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Two years with mesh skin grafting
Two Years with Mesh Skin Grafting JAMES C. TANNER, JR. M.D., JACQUESJ. VANDEPUT, M.D., AND WILLIAM H. BRADLEY, B.S.,
>4tZunta,Georgia
From the Atlanta Research Institute and the Department of Surgery, Crawford W. Long Hospital of Emory University, Atlanta, Georgia.
ITHIN the last two years something has done about early skin coverage of major burns. Mortality has been substantially reduced in the past three decades by practically eliminating death due to shock and fluid imbalance. Anti-infectious therapy has been further enhanced by an increased number of more effective and more specific antibiotics. Spreading infections have been curbed by better topical antibiotics [1,2] and topical antiseptics [3 1. In contrast to the advancements in medical therapy, there has been no real progress in resurfacing of denuded areas since Reverdin’s [PI, postage original “greffe epidermique” stamp grafts, and Padgett’s “calibrated intermediate skin grafts” [5]. Of course, further development produced the electrical dermatome and made split thickness grafts easily and quickly obtainable. Recognizing the need for more efficient use of available donor skin, we devised an expanding skin graft called the “Mesh Skin Graft” [6]. It has the advantages of the sieve graft 171and modified sieve graft [8] plus 300 per cent expansion ; it has been used clinically since July 1963. This paper presents (1) results, (2) indications other than burns, and (3) improvements in equipment and methods of application from experience gained in 250 clinical cases.
W been
RESULTS Each surgeon using this method of grafting major burns was pleased with the increased area covered by utilizable skin, the rapidity of healing of open spaces (Fig. l), the increased Vol. 111, April
1966
percentage of takes, and the decreased donor area required. Take of the mesh grafts was uniformly total or near total on well prepared recipient areas using closed postoperative care. Stone and Hobby [9] reported 98 per cent take of their mesh grafts applied to forty-five severely burned patients and four patients with chronically ulcerated areas ; they also noted a marked diminution in mortality as compared to the previous year. A take of 90 per cent plus has been generally achieved over the average recipient burned area resulting in quicker skin coverages, more rapid elimination of infections, shorter hospital confinements, and less morbidity and mortality. The shorter times required for skin coverage permit earlier use of the affected joint and muscles. Thus, these expanding skin grafts helped to reduce the cachexia produced by long inactivity, extensive open wounds, and continuing infection. The first application of the mesh graft in a human subject was to a chronically infected extremity burned six months previously. It took 100 per cent, and Figure 2 shows the mesh pattern visible at two years. This pattern became progressvely less noticeable and was less conspicuous in light skin than in dark skin. The flexibility of the mesh graft allows it to adapt to irregular areas, and this feature contributes to the improved percentage takes on areas such as the neck, axillae, and breast. Wrinkling was not seen in mesh grafts fixed under physiologic tension. Mesh grafts have been used quite satisfactorily for scalp replacement since baldness results anyway. In fact, the genitalia, hands, and soles of the feet are the only areas not mesh grafted in this group of patients. Some graft failures were encountered. In all cases the reasons were apparent and invariably
543
544
Tanner,
Vandeput,
and Bradley
1
2
FIG.
1. Newly appliedmesh graft.
FIG.
2. The first mesh graft two years postoperatively.Note visible mesh pattern.
FIG.3. The Tanner-VandeputMeshgraftDermatome. due to infection, improper fixation and immobilization, or open postoperative technic. The first two causes of failures affect all skin grafts alike; the open method was especially undesirable since the greatly increased cut edge exposure rendered the mesh graft more vulnerable to dehydration, resulting in a lower percentage of takes.
The other indications for mesh grafting are the same as those pointed out by Douglas [7] in 1930 with additions made by Dragstedt and
[8] in 1937. The advantages are that it improves drainage, prevents accumulation of serum or exudate between the graft and underlying bed, and so affords a better opportunity of overcoming wound infection and of graft survival. The results of mesh grafts applied to wounds with excessive discharge, comprising 10 per cent of these cases (such as unclosable pilonidal wounds, chronic ulcers, defects from radical breast surgery, defects from nonviable skin flaps after radical neck surgery, and meningocele defect with spinal fluid leakage), have
Wilson
American
Journal of Suvgery
54.5
Mesh Skin Grafting
Stroke
1”
This
Direction
FIG. 4. The Dermacarrier. A, thick and thin pieces of plastic are bondedtogether at one end. B, thin plastic is drawn over sheet graft and thick plastic.
been most encouraging and show increased percentage of take and decrease in healing time. IMPROVEMENTS
IN EQUIPMENT
METHODS
OF APPLICATION
AND
1. The Meshgraft Dermatome@* has been developed from a very crude device, through a series of improvements, to the present simple and efficient instrument (Fig. 3) which rapidly converts any number of sheet grafts to mesh grafts. 2. The Dermacarrier@* is composed of a thick and a thin piece of plastic bonded together at one end. (Fig. 4.) It is used to hold the skin flat while being carried through the Meshgraft Dermatome. The thick plastic affords a firm backing for the skin while being perforated with the circular blades. 3. Fixation of the grafts has been accomplished by the following methods. Sutures, small and absorbable, proved satisfactory; however, synthetic nonabsorbable su* ZimmerManufacturing Co., Warsaw, Indiana. Vol. 111, April
1966
tures were better tolerated in infected wounds. Maximal expansion is obtained and maintained best with sutures. 3M Steri-Strips@‘t were used for fixation of the mesh grafts in several of the most recent cases and found to save time, eliminate foreign body reactions and stitch abscesses associated with needle punctures (due to innoculation of subcutaneous tissues with skin pathogens), and prevent necrosis of the wound edges and underlying tissue by sutures that are tied too tightly [IO]. Steri-Strips do not maintain full expansion as do sutures. Strips measuring >$ inch allow adequate drainage while wider strips may accumulate contaminated exudate. This method of fixation has been used very successfully and was most beneficial in small or irregular areas or when the extent of the lesion was ill defined. M-2-C Adhesive1 was use6-1;‘8r fixation of the mesh skin graft. This glue solidified in seconds and adhered very well to skin, saving much time ; it was used most advantageously when the graft was of sufficient size to overlap the border of the defect. It is therefore recommended primarily for use in small defects, such as chronic ulcers, when the mesh is employed for its property of free drainage rather than for expansion. It has the disadvantage of devitalizing that portion of the graft on which it is applied plus not adhering to moist surfaces. In other respects, it has the same advantages as the Steri-Strips. Very satisfactory results have been obtained with its use. No fixation other than mildly compressive bandages and adequate immobilization of involved body area has been successfully used and is quite satisfactory; however, maximal expansion is not obtained. 4. The timing of skin grafting varied in this series. In most of these cases debridement, at t Medical Products Division, 3M Company, St. Paul, Minnesota. $ Methyl 2-Cyano acrylate Monomer, Ethicon, Inc., Sommerville,
New Jersey.
546
Tanner,
Vandeput,
and Bradley the open spaces in five to ten days. This delayed method of meshing and applying stored autografts has the same advantages as simultaneous debridement and grafting plus better vascularized recipient sites. COMMENTS
FIG. 5. Photomicrograph of a mesh graft five weeks postoperatively. Note the ribbons of skin have hair follicles and rete pegs and that the scarrous epithelium does not.
the appropriate time, was performed with the patient under general anesthesia and later, after vascularity of the wound bed improved, multiple operative nracedures using general anesthesia were required for skin coverage. Two variations in the timing of skin grafting were employed, as follows: A. Eight patients were surgically debrided and immediately partially or totally covered with mesh skin grafts, depending on the patient’s general condition and percentage of burn. The grafts took and grew well on freshly denuded areas because of excellent drainage properties. They were, of course, placed in contact with viable vascularized tissue. Concomitant debridement and grafting reduced the number of general anesthetics, operative procedures, and days of hospitalization Ill]. B. Three patients were debrided and skin grafts removed for storage, using the technic of Matthews [12]. The debrided wounds and donor sites were dressed. On the third to fifth postoperative day the patients were returned to the operating room ; under heavy sedation, not general anesthesia, the dressings were removed, and the stored autografts meshed, placed on the granulating wounds, and fixed with 3M SteriStrips and mildly compressive bandages. These stored autografts had a near total take, and the epithelium grew from the cut edges and covered
The mesh skin graft was developed for the express purpose of covering a larger area with a smaller piece of skin. With the length cuts used, each square inch of skin (when meshed and fully expanded) covered 3 square inches of raw surface and healed in seven to ten days. Improved drainage allowed skin to be applied earlier on areas not in the best condition and took better than sheet grafts. Variable expansion permitted the mesh graft to fit into defects with irregular borders, and the flexibility allowed good conformity to concave and convex surfaces. These features resulted in increased takes on areas such as the axilla, poples, neck, and breast. Size of the donor areas decreased in proportion to the expansion of the mesh graft. This in turn reduced blood loss at surgery, postoperative pain, and area of donor site scarring. The surface lost with postage stamp grafts, due to skin contraction, was regained by suturing the mesh grafts in place with physiologic tension. Keloid formation was less than expected and apparently was related to more rapid skin coverage. Greatly increased (tenfold) cut edge exposure, from which epithelium grows, accounted for the earlier skin coverage which eliminated infection with all its complications. Concomitant debridement and grafting or debridement and removal of grafts for storage to be applied three to five days later further reduced the number of general anesthetics, operative procedures, and days of hospitalization. Disadvantages encountered consisted of a permanent mesh pattern and the necessity of an extra maneuver at the operating table. Few ulcerations were observed after the immediate postoperative period even though the multiple islands of scarrous epithelium should render it less resistant to trauma. A photomicrograph of a healed mesh graft at five weeks is shown in Figure 5. CONCLUSION
Information obtained from these cases indicated the following. American
Jouvnal
ofSurgery
X
Mesh Skin Grafting 1. The mesh graft is of most value in covering large skin defects on patients with insufficient donor areas. 2. Wounds with excessive discharge are covered more easily with mesh grafts. 3. Open postoperative care should not be used. 1. The healed mesh graft is cosmetically inferior to sheet grafts; however, it is satisfactory and is cosmetically superior to postage stamp grafts. 5. Skin coverage is facilitated by simultaneous debridement and grafting or delayed application of stored autografts. A. Less donor area is required. 7. The mesh graft is very adaptable. 8. The use of glue and adhesive strips is advantageous in many cases. Acknowledgment. We are grateful and indebted for case histories and photographs contributed by Drs. H. Harlan Stone and J. D. Martin of Grady Memorial Hospital, Dr. John A. Boswick of Cook County Hospital, Drs. Arthur L. Humphries and William H. Moretz of The Medical College of Georgia, Dr. James C. Thompson of the University of California, Dr. Joseph D. Carlisle of Pontiac General Hospital, Drs. J. R. Lewis and J. Hagan Baskin of Crawford W. Long Hospital, Dr. P. C. Shea, Jr., of St. Joseph’s Infirmary, Atlanta, Georgia, and Dr. K. Durrani of The Straith Memorial Hospital, Detroit, Michigan.
Vol. 111, A+1
1966
REFERENCES
1. STOSE, H. H., MARTIN, J. D., HUGER, W. E., and KALB, J. Gentamicin sulfate in the treatment of pseudomonas sepsis in burns. .‘$l~r~. Gynec. & Obst., 120: 351, 1965. 2. BOS~XK, J. A. Report on Effects of Topical Sulfamylon at 2nd International Congress of Kesearch in Burns, Edinburgh. Scotland, September 1965. 3. MOYER. C. A.. BRENTANO, L.. GRAVENS. D. L., MARGRAF, H. W., and MONAFO, W. W., JR. Treatment of large human burns with 0.5Vc silver nitrate solution. .4rch. Surg., 90: 812, 1965. 4. REVERDIN, J. L. Greffe epidermique. Hull. Sot. Imp. chir. Paris, 10: 493, 1869. 5. PADGBTT, E. C. Calibrated intermediate skin grafts. Surg. Gynec. & Obst., 69: 7i9, 1939. 6. TANNER, J. C., VANDEPUT, J,, and OLLEY. J. F. The mesh skin graft. Plast. &’ Reconstruct. S&g., 34: 287, 1964. 7. DOUGLAS, B. The sieve graft; stable transplant for covering large skin defects. Sz~rg. Gynec. & OK, 50: 1018, 1930. 8. DRAGSTEDT, L. R. and WILSOP~‘, H. A modified sieve graft; full thickness skin graft for covering large skin defects, Surg. Gynec b Obst., 65: 104, 1937. 9. STONE, H. H. and HOBBY, L. W. Use of the mesh dermatome with split-thickness grafts for major burns. Am. Surgeon, 31: 583, 1965. 10. GOLDEN, T., LEVY, A. H., and O’CONNOR, W. T. Primary healing of skin wounds and incisions with a threadless suture. Am. J. Swg., 104: 603, 1962. 11. TANNER, J. C., VANDEPUT, J., and BRADLEY, W. H. Mesh skin grafting: report of typical case. J. Occupational Med., 7: 175, 1965. 12. MATTHEWS, D. N. Storage of skin for autogenous graft. Lancet, 1: 775. 1945.
>4tZunta,Georgia
From the Atlanta Research Institute and the Department of Surgery, Crawford W. Long Hospital of Emory University, Atlanta, Georgia.
ITHIN the last two years something has done about early skin coverage of major burns. Mortality has been substantially reduced in the past three decades by practically eliminating death due to shock and fluid imbalance. Anti-infectious therapy has been further enhanced by an increased number of more effective and more specific antibiotics. Spreading infections have been curbed by better topical antibiotics [1,2] and topical antiseptics [3 1. In contrast to the advancements in medical therapy, there has been no real progress in resurfacing of denuded areas since Reverdin’s [PI, postage original “greffe epidermique” stamp grafts, and Padgett’s “calibrated intermediate skin grafts” [5]. Of course, further development produced the electrical dermatome and made split thickness grafts easily and quickly obtainable. Recognizing the need for more efficient use of available donor skin, we devised an expanding skin graft called the “Mesh Skin Graft” [6]. It has the advantages of the sieve graft 171and modified sieve graft [8] plus 300 per cent expansion ; it has been used clinically since July 1963. This paper presents (1) results, (2) indications other than burns, and (3) improvements in equipment and methods of application from experience gained in 250 clinical cases.
W been
RESULTS Each surgeon using this method of grafting major burns was pleased with the increased area covered by utilizable skin, the rapidity of healing of open spaces (Fig. l), the increased Vol. 111, April
1966
percentage of takes, and the decreased donor area required. Take of the mesh grafts was uniformly total or near total on well prepared recipient areas using closed postoperative care. Stone and Hobby [9] reported 98 per cent take of their mesh grafts applied to forty-five severely burned patients and four patients with chronically ulcerated areas ; they also noted a marked diminution in mortality as compared to the previous year. A take of 90 per cent plus has been generally achieved over the average recipient burned area resulting in quicker skin coverages, more rapid elimination of infections, shorter hospital confinements, and less morbidity and mortality. The shorter times required for skin coverage permit earlier use of the affected joint and muscles. Thus, these expanding skin grafts helped to reduce the cachexia produced by long inactivity, extensive open wounds, and continuing infection. The first application of the mesh graft in a human subject was to a chronically infected extremity burned six months previously. It took 100 per cent, and Figure 2 shows the mesh pattern visible at two years. This pattern became progressvely less noticeable and was less conspicuous in light skin than in dark skin. The flexibility of the mesh graft allows it to adapt to irregular areas, and this feature contributes to the improved percentage takes on areas such as the neck, axillae, and breast. Wrinkling was not seen in mesh grafts fixed under physiologic tension. Mesh grafts have been used quite satisfactorily for scalp replacement since baldness results anyway. In fact, the genitalia, hands, and soles of the feet are the only areas not mesh grafted in this group of patients. Some graft failures were encountered. In all cases the reasons were apparent and invariably
543
544
Tanner,
Vandeput,
and Bradley
1
2
FIG.
1. Newly appliedmesh graft.
FIG.
2. The first mesh graft two years postoperatively.Note visible mesh pattern.
FIG.3. The Tanner-VandeputMeshgraftDermatome. due to infection, improper fixation and immobilization, or open postoperative technic. The first two causes of failures affect all skin grafts alike; the open method was especially undesirable since the greatly increased cut edge exposure rendered the mesh graft more vulnerable to dehydration, resulting in a lower percentage of takes.
The other indications for mesh grafting are the same as those pointed out by Douglas [7] in 1930 with additions made by Dragstedt and
[8] in 1937. The advantages are that it improves drainage, prevents accumulation of serum or exudate between the graft and underlying bed, and so affords a better opportunity of overcoming wound infection and of graft survival. The results of mesh grafts applied to wounds with excessive discharge, comprising 10 per cent of these cases (such as unclosable pilonidal wounds, chronic ulcers, defects from radical breast surgery, defects from nonviable skin flaps after radical neck surgery, and meningocele defect with spinal fluid leakage), have
Wilson
American
Journal of Suvgery
54.5
Mesh Skin Grafting
Stroke
1”
This
Direction
FIG. 4. The Dermacarrier. A, thick and thin pieces of plastic are bondedtogether at one end. B, thin plastic is drawn over sheet graft and thick plastic.
been most encouraging and show increased percentage of take and decrease in healing time. IMPROVEMENTS
IN EQUIPMENT
METHODS
OF APPLICATION
AND
1. The Meshgraft Dermatome@* has been developed from a very crude device, through a series of improvements, to the present simple and efficient instrument (Fig. 3) which rapidly converts any number of sheet grafts to mesh grafts. 2. The Dermacarrier@* is composed of a thick and a thin piece of plastic bonded together at one end. (Fig. 4.) It is used to hold the skin flat while being carried through the Meshgraft Dermatome. The thick plastic affords a firm backing for the skin while being perforated with the circular blades. 3. Fixation of the grafts has been accomplished by the following methods. Sutures, small and absorbable, proved satisfactory; however, synthetic nonabsorbable su* ZimmerManufacturing Co., Warsaw, Indiana. Vol. 111, April
1966
tures were better tolerated in infected wounds. Maximal expansion is obtained and maintained best with sutures. 3M Steri-Strips@‘t were used for fixation of the mesh grafts in several of the most recent cases and found to save time, eliminate foreign body reactions and stitch abscesses associated with needle punctures (due to innoculation of subcutaneous tissues with skin pathogens), and prevent necrosis of the wound edges and underlying tissue by sutures that are tied too tightly [IO]. Steri-Strips do not maintain full expansion as do sutures. Strips measuring >$ inch allow adequate drainage while wider strips may accumulate contaminated exudate. This method of fixation has been used very successfully and was most beneficial in small or irregular areas or when the extent of the lesion was ill defined. M-2-C Adhesive1 was use6-1;‘8r fixation of the mesh skin graft. This glue solidified in seconds and adhered very well to skin, saving much time ; it was used most advantageously when the graft was of sufficient size to overlap the border of the defect. It is therefore recommended primarily for use in small defects, such as chronic ulcers, when the mesh is employed for its property of free drainage rather than for expansion. It has the disadvantage of devitalizing that portion of the graft on which it is applied plus not adhering to moist surfaces. In other respects, it has the same advantages as the Steri-Strips. Very satisfactory results have been obtained with its use. No fixation other than mildly compressive bandages and adequate immobilization of involved body area has been successfully used and is quite satisfactory; however, maximal expansion is not obtained. 4. The timing of skin grafting varied in this series. In most of these cases debridement, at t Medical Products Division, 3M Company, St. Paul, Minnesota. $ Methyl 2-Cyano acrylate Monomer, Ethicon, Inc., Sommerville,
New Jersey.
546
Tanner,
Vandeput,
and Bradley the open spaces in five to ten days. This delayed method of meshing and applying stored autografts has the same advantages as simultaneous debridement and grafting plus better vascularized recipient sites. COMMENTS
FIG. 5. Photomicrograph of a mesh graft five weeks postoperatively. Note the ribbons of skin have hair follicles and rete pegs and that the scarrous epithelium does not.
the appropriate time, was performed with the patient under general anesthesia and later, after vascularity of the wound bed improved, multiple operative nracedures using general anesthesia were required for skin coverage. Two variations in the timing of skin grafting were employed, as follows: A. Eight patients were surgically debrided and immediately partially or totally covered with mesh skin grafts, depending on the patient’s general condition and percentage of burn. The grafts took and grew well on freshly denuded areas because of excellent drainage properties. They were, of course, placed in contact with viable vascularized tissue. Concomitant debridement and grafting reduced the number of general anesthetics, operative procedures, and days of hospitalization Ill]. B. Three patients were debrided and skin grafts removed for storage, using the technic of Matthews [12]. The debrided wounds and donor sites were dressed. On the third to fifth postoperative day the patients were returned to the operating room ; under heavy sedation, not general anesthesia, the dressings were removed, and the stored autografts meshed, placed on the granulating wounds, and fixed with 3M SteriStrips and mildly compressive bandages. These stored autografts had a near total take, and the epithelium grew from the cut edges and covered
The mesh skin graft was developed for the express purpose of covering a larger area with a smaller piece of skin. With the length cuts used, each square inch of skin (when meshed and fully expanded) covered 3 square inches of raw surface and healed in seven to ten days. Improved drainage allowed skin to be applied earlier on areas not in the best condition and took better than sheet grafts. Variable expansion permitted the mesh graft to fit into defects with irregular borders, and the flexibility allowed good conformity to concave and convex surfaces. These features resulted in increased takes on areas such as the axilla, poples, neck, and breast. Size of the donor areas decreased in proportion to the expansion of the mesh graft. This in turn reduced blood loss at surgery, postoperative pain, and area of donor site scarring. The surface lost with postage stamp grafts, due to skin contraction, was regained by suturing the mesh grafts in place with physiologic tension. Keloid formation was less than expected and apparently was related to more rapid skin coverage. Greatly increased (tenfold) cut edge exposure, from which epithelium grows, accounted for the earlier skin coverage which eliminated infection with all its complications. Concomitant debridement and grafting or debridement and removal of grafts for storage to be applied three to five days later further reduced the number of general anesthetics, operative procedures, and days of hospitalization. Disadvantages encountered consisted of a permanent mesh pattern and the necessity of an extra maneuver at the operating table. Few ulcerations were observed after the immediate postoperative period even though the multiple islands of scarrous epithelium should render it less resistant to trauma. A photomicrograph of a healed mesh graft at five weeks is shown in Figure 5. CONCLUSION
Information obtained from these cases indicated the following. American
Jouvnal
ofSurgery
X
Mesh Skin Grafting 1. The mesh graft is of most value in covering large skin defects on patients with insufficient donor areas. 2. Wounds with excessive discharge are covered more easily with mesh grafts. 3. Open postoperative care should not be used. 1. The healed mesh graft is cosmetically inferior to sheet grafts; however, it is satisfactory and is cosmetically superior to postage stamp grafts. 5. Skin coverage is facilitated by simultaneous debridement and grafting or delayed application of stored autografts. A. Less donor area is required. 7. The mesh graft is very adaptable. 8. The use of glue and adhesive strips is advantageous in many cases. Acknowledgment. We are grateful and indebted for case histories and photographs contributed by Drs. H. Harlan Stone and J. D. Martin of Grady Memorial Hospital, Dr. John A. Boswick of Cook County Hospital, Drs. Arthur L. Humphries and William H. Moretz of The Medical College of Georgia, Dr. James C. Thompson of the University of California, Dr. Joseph D. Carlisle of Pontiac General Hospital, Drs. J. R. Lewis and J. Hagan Baskin of Crawford W. Long Hospital, Dr. P. C. Shea, Jr., of St. Joseph’s Infirmary, Atlanta, Georgia, and Dr. K. Durrani of The Straith Memorial Hospital, Detroit, Michigan.
Vol. 111, A+1
1966
REFERENCES
1. STOSE, H. H., MARTIN, J. D., HUGER, W. E., and KALB, J. Gentamicin sulfate in the treatment of pseudomonas sepsis in burns. .‘$l~r~. Gynec. & Obst., 120: 351, 1965. 2. BOS~XK, J. A. Report on Effects of Topical Sulfamylon at 2nd International Congress of Kesearch in Burns, Edinburgh. Scotland, September 1965. 3. MOYER. C. A.. BRENTANO, L.. GRAVENS. D. L., MARGRAF, H. W., and MONAFO, W. W., JR. Treatment of large human burns with 0.5Vc silver nitrate solution. .4rch. Surg., 90: 812, 1965. 4. REVERDIN, J. L. Greffe epidermique. Hull. Sot. Imp. chir. Paris, 10: 493, 1869. 5. PADGBTT, E. C. Calibrated intermediate skin grafts. Surg. Gynec. & Obst., 69: 7i9, 1939. 6. TANNER, J. C., VANDEPUT, J,, and OLLEY. J. F. The mesh skin graft. Plast. &’ Reconstruct. S&g., 34: 287, 1964. 7. DOUGLAS, B. The sieve graft; stable transplant for covering large skin defects. Sz~rg. Gynec. & OK, 50: 1018, 1930. 8. DRAGSTEDT, L. R. and WILSOP~‘, H. A modified sieve graft; full thickness skin graft for covering large skin defects, Surg. Gynec b Obst., 65: 104, 1937. 9. STONE, H. H. and HOBBY, L. W. Use of the mesh dermatome with split-thickness grafts for major burns. Am. Surgeon, 31: 583, 1965. 10. GOLDEN, T., LEVY, A. H., and O’CONNOR, W. T. Primary healing of skin wounds and incisions with a threadless suture. Am. J. Swg., 104: 603, 1962. 11. TANNER, J. C., VANDEPUT, J., and BRADLEY, W. H. Mesh skin grafting: report of typical case. J. Occupational Med., 7: 175, 1965. 12. MATTHEWS, D. N. Storage of skin for autogenous graft. Lancet, 1: 775. 1945.