deeper Iayers. It is usuaIIy appIied in aqueous soIutions in concentrations from 2f5 per cent up to 40 per cent. In the higher diIution (z&5 per cent) appIication by means of constant baths, or sprays every fifteen or twenty minutes, wiI1 produce an eschar which is impermeabIe to air within twenty-four to forty-eight hours. In the Iower diIution (30-40 per cent) it is usuaIIy appIied on dressings saturated with the soIution, or by means of a spray gun used every two to three hours. Tannic acid is best used on cIean burns or those that have had an operative dbbridement. If a burn has not been cleansed or has been infected, tannic acid wiI1 cover over the raw areas, but wiI1 mask the infection going on underneath the coaguIum. To prevent Iate infection it is necessary to use a sterile bed with cradle, so sprays may be done without contamination. An isoIated room or cubicIe and specialized nursing care are aIso required.

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After an eschar has been properly formed the patient has no discomfort and may move about at wiI1. Eschars over joints or over areas which are IiabIe to macerate by apposition of surfaces, must be watched for cracking, and rigid care taken to prevent sepsis. ProIonged appIication of tannic acid thickens the eschar and predisposes to immobiIity with cracking upon movement. Therefore it is essentia1 to stop the appIication as soon as a thin coating has formed. As the eschar dries, it wiI1 turn down at the edges into the norma skin. It wiI1 begin to pee1 away as soon as the area beneath has epitheIiaIized. The time invoIved before this occurs depends on the depth and extent of the origina burn. Burns invoIving the subcutaneous Iayers or muscIe wiI1 not hea under an eschar, unIess there are many residua1 isIands of skin from which the epithelium wiI1 grow to cover those surfaces from which it is Iost. When a Iarge granuIating area remains, the eschar over it wiI1 become soft. This does not indicate that infection is present if proper care has been taken to prevent it. It does mean that the area beneath is not covered with skin and probabIy wiI1 never be covered, without some additiona heIp from surgery. This is contrary to the opinion heId by many, that infection is the norma sequence to the tannic acid treatment of burns. This softened area shouId be removed, however, and the granuIating area covered with an appropriate type of skin graft. OccasionaIIy when the burn has been deep, and when the tannic acid solution in lower dilution (30-40 per cent) has been applied, the eschar wiI1 be found to adhere tightIy. In these instances operative dhbridement may again be necessary, but as a general ruIe appIications of saIine or boric packs accompIish its remova without diffIcuIty. Under the rkgime recommended for the treatment of burns with tannic acid, perhaps the greatest diffIcuIty encountered is the handIing of the patient during the period twenty-four to forty-eight-hour

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whiIe the tanning is taking pIace. In order to shorten the time of application and thereby decrease the danger of sepsis, a more rapid method of tannmg is desirabIe. The combined action of tannic acid and siIver nitrate on a freshIy burned surface meets this requirement. The burn is debrided in exactIy the same manner as described previousIy. Sponges wet with tannic acid, 5 per cent, are then daubed over the wound unti1 a11 of the surface is IightIy tanned. This is immediately foIIowed by an application of IO per cent siIver nitrate. Within a few minutes a thin, firm, pIiabIe eschar is formed. The patient is then pIaced in a steriIe bed with a heated cradIe over him. Within a few hours the eschar is dry and soIid, having the appearance of a four or five-day oId eschar formed by tannic acid aIone. The possibiIity of argyria occurring from the siIver nitrate may be discounted. The onIy possibIe disadvantage with this method is the questionabIe coaguIation and destruction of smaI1 skin isIands by the action of the siIver nitrate. This combination of tannic acid and siIver nitrate has been used to treat the donor site of a razor graft. If the razor graft has been properIy raised, the donor site is anaIogous to a surgicaIIy cIean, second degree burn. With the use of these agents it has been noted that there is a definite tendency for the donor site to hea at a much slower rate than if an ordinary ointment dressing had been appIied. This raises the question of whether burns treated with this method are aIso retarded in their heaIing. It has been impossibIe to determine this because of the diffIcuIty in judging from first inspection, the severity of the burn and the individua1 variation’ in abiIity of epitheIiaIization. Gentian vioIet has suppIanted the use of tannic acid in many cIinics. This dye, in aqueous 1-2 per cent soIution, has no actua1 coaguIating power, so that the eschar formed is one composed of the norma1 tissue Auid which has been exuded from the burn and which has been heaviIy

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impregnated with the dye. It does have some desiccating effect so that it quickIy causes a crust to form, but it does not produce its eschar with the same degree of rapidity as tannic acid. In this way more tissue fluid is Iost when a Iarge area is burned. This dye in some cIinics is used in combination with other dyes, such as acri vioIet and briIIiant green. AIone, and in combination, gentian vioIet produces its principIe effect by its IethaI action on the It is therefore not so bacteria present. necessary to have the wound surgicaIIy cIean as it is with tannic acid. AI1 foreign materia1 and dead skin, however, must be removed, but an operative dkbridement with scrubbing is not absoIuteIy essentia1. It is stiI1 debatabIe whether the so-caIIed toxemia found in burn cases is caused by the absorption of a histamine-Iike substance formed in the burned area, or by the absorption of the broken down proteins from the destruction of the skin itself, or whether it is due to an absorption of toxins produced by the bacteria present in these burn wounds. Advocates of the gentian vioIet form of treatment hoId to the Iatter view, and fee1 that the dye prevents the formation of the bacteria1 toxins by its destructive action on the bacteria. The eschar formed by gentian vioIet is thin and pIiabIe so that it is of advantage over parts where movement is IiabIe to occur. As the burn heaIs, the edges of the eschar, in contradistinction to the tannic acid eschar, begin to cur1 up at the edges and to pee1 away. Over smaI1 areas of third degree burns the eschar remains in pIace Ionger and without as rapid softening as occurs with tannic acid. If any skin isIands are Ieft, the raw areas wiI1 heaI in. Over Iarge areas of third degree burns, the eschar finaIIy softens and must be removed, in a manner simiIar to the tannic acid eschar. The penetrating staining quaIities of gentian violet constitute the main disadvantage for its use. In addition to the burn, it covers and stains everything in the vicinity. In the smaI1 hospita1 or private home the

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resuIt is disastrous. This eIement may be disregarded in Iarger cIinics that deIegate a certain ward and equipment for this type of treatment. At the ChiIdren’s HospitaI it has never been feIt that gentian vioIet was any more efficacious in the treatment of burns than the proper use of the tannic acid or the tannic acid-siIver nitrate method. Using these Iast two methods to a greater degree than a11 the others, the resuItant mortaIity rate of I.7 per cent chaIIenges a change to the routine use of gentian vioIet or any other method. Ferric chIoride in a 5 per cent aqueous soIution has recentIy been advocated for the treatment of burns. When sprayed or daubed over the freshIy burned site, a thin, pIiabIe, brown eschar is formed within six to twenty-four hours. When the burn is new, blebs may subsequentIy form which must be asepticaIIy broken and recoaguIated with the ferric chioride. If infection is to be avoided, the preparation of the patient and the burn shouId foIIow the same routines as that advocated previousIy for the appIication of tannic acid. There are two main objections to the use of ferric chIoride on burns in chiIdren. For some unknown reason, it is sometimes painfu1 to appIy. It aIso forms too thin an eschar, which even though pIiabIe, is IiabIe to crack upon too much movement. For this reason ferric chIoride wouId seem to be more appIicabIe for oIder chiIdren or aduIts whose movements may be more easiIy controIIed. It has the added disadvantage of staining Iinen, just as gentian vioIet does, so that specia1 Iaundering is required to remove the spots. The use of ferric chIoride has not been wideIy adopted as yet, but it might be substituted for tannic acid or gentian vioIet in seIected cases. Coatings of paraffin or wax have Iong been used in the treatment of fresh burns. They serve no purpose whatever except to form a firm protective covering for the burn. They do not prevent the fluid Ioss from the burned area, have no antiseptic properties, and, if used, shouId be appIied on an absoIuteIy cIean surface. In Iarge

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industria1 pIants where burns may be treated aImost immediateIy after their occurrence, the initia1 heat causing the burn has been found to be suficient to steriIize the area. Wax is sprayed upon the fresh burn without any cIeansing or dCbridement whatever. Good resuIts are reported. Wax with a Iow meIting point is used, so that when it is heated to Iiquid form it wiI1 not be hot enough to burn the patient secondariIy. It may be sprayed over the area either with a gun adapted for this purpose or with an ordinary “ FIit ” gun. After a thin coating of wax has formed, it is covered with a very thin, aImost transparent Iayer of grade A cotton. The area is sprayed again and the procedure is repeated unti1 a firm, Iayered coating has been formed. Care shouId be taken to mask the faces of both the patient and the operator to protect them from inhaIing the fine dropIets of wax. During the ensuing twenty-four hours the serum exuded from the burn Iifts up this coating. It is then removed with very IittIe pain to the patient and a new dressing appIied. These daiIy dressings are repeated until epitheIiaIization occurs. If there are areas of third degree which are smaI1 in extent, this covering keeps the granuIations flat so that epitheIiaIization may take pIace from the norma skin edges. If the third degree areas are Iarge it keeps the granuIations from becoming pouting and soft unti1 appropriate skin grafting can be carried out. At The ChiIdren’s HospitaI it has been feIt that this wax treatment had severa distinct disadvantages for the fresh burns in chiIdren. The daiIy change of dressing constituted the most serious objection. This, even though not particuIarIy painfu1 to the patients, was disturbing to them. The spray gun frightened them. They Iost a considerabIe amount of body fluid from the burned area. As this method requires more immobiIity than any other form of treatment, they had to be restrained. If they did move, they were IiabIe to Ioosen

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their dressings and run the chance of contamination to the area, with consequent infection. These possibilities were too serious to be disregarded. The wax method in conjunction with daiIy saline baths, has, however, been used to good effect as a dressing in an unheaIed oId burn. In these instances it protects and keeps the granuIations ffat during the time that heaIing is taking pIace from the periphery. AI1 of the principa1 methods of treatment for fresh burns have now been outlined with their outstanding advantages and It is clear that no one disadvantages. method is ideaI. In choosing a method it must be remembered that the patient must be kept free, first from shock, then from anhydremia, and finaIIy, from infection. The cases treated at The ChiIdren’s HospitaI in Boston have responded best to the tannic acid or tannic acid-siIver nitrate method. II.

TREATMENT

OF

UNHEALED

BURNS

If compIete epitheIiaIization does not foIIow the treatment outIined for fresh burns, the remaining granuIating areas require treatment. If these areas are smaI1, scattered and interspersed with norma skin, and if in heaIing they wiI1 not contract into a functionaIIy deforming scar, it is possibIe effectiveIy to hasten epitheIiaIization by proper care and dressings, and skin grafting is not needed. The granuIations must be clean and flat, so that the skin does not have to grow over a mound of exuberant tissue. When the granuIations are boggy and high, they may be scraped off with a sharp knife unti1 the cIean, even, fibrous tissue base is reached. This can be done so gentIy that it causes no pain whatever to the patient. The granuIations may aIso be burned with caustics. The Iatter treatment may possibIy destroy the growing edges of the skin, so that heaIing is momentariIy deIayed. The type of dressing to be used over these raw areas varies in every clinic. In

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The Children’s HospitaI, if the granuIations are red and cIean, the foIlowing unguents have been used according to the individua1 desire of the surgeon : zinc oxide, zinc oxide with castor oi1, “gadoment,” “desitin,” boric acid, and ammoniated mercury. AI1 of these seem to have about the same effect. It has been found that the cod Iiver oi1 ointments and those subjected to uItravioIet radiation keep the granuIating areas cIean, and thus secondariIy may tend to promote heaIing. More important, however, than the choice of ointment is the pressure dressing that is appIied, to prevent the granuIations from becoming edematous and boggy. When the granuIations are sIuggish, gray and chronicaIIy infected, a wet antiseptic dressing is usuaIIy empIoyed. A wide meshed, paraffIned gauze is first appIied directIy over the granuIating area to prevent the gauze impregnated with the soIution from sticking to the granuIations and causing pain. Perforated ceIIophane is used in some cIinics instead of the paraffined mesh. The ceIIophane or “siIkoid” commonIy used has too smaI1 hoIes to give adequate drainage or aIIow the granuIations to be reached by the antiseptic dressing. The outer gauze dressings may then be changed without disturbing the burned site. The solutions used in The ChiIdren’s HospitaI, depending on the individuaI’s taste, are boric acid, hypertonic saIine, hexyIresorcino1, I : IOOO merthioIate, and Dakin’s. To this list may be added euso1, which has an action simiIar to Dakin’s, but is easier to prepare. This soIution is formed by mixing boric acid (12.5 Gm.) and chIorinated Iime (12.5 Gm.) with water to IOOO C.C. The mixture is aIIowed to stand for tweIve hours and is then fiItered. It is usuaIIy too strong to be used undiIuted and so is mixed in equa1 parts with minera oi1. Again pressure dressings must be empIoyed to keep the granuIating areas Aat. When the granuIations cover a Iarge area, it is not possibIe to keep them burned down evenIy or scraped suffIcientIy to

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aIIow heaIing from the periphery. At this stage, if some type of graft is not empIoyed, proIonged hospitaIization and an irreguIar deforming scar wiI1 resuIt. If grafting is empIoyed, the most advantageous type of graft and the most advantageous time for operations must be ascertained. The patient’s genera1 condition must be evaIuated. Genera1 bodiIy support in the form of sunlight, transfusion, and good diet shouId be given unti1 the patient is in the best of physica condition. AI1 chiIdren who have been burned and confined to bed for a Iong period of time are potentiaIIy poor operative risks. Their resistance is Iow and even minor operative procedures may be extremeIy hazardous. If they have been hurt unnecessariIy during their dressings, or have not been handIed with infinite patience during this time, they may work themseIves into a nervous state bordering on shock. The importance of judging preoperativeIy the amount of operative work that the chiId wiI1 toIerate, cannot be too strongIy emphasized, especiaIIy for this group of patients. Before any operative repair is undertaken, an estimation of the exact amount of tissue destroyed and the exact amount of new skin necessary for repair of the defects is required. It is next necessary to determine the Iines of skin eIasticity, so as to avoid the development of contractures after the repair is compIeted. It is imperative that the surgeon be abIe to visuaIize the case when it is compIeteIy cured. From this stage it is necessary for him to work backwards in imaginative operative steps, to the condition as it exists in its unheaIed state. If a surgeon cannot do this, he must be seriousIy advised to have his burn cases treated by someone who has this ability. Some areas of granuIation may be of such size and in such position, that they may be excised compIeteIy. Where this is done, the remaining defect must be covered with either a free graft or a transposed ffap from the surrounding good skin. The decision to adopt the technique of tota excision and graft, requires nice judgment

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in addition to an understanding of skin tension and functiona tension of the part. When the raw area is massive (Figs. 1-8) such as that invoIving an entire Iimb or the trunk, it is impossibIe to excise the area compIeteIy, incIuding its deeper scarred portions, and to cover it in one operative maneuver with either free grafts or a flap. In this instance one is concerned first with epitheIiaIization, and second with the contractures which may result. The isIand graft (Riverdin, pinch, smaI1 thin or smaI1 deep) is the graft empIoyed in most cIinics to cover these Iarge, raw areas. EssentiaIIy this is a smaI1 isIand of skin taken by inserting a needIe into the epidermis, Iifting it up to make a mound, and cutting off the mound with a razoredged knife. After cutting, this isIand of skin is roughIy 5 mm. in diameter and triangular in vertica1 section. The edge is thin and is composed of epidermis onIy, whiIe the center represents the dermis and sometimes the subcutaneous Iayer. These grafts are transferred to the raw area on the point of the needIe that Iifted them from their bed. Here they are either pIaced on the top of the granuIations or are imbedded in them as one wouId sow seeds in Ioose earth. They are spaced evenIy, preferabIy about one inch apart. Either a wet dressing over paraffIned mesh or an ointment dressing is then applied and the entire area bandaged tightIy. Because these granuIations are aIways chronicaIIy infected there wiI1 be a marked puruIent discharge within forty-eight hours. If paraffIned mesh has been pIaced directly in contact with the grafted area it is possibIe to change the outer dressing without disturbing the skin isIands. A miId antiseptic may be used to impregnate the dressing in an effort to control the sepsis. It must be emphasized that antiseptics strong enough to combat the infection eff&ientIy, generaIIy kiI1 the germinating skin isIands. After seven to ten days, the isIands that are viabIe wiI1 be suffrcientIy anchored. They shouId then begin to show thin transIucent rims which indicate that new epitheIium is

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growing from them. SubsequentIy attention must be centered on keeping the area as cIean as possibIe by soaks or sprays of antiseptic soIutions, and in addition, on keeping the granuIations Aattened unti1 the epitheIium of one isIand meets that of its neighbor. The time required for this to occur depends on the origina defect Ieft between the impIanted isIands, the genera1 condition of the patient and the gentIeness with which the first dressings are done. When the area has heaIed, there remains a speckIed, pinkish, thickened scar dotted evenIy by circIes of white skin representing the origina isIands. As the scars contract, the isIands become indented, giving the area a pock-marked appearance. As months, perhaps years, go by, the scarred portion becomes more pIiabIe and the coIor fades to a shiny white, the skin isIands now appearing as darker spots because they stiI1 retain the pigments of norma skin. This type of graft aIways produces an unsightIy scar. (Fig. 12.) For this reason it shouId be used only in the exceptiona case in which a11 other types of grafts are impractica1. It hastens epitheIiaIization but does not repIace the deeper tissues which may be Iost. Because of this and the excessive inter-isIand scarring, the areas treated in this manner are much more IikeIy to deveIop Iater contractures which must be reIived by further surgery. Since these isIand grafts may be taken and impIanted under IocaI anesthesia, they become of use in cases with extensive burns in which a genera1 anesthesia is contraindicated. Patients with advanced tubercuIosis or those with marked renaI or cardiac insuffIciency faI1 into this group. TheoreticaIIy one might find a case with such extensive burns that the area of norma skin remaining was insuffrcient to meet the requirements for any other type of graft except the isIand graft. This situation has never been encountered in The ChiIdren’s Hospital. There has aIways been enough skin so that razor grafts might be empIoyed instead of the isIand grafts. Grafts taken from peopIe other than the

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patient, are not advisabIe. Some cIinics use this heterogeneous skin for dressings. When the first gauze dressing is removed the heterogeneous skin often has the appearance of having grown successfuIIy, but from three weeks up to nine months it wiI1 graduaIIy puI1 away, Ieaving beneath, the patient’s skin which has grown in from the periphery. The isoIated reports of successfu1 heterogeneous grafts, can usuaIIy be interpreted in this fashion. In spite of a11the Iimitations, these isIand grafts are used far more frequentIy than any other type. In the hands of the genera1 surgeon, they have more viabiIity because they require a Iess speciaIized technique than that required for razor grafts, fuI1 thickness grafts or transposed Aaps. NevertheIess, the resuIts obtained with these isIand grafts are generaIIy inferior to those obtained from a11 the other grafts. This factor, therefore, practicaIIy eIiminates them from use by the surgeon speciaIIy trained in this type of work. It is generaIIy conceded that Iarge, uniformIy cut razor grafts (OIIier-Thiersch, spIit Thiersch), appIied to the same area as that described previousIy for isIand grafts, wiI1 give a much better cosmetic and functiona1 resuIt. In order to produce a better end resuIt, however, the “take” of this type of graft must be perfect, and therefore speciaIized care is required through a11 stages of the procedure. There are two types of razor grafts: (I) a thin sheet of skin which incIudes the epidermis and onIy the tip of the derma1 papiIIae; and (2) a thicker one (spIit Thiersch) which incIudes nearIy a11 of the papiIIae and some of the dermis, but none of the subcutaneous tissues. The thin razor graft may be used to cover areas which wiI1 normaIIy require IittIe stress or strain (abdomen, thighs), whiIe the thicker one is appIicabIe to those areas which might receive more trauma (hands, feet, joints). Before the use of either graft is contemplated, the genera1 condition of the patient must again be carefuIIy evaIuated. The procedure of razor grafting is more

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shocking to the debiIitated chiId than isIand grafting. GranuIations must be as cIean and as firm as it is possibIe to make them. In The ChiIdren’s HospitaI the donor and recipient sites are thoroughIy cIeansed with soap, aIcoho1 and ether. Because the area required for both sites occasionaIIy invoIves the entire body from head to ankIes this cIeansing is diffIcuIt and awkward, and endangers the patient from exposure. Hot steriIe bIankets are used to cover as much of the patient as possibIe. Heated operating tabIes are desirabIe. The raw area is prepared for the reception of the grafts, by first removing the granulations with a sharp scaIpe1 down to the firm fibrous tissue base which is aIways present. If the recipient area is in a position where further concentric contracture wiI1 not be harmful or disfiguring, (such as center abdomen, chest or back), this fibrous tissue base may then form the bed for the new skin. If, however, it happens to be Iocated over a joint, axiIIa, neck, antecubita1 space, popIitea1 space, or groin, this fibrous tissue base must also be removed unti1 the norma subcutaneous tissue is reached. If further contractures are to be prevented, a11 of the scar tissue must be excised. The norma skin at the periphery of the defect must be undercut for a distance of I to 2 inches. As this retracts, the origina defect increases in size. The area upon heaIing wiI1 tend to contract to some extent, but this wiI1 have been compensated by making the raw area Iarger by the under-cutting. EarIy massage and movement wiI1 heIp to prevent contracture of the graft. It is known that razor grafts wiII hea if pIaced directIy on top of the granuIations that have been cIeansed but not scraped or excised. The percentage of successful grafts produced by this method is considerabIy Iower than if the granuIations have been removed. If these and the deeper scar tissue are alIowed to remain and the grafts do take, the Iate contraction is excessive. (Figs. 57, 58, 64.) The end result is usuaIIy far inferior to that produced when the

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recipient site is properIy prepared. The Iack of reaIization that a razor graft wiI1 grow on normaI subcutaneous tissue, accounts for the faiIure of many men to use it at the most advantageous time. After preparation of the recipient area, a cIoth pattern of the defect is made. The pattern is then inverted on a Iarge board and covered with a sheet of “TuIIe Gras,” (wide meshed, steriIe gauze which has been impregnated with vaseIine gg per cent, compound tincture benzoin I per cent). Some surgeons fee1 that oiIy or greasy dressings are undesirable. In The ChiIdren’s HospitaI there has never been any occasion to fee1 that they were detrimenta to the heaIing of the graft. On the contrary, it is feIt that they may even be beneficia1 to healing. The grafts are then cut. By means of a flat board or a BIair suction apparatus the skin is flattened just ahead of a Iong razor knife. It is difI?cuIt to describe the cutting of the razor graft, but essentiaIIy it consists of a rhythmic to and fro motion of the knife on a pIane paraIIe1 to that of the skin. Most surgeons use the motion of the shouIder onIy, hoIding a11other joints fixed. The thickness of the graft shouId be uniform. This may be judged by the degree of transparency of the raised portion as it runs over the back of the knife. Any incision through the dermis must be avoided and if it occurs, must be sutured. With practice, farge pieces of skin of uniform thickness may be removed from aImost any area of the body. On chiIdren, the donor sites are usuaIIy the thighs and occasionaIIy the upper arms. If the chiId is emaciated, the skin Ioose and ineIastic, the grafts are much more diffIcuIt to cut. In these cases the buttocks, Ioins, and back are preferabIe sites. AI1 that is necessary is extreme patience, pIus a IittIe experience, a very sharp knife, and a donor area that may be pressed out suf6cientIy so that a graft may be cut. As the grafts are raised, an assistant may lay them out, epidermis down, on the mesh pattern, or they may be stored in saIine between Iayers of gauze and a11 Iaid out on

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the pattern Iater. The grafts are placed on the pattern so that the edge of one overIaps its neighbor I3y a margin of I or 2 mm. The mesh pattern is then transferred to the bed prepared for it. Great care must be taken to controI a11 oozing in the recipient site and to prevent the presence of hematoma or foreign bodies (lint, bits of suture materia1, etc.). The edges of the mesh and graft are then sutured as a Iayer to the surrounding skin with four zero plain catgut on an eyeIess needle. These fixation sutures prevent the graft from becoming dispIaced, as the dressing is applied. The dressing is as important as any other part of the procedure. If a graft has been poorIy cut or the recipient site improperIy prepared, and a good dressing is applied, at Ieast some of the graft wiI1 take. On the other hand, no matter how perfect the preparation of the graft or the recipient site, none of it wiII take if an improper dressing is applied. Absolute immobilization of the part combined with adequate pressure to the grafted areas are essentia1, but are more diffIcuIt to obtain in chiIdren than in adults. At The Children’s HospitaI a gauze pad approximateIy I inch in thickness and sIightIy smaIIer than the grafted area is pIaced over the meshed pattern. Over this are pIaced severa more Iayers of ffat gauze and then either a sheet of sponge rubber or a sea sponge. These a11are firmIy bandaged in pIace with eIastic adhesive (EIastopIast) over which is placed an elastic (ACE) bandage to prevent the roIIing of the edges of the EIastopIast. Appropriate spIints or pads are used to immobiIize the part SuffIcientIy. PIaster casts have been found to be of IittIe vaIue in immobiIization for grafts in chiIdren. After the pIaster is dry and the padding becomes compressed, the patient often is abIe to move just enough to dispIace the pressure over the graft. Casts without padding cannot be appIied safeIy to produce the proper amount of pressure. The donor sites are usuaIIy dressed with tannic acid, vaseIined gauze or the TuIIe

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Gras previousIy described. The Iatter dressing changed every forty-eight to seventytwo hours has been found to be the most desirable. The dressing over the grafted site is changed from the fourth to eighth day depending upon the d&ire of the surgeon. The area is carefuIIy sponged with saIine or the patient is immersed in a saIine bath. A dressing with the identica1 pressure is then reappIied. This is changed at twenty-four to forty-eight hour intervaIs unti1 the tweIfth to fourteenth day, when oil massage and movement of the part are instituted. If the area is compIeteIy heaIed, which it shouId be under this regime, no more dressings are required and active physiotherapy may be started. It has been found that these razor grafts have a wide applicability. With but few exceptions they produce a good cosmetic and functiona resuIt in aImost a11 unheaIed burns. The main contraindications arise in the patient who is in such poor physica condition that the operative procedure wouId be fata1, or in one for whom, because of other systemic abnormaIities, the use of a genera1 anesthetic is not advisabIe. They are also contraindicated in chiIdren over those areas where a pressure dressing is not practica1, such as the ears, penis, vagina, anus, and Iips. In aduIts these same sites may be covered with razor grafts with IittIe danger of their 10s~. As these razor grafts produce a slightly shiny surface, they are sometimes not so desirable for facia1 burns as full thickness grafts that do not have this superficia1 appearance. OccasionaIIy in dark skinned individuaIs the razor grafts become more deepIy pigmented than the surrounding skin. This resuItant disfigurement is usuaIIy we11 masked by proper appIication of cosmetics. Case I (Figs. 1-8) shows the resuIt of razor grafting in three stages to cover a Iarge unheaIed burn. The contractures were prevented entireIy in the groin, but onIy partiaIIy in the axiIIa. Donor areas in this case were the unburned portion

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of the back, buttocks and thighs. Further grafting of skin and subcutaneous tissue is now being done in the axiIIa. III. PLASTIC

REPAIR AND

OF BURN

CONTRACTURES

DEFORMITIES

After the burn is heaIed and it is evident that contractures are deveIoping, it is wise to empIoy vigorous massage with physioand occupational therapy for a period of at Ieast six months before corrective operations are considered. This six months deIay has obviated the necessity of many operations which at first the surgeon thought wouId be required. OccasionaIIy, however, a case seemingIy cured at the time of hospita1 discharge wiI1 not receive this routine treatment and wiII reappear later with most distressing deformities. The primary consideration of every case with a burn contracture is to achieve a correct evaIuation of the amount and type of tissue Iost in the origina burn, the entire repIacement of which is required for a good functiona and cosmetic resuIt. The chiId patient must be in robust health, for frequentIy a repair wiI1 require a period of severa months in bed, interposed with frequent operative procedures. ChiIdren must aIso receive as much genera1 supportive treatment as it is possibIe to give them in the nature of good food, sunIight, iron, and, if necessary, transfusions. The chiId must aIso learn to be unafraid of his attendants. With gentIeness and ingenuity the confidence of chiIdren is rapidIy gained and heId. OccasionaIIy children, undergoing these long pIastic repairs, begin to iose their nerve, become apprehensive, fussy and irritabIe. When this happens, it requires extreme patience and kindness to keep them happy and cooperative. The operative principIes for repair of a burn scar are to remove it as compIeteIy as possibIe, to fiI1 the area Ieft by this remova with norma skin, and to hoId the edges of this new skin in approximation, so as to form the Ieast noticeable residual scar. The simpIest procedure, in principle, is excision

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of the scar with direct approximation of the edges. This procedure can onIy be empIoyed for a scar that is narrow and is situated in a position that wiI1 aIIow the surrounding skin to stretch suffrcientIy to cover the defect without producing tension on the new scar or on some neighboring structure. Narrow scars of the face and wider ones over the rest of the body may be repaired in this fashion. After excision it is necessary that the norma skin edges be undercut widely and compIete hemostasis effected. The wound is then sutured with the Ieast possibIe amount of trauma to the borders. In The ChiIdren’s HospitaI the skin edges are never handIed with forcepsinstead, fine sharp hooks are imbedded in the subcutaneous tissue. If the skin edges must be touched at aI1, smaI1 rubber covered forceps wet with saline are employed. A 4 zero to I I zero pIain catgut suture on an eyeIess needIe is used for approximation of the subcutaneous tissue and a 5 zero dermic suture on an eveIess needIe for the skin. Whenever poss:bIe a subcuticuIar stitch of this line dermic suture is used to avoid suture marks. Dressings are not appIied to wounds on the face. These are usuaIIy treated with iced, steriIe, boric acid compresses constantIy for forty-eight hours, and after that, sponging as frequentIy as is necessary to keep them cIean. The chiId must be quieted with sedatives and shouId be restrained, to keep the incision from injury. The sutures, if interrupted, are removed as soon as the wound is heaIed three to seven days, and, if subcuticular, five to seven days. Wounds eIsewhere on the body are dressed with dry gauze and are Ieft undisturbed, unti1 the sutures are removed. FrequentIy a sea1 proof varnish is appIied over these wounds. This varnish is composed of coIphony, drams 3 ; compound tincture benzoin, drams 4; baIsam of ToIu, dram I; iodoform, dram I ; and ether to 5 ounces. It is applied directIy over the incision. WhiIe the varnish is stiI1 “tacky,” a strip of meshed tape is Iaid aIong the wound so as entireIy to cover it. This soon

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adheres tightly, and compIeteIy seaIs the wound. It is very diff&uIt to disIodge this tape except by the use of acetone. In cases

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fIap is rotated into the defect and the edges approximated to form an inverted L or J. Case III (Figs. 13-17) iIIustrates the use

FIG. 3. FIG. I. FIG. 2. FIG. 4. FIGS. I, 2,3 AND 4. Case I. FIGS. I AND 2, burns from fire, seen four and one-haIf months after the accident. On entry, raw areas were covered with a thickened crust composed of pus, gentian vioIet and tannic acid. After two weeks of daiIy saIine baths, foIIowed by eusol dressings, the granuIations became healthy. FIGS. 3 AND 4, resuIt of razor grafts to groin, arm and axiIIa, relieving the contractures in these sites. See also Figures 5, 6, 7 and 8. -

where sIight movement of the part may occur it may be of great heIp in preventing direct stress on the suture Iine. A few of the common eIaborations of the simpie scar excision and advancement of the neighboring skin wiI1 be described. After the scar has been excised and the adjoining skin freed so that the surrounding structures are in their norma reIationships, one may find a defect shaped Iike a V. This may be cIosed in the shape of a Y. This procedure is usuaIIy known as a V-Y advancement or extension. This same V-shaped defect may aIso be fiIIed by a rotation flap. A wide curviIinear incision is made IateraIIy from the top of one of the bars of the V and the skin outIined by this incision undermined to form a Iarge free ffap on a wide base. The

of a rotation ffap which was used to fiI1 the defect Ieft when a Iarge scar of the cheek was compIeteIy excised, and the norma edges undermined. After the undercutting of the edges, the raw surface to be covered, was equa1 to nearIy doubIe the scarred area photographed in Figure 13. The entire neck on this side was outIined and freed to swing on a wide hinge at the midIine anteriorIy. It was rotated into pIace and sutured so that no defect remained. An error in the judgment of viabiIity was made, so that two smaI1 portions of skin just anterior to the ear perished. These areas, however, fiIIed in quickIy and are now not noticeabIe. They may need to be repaired at a Iater time by simpIe excisions. Transposed ffaps differ sIightIy from rotation Aaps in that the arc of the swing

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of the transposed Asp is more acute at its hinge or pedicIe, instead of being a gradua1 advancement of the entire Asp. These are

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IongitudinaIIy aIong the bridIe of the web. At the upper end of this first incision a second is made IateraIIy at an angIe of

FIG. 5. FIGS. 5, 6, 7 AND

FIG. 6. FIG. 7. FIG. 8. 8. Case I. FIGS. 5 AND 6, resuIt of the second razor graft to upper chest and across abdomen. FIGS. 7 AND 8, result of the third razor graft, compIeteIy covering all the raw areas.

often used for contractures of the eyelids where a flap is raised from the upper and transposed to the Iower Iid with the hinge at the outer canthus. It is aIso appIicabIe in Iike fashion for horizonta1 contractures of either Iip. (Case IV, Figs. 18-25.) A speciaIized form of the transposed Aap is one in which the origina incisions have the configurations ‘of the Ietter Z. This is appIicabIe for a scarred band or web contracture having a thin base, so that it is possibIe to pick it up between the fingers as a shelf of tissue. A web contracture with a thick base is usuaIIy indicative of a deepseated scar from the Ioss of a Iarge amount of subcutaneous tissue. The Iatter is best repaired by methods repIacing this Ioss rather than the mere transposition of skin Asps. In a Z-ffap very IittIe, if any, scar tissue is excised. The initia1 incision is made

from 45 to 60 degrees to the first. At the Iower end of the first incision, a third is made, paraIIe1 to the second but in the opposite direction to it. (Fig. 28.) The completed incisions wiI1 then form a Z. As the scar tissue is reIeased, this incision wiI1 spread and outIine two trianguIar flaps. (Fig. 29.) After these are freeIy mobiIized it wiI1 be found that the two flaps may be transposed and approximated in the form of a Z which has been reversed (S). If the surrounding skin is of norma eIasticity, this procedure Iengthens the distance between the ends of the first incision aIong the bridIe by approximateIy haIf the Iength of the side incisions. If a web has formed which is so Iarge that a singIe Z wiI1 not reIease it without danger to the viabiIity of the flaps, a series of Z’s may be done with good effect.

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Cases V and VI (Figs. 26-36) show the result of using this method for release of a contracted popIitea1 space and an axiIIa.

FIGS. 9, 10, II AND 12. Case II. Burns from tire seen two and one-half months after injury. Patient was treated in a neighboring hospital with isIand grafts which grew on the neck, but not on the chest. FIGURES 9 AND 12 show the condition on entry, with isIand grafts dotting the areas. FIG. IO, resuIt eight days after the unheaIed area was compIeteIy excised and covered with razor grafts. FIG. I I, condition four months after razor grafting. FIG. 12, poor cosmetic resuIt obtained by the isIand grafts which had been used on the neck. These scars will need repair Iater.

There are a few precautions to be observed in using this particuIar type of flap. The edges to be cut are best outIined with sterile ink before the incisions are made. If one is not very famiIiar with the procedure, the corners shouId be numbered so that they may Iater be identified when they become dispIaced by the reIease of the scar.

,attment

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To insure the success of a transposed, advancement or rotation flap, a few genera1 ruIes may be cited: (I) In outIining a singIe ffap for reIeasing a scar, the Iong axis of the Aap shouId be designed so that it is raised approximateIy at right angIes to the defect to be fiIIed. (2) In raising a singIe ffap, one must visuaIize the method to be used to fiI1 the defect Ieft by this raising and prevent a resuIt in the donor site that disfiguring or deforming. (3) 0 wiI1 be either The hinge of a Aap shouId aIways be as wide or preferabIy wider than any other part of the flap. (4) The hinge shouId not be rotated more than go degrees. (5) There must be absoIute hemostasis, preferabIy obtained by crushing the ends of the vesseIs, or by hot pressure packs, rather than by Iigatures. This is primariIy to minimize the amount of foreign materia1 under the flap. (6) There shouId be no tension on the sutured incisions. If tension does exist it must be evenIy divided I between the subcutaneous sutures. Tension on the skin must be avoided so as to prevent the scar from becoming wide and unsightly at a Iater date. It is frequently impossibIe to transpose the skin in the vicinity of a burn contracture without causing more deformity than that aIready present. It is therefore necessary to convey tissues from a more remote site that is abIe to compensate cosmeticaIIy and functionaIIy for its 10s~. When onIy skin is transpIanted it is possibIe temporariIy to interrupt its bIood suppIy and transpose it as a free graft (fuI1 thickness, sieve, or razor graft). However, if subcutaneous tissue and fascia are to be transpIanted with the skin, a constant source of nutrition is needed. The viability of this Iatter graft is then dependent upon retaining the attachment of one portion to the mother site, during the time when a new biood supply is being estabIished from the bed into which it is transpIanted. These grafts are generaIIy termed pedicIe ffaps. In empIoying pedicIe ffaps the recipient site is prepared first. The exact amount of

NEW SERIES VOL. XXXIX,

FIG. 14.

No. 1

MacCoIIum-Treatment

FIG. 15.

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American JOU~IMI of surgery 29 I

FIG. 16.

1”

in that it does not s FIG. 14, scar compIeteIy excised (stripedj, the undermining (stippIed), and the incision (heavy Iin&) outIininn the rotation Aao on the neck. FIG. 14. method of rotating the Aao uoward. with the hinge in the mid&e anteriorIy. FIG. 16, completed suture line. FIG. 17, res& two w’eek’s afte; operation. TLo small areas of necrosis deveIoped just anterior to the ear. These heaIed rapidIy and are now hardIy noticeabIe.

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FEIGWARY,1938

FIG. 18.

FIG. 25. FIG. 19. FIGS. 18 TO 25. Case IV. Burn seen three weeks after insertion of a Iive eIectric wire into the mouth. FIG. 18, loss of skin, muscle and mucous membrane. FIG. 19, asymmetry of the mouth after heaIing has taken place. FIG. 20, scar of the lip and Aap of mucous membrane (dotted line) and the undermining (stippled), carried out on the inside of the mouth. FIG. 21, vertica1 section of the head, showing the outlined flap being transposed to HI the deft?ct Ieft after the scar was excised. FIG. 22, Aap sewed into place. FIG. 23, cIosure of the donor site of the transposed flap. FIG. 24, reaIignment of the lip and formation of new vermiIion borders. FIG. 25, resuIt two weeks after operation. The smaI1 amount of scar tissue remaining directIy above the newIy formed vermilion portion of the upper Iip is stiI1 slightly disfiguring, but should be easiIy masked by cosmetics in Iater Iife.

New

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MacCoIIum-Treatment

tissue required is marked off on a pattern. MateriaI convenient for patterns is a thin, dry, unbIeached cotton cloth that is pressed

FIGS.

21-24.

American~~~~~~~ofsurgery 293

there is practicaIIy no form of fixation that wiII keep them from trying to squirm into one more comfortable to them. This

Captions

firmly on the recipient site; the Iatter outIines its own contour by a bIood stain. Another pattern material is transparent ceIIophane through which the edges may be seen and marked by steriIe ink. The pattern is then transferred to the donor site and the required amount marked again by ink or scratch marks. It iti extremeIy important that a11 the steps in moving this pedicIe be pIanned carefuIIy in advance. It is obvious that if the pedicIe is to be transpIanted directIy to the recipient site, both the donor and recipient areas must be so situated that the parts of the body invoIved may be approximated without tension on the pedicle and heId in this approximation comfortabIy until heaIing has taken pIace. It is also important that the position in which the body is fixed during this stage be a neutra1 one and not one requiring unnatura1 and therefore uncomfortabIe contortions of the parts. If chiIdren are fixed in a position causing painful muscle strain,

of Burns

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may cause tension or kinking of the pedicIe and consequentIy the death of the graft. After the donor area has been pIanned, the pedicIe is outIined and undercut. It is to be remembered that the origina pattern does not include the pedicIe to the ffap, so an extension must be made on one border of the pattern to provide for it. The patient is then fixed into the position in which he wiI1 remain whiIe the graft heaIs,and the Asp is sewed into place. If the flap is transferred to the face, a subcuticuIar dermic suture is the best for approximation of the skin edges. If it is transferred eIsewhere, interrupted skin sutures may be used. The raw area Ieft by raising the flap may now be cIosed by undercutting the edges and by direct suture. Care shouId be taken not to endanger the bIood supply to the Aap by undercutting this too wideIy, If the defect Ieft by the flap is too Iarge or in a position where this procedure for closure is not

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FIG. 26. FIG. 27. FIGS. 26 TO 32. Case V. Scar contracture from a burn sustained one year before Figures 26 and 27 were taken. Patient waIked with onIy the toes of the right foot touching the floor. FIG. 28, z incision with the necessary undermining (stippled). FIG. 29, transposition of the two trianguIar flaps outIined by the z incision. Note that the Ieg can now be straightened. FIG. 30, incision sutured in the form of a z that has been turned backward. FIGS. 31 AND 32, Ieg straight with perfect function.

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FIG. 32.

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advisabIe, it may be covered with a razor graft. This prevents the discharge and drainage which takes pIace from any raw

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for the revascuIarization depends on the size of the Aap and the vascuIarity of the bed in which it is placed. The average safe

FIG. 33.

FIG. 34. FIG. 35. FIG. 36. FIGS. 33, 34, 35 AND 36. Case VI. Burn from fire seen six months after injury. Arm could be raised no higher than is shown in Figure 33. The arm was released with a z incision, which improved the condition, but was not adequate to relieve the webbing compIeteIy. FIGS. 34 AND 35, secondary webbing one year after the first operation. FIG. 36, result after a second operation, using another z incision. Function is now exceIIent.

area and eliminates consequent danger of infection to the flap. When the bIood suppIy from the new site becomes estabIished the pedicIe may be severed from the flap. The time required

interva1 before severing the pedicIe is fourteen days after transpIantation. In some instances this may be shortened to ten, or Iengthened to twenty-one days. If the pedicIe is abnormaIIy broad, it may

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FIG. 37.

FIG. 42. 42. Case VIL Scarring of the dorsum of the foot from burn, treated in another hospital with isIand grafts. Scar was thin and continually broken by the wearing of shoes. FIG. 37, extent of scar, island grafts, and a few areas recently excoriated by trauma. FIG. 38, scar tissue being removed down to the tendon sheaths. FIG. 39, pedicle Aap raised from the posteromedial side of I, the opposite thigh. FIG. 40, position of patient during the three weeks necessary for the pedicle to be revascularized from its new bed. FIG. 41, flap sutured into position on the foot ‘Ithe pedicIe returned to the thigh and the donor area covered with razor grafts. FIG. 42, Rap on the foot three months after operatior t.“Function now excellent. FIGS.

37 TO

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be a safer procedure to separate it from the graft in two or more stages. This aids in the stimuIation of an adequate bIood suppIy from the new bed. After the flap has heaIed and adequateIy covers the recipient site, the tissue forming the pedicIe may be returned to its origina bed. However, if there has been an error in measurement of the amount of tissue required to 611 this defect, the pedicle may be incIuded with the flap. If the Asp required is Iarger than it is thought possibIe to keep aIive by the pedicIe pIanned for it, it is often of vaIue to “deIay” the ffap before transfering it. This procedure of deIaying consists of first undercutting the most distai portion of the outIined Asp and immediateIy sewing it back into the bed from which it was raised. Before the vesseIs from this bed grow back into it, it is again raised (five to nine days), but now with the rest of the flap, and transferred. This is often of great advantage in moving a Iarge piece of skin. This process of deIaying has one disadvantage. It increases the amount of scar tissue in the basa1 Iayers and generaIIy produces a sIightIy thicker, Iess pliable covering. Indications for the use of the pedicIe flap are many. FIaps to the face require the additiona consideration of coIor matching. For burns invoIving the nose, a flap may be brought down from the forehead or up from the chest. For those invoIving chin or cheek, flaps may be brought from the acromiopectora1 region or from the suprascapuIar region. This method of grafting is particuIarIy appIicabIe to burns of the hands, forearm or antecubita1 space. In these instances skin is borrowed from over the IateraI thoracic cage or anterior abdominal waI1. This method is aIso used for repIacing scars of the feet. In this Iatter occasion the f-Tap is obtained from the opposite thigh as the patient is fixed in a position resembIing an Indian squat. (Case VII, Figs. 37-42.) This type of ffap is not usuaIIy appIicabIe for burn scars of the neck, axiIIa and groin, unIess transferred

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by way of some intermediate host, such as the arm. FrequentIy more skin and subcutaneous tissue are needed than it is possibIe to transfer by means of either a direct or a deIayed pedicIe flap. On these occasions a tubed pedicle or rope graft may be empioyed. When this type of graft is used the recipient area is not prepared at the first operation. It is, therefore, necessary to visuaIize the norma contour of the recipient part so that an accurate judgment may be made of the amount of tissue necessary for repIacement. The pattern usuaIIy takes the form of a rectangIe and in chiIdren shouId generaIIy not exceed g inches in length and 4 inches in width. The donor site chosen is usuaIIy the abdomen, Ioin or back. Incisions are made aIong the two Iong sides of the rectangIe and are carried down to the required depth. In thin individuaIs these incisions may extend to the fascia. It is best to make the incisions paraIIe1 to the direction of the main bIood suppIy to this area, and it is inadvisabIe to raise or extend a flap across the midline of the body. Both of these precautions heIp to insure an adequate bIood suppIy to the flap. The skin between the two incisions is undercut and freed. After hemostasis has been effected, the edges of the bar of Ioosened skin are brought together and sutured, skin side out, in the form of a roI1 of tissue attached at both ends, not unIike the handIe of a satchel. (Figs. 45, 52, 59.) It is important that these edges be united with a fine suture, taking smaI1 bites of skin so as to avoid stranguIation of the bIood suppIy to the edges. When compIeted, the sutures must be under no tension whatever. If tension does exist, it indicates that too much subcutaneous tissue has been incIuded in the rope. This excess must be removed. As the rope aIways suffers sIightIy from impairment of its bIood suppIy and Iymphatic drainage, it may become temporariIy swoIIen and edematous after it is raised. If the rope is tense at the time of its origina tubing, it wiI1 become more

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tense when this post-operative sweIIing occurs. This may become so acute that the remaining bIood suppIy is cut off, with consequent death of the rope. If the tubed pedicIe has been we11 pIanned and the raising of it we11 executed, no appreciabIe sweIIing or danger of viabiIity shouId exist. The defect Ieft by raising this rope may then be cIosed by wideIy undermining the IateraI edges and approximating them by direct suture. (Figs. 45, 46, 59, 60.) If the defect is too Iarge to cIose in this fashion due to inability to undermine adequateIy or to the resuhing tension on some other structure, it is possible to cover it with razor grafts. (Figs. 52 and 53.) In some instances it is diffIcuIt to produce enough pressure on the razor graft to make it take, as pressure on the rope from the thick dressing under it is to be avoided. It is obviousIy advisabIe to cover this area at the time of the original operation in order to avoid oozing from the region and the Iow grade infection that is aIways present on any granuIating surface, but the viabiIity of the rope itseIf must not be endangered. If necessary the raw area must be Ieft to granuIate in. The post-operative care of the rope requires carefu1 attention to the circuIation. If it is bIue in coIor it must be examined for hematoma; shouId this be found immediate attempts must be made to evacuate it. If the rope becomes white and edematous, earIy massage and wet heat prove of great aid in reducing the sweIIing. In order that these compIications may be observed if they occur, dressings shouId not be pIaced over the top of the rope. In chiIdren this obviousIy necessitates restraining the entire body and particuIarIy the hands so that the patient wiI1 not injure it. The sutures are usuaIIy removed from both the rope and the donor area on the seventh or eighth post-operative day. The patient may then be ambuIatory unti1 the next operation. The second stage is usuaIIy performed twenty-one days after the rope is raised. One end of the rope is then transferred from its origina bed to a new one in the

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region in which the rope is to be impIanted* When this end is undercut and severed, there is aIways a temptation to incIude more skin than was originaIIy outlined. This procedure is decidedIy hazardous as this portion may have an independent bIood suppIy. The resuIt wiI1 often be a poor attachment of the pedicIe. The safest procedure is to cut the rope exactly at a perpendicuIar to the ends of the origina IongitudinaI incisions which are now demarcated by linear scars. A V-shaped incision is now made at the site of attachment. This site must be in a position so that the rope when heId there will be neither kinked nor under tension. The Aap outIined by this V is then raised and sewed to the under surface of the raised end of the rope, in order to produce a compIeteIy cIosed incision. A convenient method for transferring a rope to a distant site is to attach it to an arm or Ieg which is immobiIized in position with pads and eIastic bandages until heaIing has taken pIace. The third stage is done when the surgeon is satisfied that the bIood suppIy through the new attachment is sufficient to suppIy the entire tube when the other end is cut Ioose from its origina bed. The usua1 time aIIotted is twenty-one days from the time of the first detachment. The circuIation may be tested by stripping the rope of bIood as one wouId strip air from a rubber tube and then pinching it tightIy at the end next to be detached. If the rope remains paIe and white, operation had best be deIayed, but if the coIor returns to norma and there is good bIanching and return of coIor upon digita pressure, it can safeIy be cut Ioose. The second end is then detached in a manner simiIar to the first and impIanted near the area in which it is to be used. If the first attachment has been to an arm or Ieg, the distance of this jump is a comparativeIy Iong one. The extremity shouId be immobiIized so that the end now to be attached may be impIanted directIy in the area in which it wiI1 permanentIy rest. Again the extremity is fixed by bandages so that the rope remains un-

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It is obvious that this method, necessitatkinked and under no tension unti1 heaIing ing a series of operations, must be seIected is compIete. The fourth stage of transfer usuaIIy con- for onIy those individuaIs who are in fairIy robust heaIth. The onIy rea1 disadvantage sists of implantation of the graft. It again takes pIace approximateIy three weeks to the use of the rope method is the time it after the Iast operation. The rope is first takes, with a11 the consequent Iimitations for the patient. The resuIts achieved with cut Ioose from its intermediate host (i.e., arm or Ieg), by dissecting this end away it, however, are generaIIy superior to any from the V-shaped flap originaIIy raised type of Asp. The surgeon has a much wider from this site to cover the raw area on the margin of safety in handIing it and a rope. The ffap is trimmed of scar tissue and greater amount of tissue at his disposa1 for is repIaced in its origina site so that the onIy remedying the defects. Cases VIII, IX and X (Figs. 43-66) show residua1 defect on the intermediate host is a fine, hairIine scar. The rope is then incised the stages of repair of scar contractures by means of the rope graft. OccasionaIIy it for its entire Iength aIong the scar formed by its tubing. This and a11 of the deeper wiI1 be noted that a rope graft appears scar tissue must be removed, to aIIow the thick and rather fuI1, directIy after impIantation. By strenuous massage and rope to unroI1 to the extent of the Aap that excercise for a six month period, the Aap originaIIy formed it. The remova of this scar and fibrous tissue must be done with wiI1 thin out and Iose this appearance. If, the greatest of care to avoid injury to the at that time, it stiI1 remains thickened, one IongitudinaI vesseIs which supply the flap. edge of it may be raised, the flap undercut, An incision the same Iength of the rope is thinned by remova of the excess tissue, then made in the scarred area which is to and reIaid. When rope grafts are to be used be repIaced. It is best to avoid excision of to repIace areas that are ordinariIy visibIe to the pubIic, it is wise to caution the this scar tissue unti1 it is certain that there patient of this possibility of reIaying before is suflicient skin in the rope to fiI1 the defect. If the rope has been properIy pIanned the the repair is begun. One speciaIized form of flap remains to amount wiI1 be ample, but it is often surprising how wide this singIe incision wiI1 be mentioned. It is known as a gauntIet gape upon reIease of tension. It is most flap, and may be described as a doubIe ended pedicIe Aap or an untubed rope important that the incision in the recipient site extend through the compIete depth of graft. It is appIicabIe for defects on the the scar. This may require a carefu1 and flexor and extensor surfaces of fingers, perhaps diffrcuIt dissection of the essentia1 hands, forearm, feet and Iegs. The Aap is nerves and bIood vesseIs, from a pannus of raised in exactIy the same fashion as a tubed pedicIe, except that instead of tubing thick fibrous tissue. If the amount of tissue suppIied by the the skin, the recipient area is passed rope is adequate, it is better to excise the beneath the bar of skin. Here the dista1 and proxima1 borders of the defect are sutured scarred area compIeteIy. The rope now to the two sides of the flap. The appendage reIeased to its limit, is sutured into the is fixed in this position unti1 the Aap defect Ieft by this excision. Hemostasis is adheres. At an interva1 of fourteen to again important, for a hemotoma beneath twenty-one days the two pedicIes are the ffap wiI1 seriousIy endanger its viabiIity. severed and the IateraI edges of the defect If a hematoma does develop, it must be trimmed and sutured. There are few expressed immediateIy and compIeteIy. If a instances where this doubIe hinged pedicIe smaI1 cIot of bIood remains after insuflicient is required, as most defects in these areas evacuation, it wiI1 produce a deepIy thickmay be adequateiy handIed with the singIe ened, Iess pIiabIe flap. hinged pedicIe flap.

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0SccasionafIy burns may destroy Iarge area KSof skin, without destroying the subcuta lneous tissue. In these cases the resuIt-

FIG. 43.

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FEBRUAEY, 1938

graft. Into this category faI1.s the tr ‘anspIantation of razor grafts, fuI1 thick :ness grafts, and sieve grafts.

FIG. 44.

FIG. 45. FIG. 46. FIG. 47. FIGS. 43 TO 47. Case VIII. Heavy scars of the neck from burn with fire one year previous to the taking of Figures 43 and 44. Note in these the Iack of the normaI neck Iine and the downward pull on the mouth. FIG. 45, tubed pedicIe raised on the abdomen. The donor site was cIosed by direct suture beneath the rope. FIG. 46, transfer of the media1 end of the rope to * the right arm. Note Iine of cIosure of donor site on abdomen. FIG. 47, transfer of the Iateral end of the rope to the neck after some of the scar tissue had been excised. The arm serves as the host unti1 the bIood suppIy is reestabIished from the end on the neck.

ant deformity, upon rehe ved by mere skin skin aIone is needed, it bIe I:o transfer this in

heaIing, may be repIacement. When is frequentIy possithe form of a free

The technique of transpIantation of razor grafts has aIready been described, ,On the face they may be used to good effec t to repIace scars in regions where the surrou md-

New SERIESVOL. XXXIX,

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MacCoIIum-Treatment

ing skin is fuII and of an eIastic nature. For exampIe: ExceIIent eyeIids may be made from thick (or spIit) razor grafts. Thin

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described previousIy in Section II. To achieve a good cosmetic as we11 as functiona1 resuIt, it is imperative that onIy Iarge

FIG. 48.

FIGS. 48, 4g

AND

FIG. 49. FIG. so. 50. Case VIII. Tubed pedicIe roIIed out and sutured into defect Ieft by com-

pIete excision of the scar. Note neck contour and reIasc of tension on the mouth.

razor grafts may be used to Iine the skin ffaps repIacing cheek or nasal defects. These epidermal grafts stand up we11 in mouth, nose, vagina or anus, do not macerate and if raised thinIy enough, wiI1 not be hairy. They are aIso used to cover defects on the forehead and skuI1. In the Iatter site, subcutaneous tissue wiI1 proIiferate underneath them so they are soon at the same IeveI with the surrounding skin, the onIy noticeabIe remaining mark being a shiny surface. When webs containing but IittIe deep scar deveIop in the axiIIa or groin, a compIete excision of the scar and repIacement with thick razor grafts may be done. (Case X, Figs. 64-66; Case XI, Figs. 67-70.) After this procedure carefu1 attention must be paid to exercise and massage of the grafts to keep them from contracting again. Thick razor grafts may aIso be used for both flexor and extensor surfaces of the hands and feet. They bear up very we11 under pressure, but are best used when a pannus of the norma subcutaneous tissue exists. Razor grafts to a11 these areas foIIow the genera1 principIes in regard to raising, fixation and after-care as that

singIe grafts be used. For this reason unIess the surgeon has the abiIity to cut one graft that wiI1 cover the area in which it is needed, he had best use some’ aIternative graft with which he may be more familiar. FuII thickness grafts (WoIfe-Krause) require by far the most meticuIous technique of any to insure a successfu1 resuIt. There is absoIuteIy no reason for choosing to impIant a fuI1 thickness graft unIess it remains one after it is heaIed. If, when the first dressing is removed, it is found that the superficia1 epiderma1 Iayers have sIoughed, but that the deeper derma1 Iayers are stiI1 viabIe, the resuIt upon heaIing wiI1 be exactIy simiIar to that which wouId have been produced if a razor graft had been used. The fuI1 thickness graft, to be considered successfu1, must be exactIy simiIar to the surrounding skin in coIor, sheen and texture. A graft that faiIs to meet these requirements may be considered a cosmetic faiIure. Therefore, the decision to use this graft in preference to any other, requires nice surgica1 judgment and abiIity. The recipient area for the fuI1 thickness graft is first prepared by excision of the

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scar tissue. It is necessary that a11 of the deep fibrous tissue be removed, in order to insure a good cosmetic result. It is

FIG. 51.

FE%BRU.UW, 1938

of Burns

area and marked out with steriIe ink. Donor areas most frequentIy used for hairIess grafts are the posterior surface of the

FIG. 52.

FIG. 53.

FIG. 54. FIG. 55. FIG. 56. FIGS. 5 I TO 56. Case IX. Burn from fire seen five months after injury. FIG. 51. right a&a scarred, but abIe to be stretched, with exercise and massage. The Ieft axi& cannot be raised any higher than the position shown in the photograph. FIG. 52, tubed pedicIe raised from the abdomen. Because of excessive scarring on chest, the donor area could not be cIosed by direct suture. Three razor grafts, placed directIy on the subcutaneous tissue, cIosed the area. These are shown beneath the rope. FIG. 53, transfer of the media1 end of the rope to the arm. FIG. 54, transfer of the IateraI end of the rope to the anterior axiIIary Iine. FIG. 55, rope unroIIed and in position in the axiIIa. To give &II further reIease of contraction, the posterior end was split IongitudinaIIy and a triangIe of skin rotated from the back into the defect made by the spIit. FIG. 56, both arms raised. Good functiona and cosmetic resuIt.

important to undercut the skin at the edges of the defect for a distance of x to 34 inch so that it wiI1 retract and compensate for any Iate contracture in this area. An exact pattern of the defect is now made, transferred to the donor

externa1 ears, the inner surfaces of the upper arms and the skin immediateIy over the iIiac crests. The choice of one of these areas depends on which skin best matches that surrounding the defect. Hair-bearing fuI1 thickness grafts for re-

New SERIFSVOL. XXXIX.

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MacCoIIum-Treatment

pIacement of eyebrows, eyeIashes, or the upper lip in the maIe are usuaIIy taken from the scaIp and occasionaIIy the pubic region. In seIecting the donor site of a hair-bearing graft, attention must be paid to the direction in which the hair Iies in its norma site. This is of importance so as to avoid a mustache growing upward or eyebrows growing in the opposite direction. The graft now is cut, using one of two techniques or sIight variations of them. The first technique requires concentric tension on the surrounding skin, so as to stretch the pattern out in as flat a pIane as the part wiI1 aIIow. This is impossibIe to do in the posterior auricuIar region, so it is often of heIp to fiI1 the subcutaneous tissue with Auid (saIine or IocaI anesthetic), so that it wiI1 faciIitate the raising of the graft. The surgeon then outIines the pattern, carrying his incision through the skin to, but not into the fatty Iayer. By carefuIIy sweeping the knife in this Iayer in a pIane paraIIe1 to the skin, the graft is tediousIy cut. If this is done rapidIy, even the most practiced pIastic surgeon is IiabIe to perforate the skin or incIude fat which is not desired. When one edge of the graft has been raised it wiI1 retract, wrinkIe and possibIy be in a position where it is IikeIy to be cut with the next motion of the knife. To avoid this the same amount of tension must be appIied to the graft as exists on the surrounding skin. To keep this tension uniform, sharp hooks may be imbedded in the raw surface of the graft or it may be roIIed up on a smaI1 cyIinder which has many sharp needIeIike projections scattered over it to catch and hoId the graft. The second technique aIIows the surgeon to cut the graft quickIy as a bIoc of tissue and to incIude as much of the fat as he wishes. After the bIoc of tissue has been removed from its bed it may be either stretched and fixed with needIes to a board, or stretched over the forefinger with the fatty surface outward. The excess tissue and fat is then carefuIIy removed with a scissors. This second technique is more traumatizing to the

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graft and offers more chance of perforation than the first. These methods require about the same operative time and shouId be chosen by the surgeon to fit his particuIar abiIity. The donor area is cIosed by undercutting and direct suture, or by covering the defect with razor grafts. The graft is now transpjanted and sewn in its new site. As in the razor graft, hematoma and foreign bodies beneath it wiI1 speI1 death to the graft. The bed to which it goes must be absoIuteIy dry and free of corrugations. Key stitches are pIaced at points that previousIy have been marked on .the graft and the edges of the donor site. When in position these shouId stretch the graft so that the tension existing in the graft is approximateIy equa1 to that existing previousIy in its norma bed. If aIIowances are made for the retraction of skin by using a pattern Iarger than the defect, the graft when sewn in place wiI1 fit the area, but wiI1 be Ioose and under no tension. This graft may quickIy become edematous and wiI1 then slough. The graft on sIight tension keeps the Iymphatics and capiIIaries open, so that this is avoided. To be correct, then, the graft wiI1 first appear to be much smaIIer than the defect which it is to cover, but by carefu1 suturing, it wiI1 easiIy stretch to the desired size. The suturing must be done with the Ieast possibIe amount of trauma. To pick up the edge with toothed forceps, as might be done in an abdomina1 incision, aImost invariabIy devitaIizes the segment of skin incIuded in the forceps. The use of sharp hooks or rubber covered forceps, with which the skin is heId as IooseIy as possibIe, is again advised. Some surgeons beIieve that perforations shouId be made in the graft to aIIow escape of ffuid. If there is adequate fixation under proper pressure this is not necessary. Fixation must be absoIute and under pressure of approximately 30 mm. of mercury per square inch. DentaI composition over which has been pIaced a rubber or a sea sponge, gauze and eIastic bandage constitute an efficient form of dressing.

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The dressing usuaIIy is changed at the time that the sutures are removed (fifth to eighth day). A reappIication of a pres-

FIG. 57.

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as a patch of skin with norma mobiIity, sheen and texture, but sIightIy pinker in coIor than the surrounding area. Within

FIG. 58.

FIG. 61. FIG. 59. FIG. 60. FIGS. 57 TO 61. Case X. Contracture resulting from burns due to fire sustained one year previous to the taking of Figures 57,58 and 64. In these figures, notice Ioss of neck Iine. downward puIl on the mouth, inabitity to extend neck, marked anterior contraction across chest, drawing shouIders forward and upward aImost to the IeveI of the ears. FIG. 59, rope raised from the onIy good skin remaining on the trunk. FIG. 60, transfer of the media1 end of the rope to the arm. FIG. 61, transfer of the IateraI end of the rope to the neck,

sure dressing for a period of five to six days after the remova of sutures is advised. When a Ioose dressing is appIied, the graft may become edematous and a Iarge bIister wiI1 form over it. The superficia1 skin is Iost and the telfture of the graft spoiIed. Within twenty-four days after transfer, the graft shouId appear

six months of impIantation, the coIor shouId match, the onIy noticeabIe mark being the fine hairIike scar at the edge. A fuI1 thickness graft is by far the best of the free grafts in appearance, but is the most diffrcuIt to transpIant. Consequently, the main indication for its empIoyment is to produce the most desirabIe

NEW SERIES VOL.XXXIX,

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cosmetic resuIt. For this reason it is usuaIIy empIoyed for facia1 defects, repIacing eyeIids, eyebrows, skin over the nasa1 bridge,

FIG. 62.

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cutting, transfer and fixation appIy when they are used in these sites. A speciaIized form of fuI1 thickness

FIG. 63.

FIG. 64. FIG. 65. FIG. 66. FIGS. 62 TO 66. Case X. FIGS. 62 AND 63, resuIt of making a GngIe in&on in the scar, extending the head, and Ming the gap thus formed with the skin of the tubed pedicle. Note how the shouIders are lowered, the reIease of the mouth, the restoration of the neck line, in spite of scars at the Iateral borders. FIG. 64, origina scarring of both axiIIae. FIG. 65, change accompIished with exercise and massage over a period of one year. This, however, did not effect sufficient reIease. FIG. 66, reIease of both axiIIae by means of a singIe transverse incision through the depths of the scar in each one, with the insertion of razor grafts. The grafts having been recentIy done show up as darker areas in the photograph. Note in this the reIease of the arms and shouIders and contour of the neck. Function is exceIIent.

cheeks and chin. If used for cheek, Iip or chin repIacement, adequate fixation of the jaws either by wiring of the teeth together or inserting a denture must be effected before one can expect it to take properIy. FuII thickness grafts are aIso used for repIacement of finger and hand defects. The same genera1 principIes of

graft is known as the sieve graft (DougIas). A pattern is made and marked as in the ordinary fuI1 thickness graft. The skin to be raised is then perforated by a sharp stee1 punch which marks smaI1 circIes about 4 mm. in diameter and about I inch apart. The graft is then raised, taking with it a thin Iayer of fat. As it is cut,

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of Burns

FIGS. 67,68,6g AND 70. Case XI. Severe burns from tire seen two years after the accident. FIG. 67, Iarge area stiI1 unheaIed after twenty-five months of treatment at home. Note that both groins are so severeIy scarred that the Iegs cannot be extended any further at the hip than the position shown in this photograph. FIG. 68, two months Iater, after covering the granuIating area with razor grafts and after reIease of the Iegs by excision of the scars in both groins and impIantatiori of razor grafts. FIGS. 6g AND 70, six months after operation. Good functiona resuIt.

FIG. 67.

FIG. 68.

FIG. 6g.

FIG. 70.

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MacColIum-Treatment

these smaI1 4 mm. circIes previously cut by the punch are Ieft behind as isIands in the donor area. The graft when finaIIy removed is fuII of hoIes evenIy spaced. When sutured in its new bed these perforations aIIow free drainage of fluid from the recipient site. The isIands Ieft in the donor site act simiIar to isIand grafts pIaced on granuIating tissue and aid in the epitheIiaIization of the area. The one advantage of this graft is the amount of skin that can be transpIanted without endangering its viabiIity. It may be fuIIy twice as Iarge as the upper Iimit of skin that may be moved as a routine fuI1 thickness graft. Because of its muItipIe perforations this graft gives a poor cosmetic resuIt for facia1 work. It is generaIIy empIoyed over surfaces where more subcutaneous tissue is needed than that which may be suppIied by a razor graft or a fuI1 thickness graft and where a pedicIe flap is contraindicated because of Iack of skin in the vicinity, or a rope graft because of Iack of time. We have now considered reconstructions requiring repIacement of the skin aIone and those requiring repIacement of the skin with its underIying tissue. In addition to these factors, the restoration of the bone and cartiIaginous supporting structure is occasionaIIy necessary. The transpIantation of either cartiIage or bone must generaIIy be reserved unti1 there has been adequate skin repIacement, unti1 a11 wounds are heaIed, unti1 the scars have become pIiabIe and unti1 a11 danger of residua1 infection has passed. StructuraI grafts can seIdom be incorporated in any type of pedicIe skin graft, and therefore are aImost aIways moved as a free graft. Each such case presents an individua1 probIem so that few generaIities can be stated. Rigid aseptic technique must be employed. Bone or cartiIage shouId never be touched except by instruments. AI1 work of modeIing and shaping of the graft to the desired contour is best done at a separate tabIe with a separate set of instruments. To avoid any possible contamination one must attempt to shape the

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graft properIy from measurement so that repeated removals, further shapings and reinsertions are not required. The usua1 donor sites for these structura1 grafts may be listed. For repIacement of skuI1 defects the inner tabIe of the iIium may be used. For reconstruction of the nasa1 bridge, either a hinged rib cartiIage graft or a hinged osteochondria1 graft from the crest of the iIium is advisabIe. A few surgeons prefer tibia1 bone for the nasa1 bridge. For structura1 support to a coIIapsed deformed aIa, a strip of ear cartiIage is the best avaiIabIe. For reconstruction of the supraorbita1 ridge and maIar zygomatic compound, bony rib or a bar of the tibia may be used. In oIder individuaIs an artificia1 denture may be more advisabIy empIoyed. For mandibuIar reconstructions tibia1 inIay grafts are empIoyed. When the externa1 ear cartiIage has been destroyed there is IittIe that can be substituted to repIace the convoIutions and “ crinkIes ” of a norma cartiIage. After suflicient skin has been transpIanted to the site, cartiIage struts from the ribs may be used to support it. In spite of this, an ear reconstructed in this fashion usuaIIy requires considerabIe imagination to regard it as cosmeticaIIy good. Making use of the knowIedge that the onIy heterogeneous grafts that wiI1 Iive are cornea and cartiIage, an ear cartiIage suppIied from a donor other than the patient has been used with good success. StructuraI supports are 0ccasionaIIy needed for fingers. Here bone from rib or tibia may be grafted on a proxima1 phaIangea1 stump that has a functional metacarpa1 phaIangea1 joint. Finger tips, incIuding naiIs, joints and tendons, have been successfuIIy grafted in two stages, by means of transpIantation of the second toe in the form of a pedicle. IV.

TREATMENT

OF ABNORMAL

BURN

SCARS

We have considered the treatment of scars caused by burns with the supposition

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that these scars represent essentiaIIy norma1 fibrous tissue. There is one type of scar that is not truIy maIignant but does tend to grow more rapidIy than it shouId. Scars of this group are known as keIoid scars. A definite distinction must be made between burns with thick unsightIy scars and those with keIoids. If, in the earIy treatment of the fresh burn, a Iarge area of granuIating tissue has been aIIowed to epitheIiaIize without the aid of adequate grafts, the resuItant scar may be very heavy, unsightIy and prominent. With constant massage over a period of two to three years these scars wiI1 tend to ffatten out and become more pIiabIe. They may stiI1 remain reIativeIy thick and unsightIy, but they Iose the rope-like appearance which wouId make one first think they were keIoida1. In patients with a true keIoid tendency the scars become thickened, and continue to thicken over a period of years. They become unsightly and may even reach a size hindering the movement of a portion of the body. In this Iatter patient, wherever the epitheIium has been broken, in the burned area or eIsewhere, there wiI1 be excessive scar formation. The treatment of simpIe thick scars without keIoid formation is primariIy prophyIactic, either by means of adequate grafting without infection or suturing parts without tension. When the situation arises in which one feeIs that this type of scar may deveIop, a superficia1 treatment with x-ray within ten days of the operation is advisabIe. The function of radiation at this earIy date is not to destroy the fIbrobIasts, but to hinder the excessive proIiferation of coIIagen. If properIy radiated, the heaIing power of the wound wiI1 not be jeopardized. If radiation is given after scars begin to thicken it wiI1 have some, but Iess, effect. The proper treatment of true keIoid scars is stiI1 debatabIe. Radiation aIone is heIpfu1, but frequentIy has been carried to such an extent that a dermatitis Iater resuIts. The scarring from over-enthusiastic radiation is not onIy disfiguring, but aIso

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painfu1 to the patient. The skin first becomes dark, then it thickens and becomes white with a tendency to crack and uIcerate upon movement. When this occurs, ointments offer IittIe reIief. The most effective treatment is compIete excision of this scar with repIacement by norma non-radiated skin from some distant site. Repeated partia1 eIIiptica1 excisions of the centra1 portion of the keIoid scar, keeping we11 within the Iimits of the keIoid for both incision and suturing, tend to narrow the scar and make it Iess noticeabIe. By this progressive method of reduction in the size of the scar, very gratifying resuIts have been obtained. Case XII (Figs. 71-74) shows the resuIt of these partiaI excisions on an unsightIy keIoid of the neck. StiII another method has produced exceIIent resuIts. An x-ray treatment is given to the skin surrounding the keIoid one week before operation. At operation a compIete excision of the scar is done, foIIowed either by grafting (Case XIII, Figs. 75-78) or by direct approximation of the norma skin. No cutaneous sutures are used, the entire wound being closed by subcuticuIar catgut. From five to seven days after suturing, another x-ray treatment is given, and a third one of equa1 intensity about six weeks Iater. The onIy objections to the use of this Iatter method in chiIdren are their variabiIity of reaction to radiation and the frequent necessity of using anesthesia to keep them quiet for the period of the treatment. However, the resuIts obtained by this method, when used correctIy, are exceIIent, so that consideration is warranted in seIected cases. SUMMARY

This paper has considered the treatment of fresh burns, unheaIed burns, scar contractures and deformities from burns, keIoid scars and structura1 deformities as they occur in chiIdren. Specific detailed instructions have been outIined for the

NEW SERIESVOL.XxX1X.

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M ac CII o urn-Treatment

FIG. 71.

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FIG. 72.

FIG. 73. FIG. 74. FIGS. 71, 72, 73 AND 74. Case XII. True keIoid scars foIIowing burns from boiling water, one year before Figures 71 and 72 were taken. FIGS. 73 AND 74, narrowing produced by two partial excisions of the scars, keeping within the boundary of the scars. Scars are stiI1 present, but are not unsightly.

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FIG. 75.

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FIG. 76.

FIG. 78. 78. Case XIII. True keloid formation in a scar, folIowing burns from fire one and one-haIf years previous to the time of FIGURES 75 AND 76. Scars Iimited the compIete extension of the leg. FIGS. 77 AND 78, excision of the Iower portion of the scar, foIIowed by razor grafts and heavy radiation. The keIoids have not returned one year after excision. FIG. 77.

FIGS. 75, 76, 77 AND

FEBRUARY.1938

NEW SERVESVOL.XXXIX. No. 2

MacCollum-Treatment

most commonly used methods of treating these conditions. The advantages and indications and contraindisadvantages, dications of each method have been discussed. In addition each type of treatment has been considered with reIation to its specific apphcation for the chiId patient as distinguished from the ad& patient.

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It must be emphasized that very rea1 differences do exist between the chiId and the aduIt both in their reaction to the burn and in their reactions to the treatment necessary for recovery from it. These differences modify the fundamentaIs of the treatment of burns and constitute the basic principIes outIined in this paper.

PRIMARY suture of the nerve [uInar] in any part of its course is followed by restoration of sensibiIity to prick in six weeks to three months. In five months, after division and suture at the wrist, it shouId be compIeteIy restored. Light touch shouId be restored in about ten months, but complete return is very slow. Unless operative repair is promptIy made, severance of tendons wiI1 resuIt in loss of function in the limb or the fingers which they govern. From-“A Textbook of Surgery” by John Homans (Thomas).