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Ulceration of lower extremities and skin grafts
ULCERATION OF LOWER EXTREMITIES AND SKIN GRAFTS JAMES BARRETT Associate
BROWN,
M.D.,
VILRAY
Professor of CIinicaI Surgery, Washington University School of Medicine
P.
BLAIR,
M.D.
Professor of ClinicaI Surgery, Washington University SchooI of Medicine
AND LOUIS
T.
BYARS,
M.D.
Assistant in Clinical Surgery, Washington University SchooI of Medicine ST. LOUIS, MISSOURI
F
ROM a study of a group of patients sent into the hospital for repair of. uIceration of the Iower extremity, it appears that, where a Iarge amount of skin has been Iost, the best repair wiI1 be by the repIacement of norma skin. Nineteen different causes of uIceration have been found, but there is a surprisingIy smaI1 percentage of varicose uIcers. The Iongest duration of continuous uIceration was twenty years, in a woman who had dressed three huge open areas every day over this entire period. Another ulcer was open and cIosed for forty-four years. If there is complete circular loss of skin, spontaneous epitheIization is greatIy retarded, and there may be a compIete Iack of growth from the Iower epitheIia1 edge. If just a little bridge of normal skin is left through the fuII Iength of the leg, spontaneous epitheIization may occur very rapidIy and occasionaIIy give a permanent bearing surface. There is, however, a tremendous individua1 variation in the rate and possibIe extent of surface heaIing in these patients. Some patients never produce any rea1 granuIations on the uIcer bed, but continue to have a dirty gray or yeIIow glistening base. AIthough this base may never be made clean, it may be excised and successfu1 grafting done. More troublesome is the Iesion that has deveIoped an excessiveIy thick, dense scar, the remova of which carries one down to bone or tendon; and perhaps stiI1 more hazardous for a successful repair is the occasional Iesion that has a deep edema under the uIcer base, 452
suggesting possibIy the beginning of an eIephantiasis. Spontaneous heaIing of permanence cannot be expected in uIcers due to arterial disease or to excessive radiation. Various microscopic pictures of the uIcer edge may be found. There may be a marked activity of epithelium as evidenced by excessive keratinization and indicating a stimuIus to epitheIia1 proliferation by the wound itseIf but with no success whatever in covering the defect. This type of benign activity might be the most responsive to conservative methods of treatment such as eIastic adhesive strapping, if the tota area is not too prohibitive. Another type of edge may show practicaIIy no epitheIia1 activity and no tendency for deep invasion. From these types any degree of epitheIia1 activity up to squamous ceI1 carcinoma may be found. The “scar” epitheIium that covers these defects spontaneousIy under conservative treatment may give a permanent bearing surface in some instances, especiaIIy if the area is not too Iarge, but it is not normal skin and can be easiIy traumatized with resultant recurrent ulceration and very slow healing. This epitheIium creeps across the scar base, does not contain hair or glands and does not have norma derma to attach it to the base. Slight infection or trauma may cause widespread denudation of this thin, Aat “scar” epitheIiaI growth. Free thick spIit grafts are suitable for the repair of leg ulcers for the following reasons : (I) They can be obtained in Iarge amounts
New SERIES VOL. XLIII. No.
L
Brown,
et al.-Grafting
rapidIy and easiIy. In one patient 128 square inches were covered and in another aImost the entire Iower Ieg was covered at
A
of Leg UIcers
A rnerican Journal of Surgery
443
in some instances, or in patients unsuited for any other type of repair. These were used once in this series after failure of a
B
FIG. I. A, complete circuIar Ioss of skin one and one-half years folIowing burn. There is excessive keratinization around the edges but no effort to bridge across in heaIing. B, compIete heaIing in one operation for each leg in which the area was excised and the defect covered with thick spIit grafts.
singIe operations. (2) They may be gotten of suitabIe thickness to give norma appearance, and a norma bearing surface that wiI1 withstand trauma. (3) The donor area from which they were taken heaIs rapidIy without deformity. (4) They can withstand transpIantation into a contaminated fieId. (5) B ecause of genera1 ease of handIing this graft, Iarge areas, incIuding unstabIe surrounding scar epithelium, are more apt to be grafted. This is especiaIIy important where an entire Ieg may have to be covered before the patient is through. (6) The postoperative care both for the patient and for the surgeon is reIatively easy. (7) Any secondary operations can be done early. (8) The use of any type of fuI1 thickness graft is not thought necessary, and, on an infected heId, it is not practica1. QuaIifications of this choice of thick spIit grafts may, of course, be made: (I) Pinch grafts or smaI1 deep grafts may advantageousIy be used without hospitalization
spht graft because of a mistake in technique. (2) DoubIe pedicIe or sIiding flaps may be used, in osteomyeIitis cases, to insure a thicker covering over the tibia. (3) Individual preference of the surgeon for some type of fuI1 thickness graft which, if successfu1, wiI1, of course, give as satisfactory a resuIt as the thick spiit graft.3 It is unnecessary to mention that any causative factors shouId be controIIed if possibIe before grafting. Improvement in circulation and contro1 of infection are probabIy the most important earIy steps. If the patient comes in with a dirty wound and surrounding area, he is usuaIIy given soap, water, and a brush and asked to do the best he can in the bathtub. Ointments or coId cream may be used if necessary to Ioosen crusts and heavy keratin deposits, and gentIe surface debridement is carried out. Continuous wet dressings either of sahne or Dakin’s sohrtion are then kept on the area, with the patient in bed and the
454
American
Journal
of Surgery
Brown,
et al.-Grafting
Ieg eIevated most of the time. It is perhaps best to use some mild application at the time of each dressing, such as 5 per cent
We11 now
of Leg Ulcers
FEBRUARY, 193~
being judged by its appearance. However, if the IowIy pyocyaneus is known to be present, it is best to delay operation until
five years.
gentian violet or other of individual choice. Very fine mesh bandage gauze or oId linen placed next to the wound is of greater benefit than the usual coarse mesh dressing gauze. In extensive areas and in badly infected wounds, the continuous saIine bath is used for one to three hours a day. EIastic pressure bandages are frequently used and this pressure may improve the entire aspect of the leg within twenty-four to forty-eight hours. These preIiminary pressure dressings may even be substituted for bed rest over several days’ time.3 No patient is operated on if there is any evidence of cellulitis or edema anywhere, and patients have been kept in bed as Iong as three weeks before operation. It is, of course, hoped that the ulcer might be sterile, but it is doubtfu1 if one of any size is ever entirely free of contamination. Routine preoperative cuhures are not done, the readiness of the wound for grafting
this is controlIed, for it is extremely harmfu1 to the growth of free skin .grafts. It is also very important that any active ringworm infection be controlIed. LocaI preparation is done with soap, water, ether, and 2 per cent iodine. The uIcer edge and base are excised down to a suitabIe bleeding surface, by undercutting (never scraping) with a knife, care being used not to expose bone or tendon; any adjacent thin “scar” epithelium is removed with the knife and the resultant defect is bound firmIy with saline gauze after any necessary bIeeders have been tied with very fine silk. Granulations must be very carefully removed if there has been recent healing over exposed bone or tendon; and, if a deep avascular base persists in spite of deep removal, it may be better to risk putting grafts directly on this rather than exposing bare bone or tendon by stilI further dis-
NEW SERIES VOL. XLIII,
No. L
Brown,
et aI.-Grafting
section. Grafts wiI1 grow on bone covered with periosteum but not where it has been stripped.
of Leg UIcers
A merican
Journal
of Surgerg
dsjj
or basted aIong the edges with running more running mattress sutures sutures; through the surface of the graft bind it
FIG. 3. A, this uker hid been open and closed for forty-four years foIlowing trauma .1 : P .r, r 1 , 7. 3 1 ‘T so unrn:1 aearn ,_~.L at tne rime or a mule-leg. B, neawx m_one operar*on anu remamea from other cause.
In long standing uIcerations there may be such a thick scar formation that a bIood suppIy to a graft cannot be maintained and, even though the graft Iooks viabIe at the first dressing, it may be progressiveIy lost. If this situation can be recognized, much troubIe may be avoided by being sure to remove compIeteIy the avascuIar scar. If it is over a Iarge surface, smaI1 areas can be done at one time rather than make the procedure too formidabIe. Thick spIit grafts up to three-fourths the thickness of the skin are obtained, usuaIIy with the aid of the suction retractor, from the same or opposite thigh, if possibIe in one piece Iarge enough to cover the whoIe defect. The graft is appIied directIy to the base, sIightIy overIapping the edges, and whipped
down to the bed of the defect. If more than one graft is used, their edges are overIapped. MuItipIe stab hoIes are cut in the graft to aIIow for drainage. Several Iayers of wet gauze are smoothIy appIied, tubes for irrigation are incorporated, good firm pressure is obtained and a dressing is appIied. Postoperative Care. The origina dressing is kept wet with saIine introduced through the irrigation tubes. After a good many observations we have concIuded that the use of the continuous wet dressing gives a better chance of “take” than a dry or a grease dressing, but, occasionaIIy, if the uIcer bed is cIean enough, a simple grease-gauze pressure dressing is used. After four days the first dressing is done, the sutures are removed and the over-
456 ‘4me&an
Journal of Surgery
Brown,
et al---Grafting
lapping edges trimmed away carefully. One per cent siIver nitrate, 5 per cent gentian violet or some other miId antiseptic is
A
of Leg UIcers
FEBRUARY, ,939
stances of infection, if an active light is begun immediateIy and carried on over severa days, much surface area can be
B
FIG. 4. A, smaII ulcer recurrent
for thirty years in the scar epitheIium over an old osteomyelitis scar; patient had had trouble in securing empIoyment because of it. B, at one operation the whole scar area was removed and covered with a thick spIit graft with compIete heaiing resulting. We11 four and onehalf years.
gentIy painted over the edges and surface. The graft and surrounding areas are usualIy found so clean that wet dressings are no longer necessary and one or two Iayers of fine mesh gauze impregnated with 4 per cent xeroform, 5 per cent scarIet red or 5 per cent zinc oxide are appIied. A good firm pressure dressing is put over this and any necessary joint lixation is continued. If there is fluid, pus, or bIood under the graft, it is evacuated through new small openings; if there is evident Ioss of any area with a gross amount of pus around it, the dead graft is trimmed carefuIly away; if there is BaciIlus pyocyaneus infection present, the whole surrounding area is washed with soap and water. In these in-
saved. Antiseptics are used IocaIIy, fine mesh gauze is appIied smoothly over the whoIe area, and a wet dressing is reapplied. Adequate irrigation with Dakin’s solution or saline is maintained to insure continual and the dressing is carefuIIy wetness, changed each day. After a few days, in clean cases and as soon as infected cases have become clean, the usual grease gauze or steriIe cold cream is used over the area, and, after suitable padding is in pIace, an elastic bandage is applied. WaIking should be prohibited for two weeks and activity curbed for another week or two after this. The patient is sent home with the elastic bandage in place to be worn whiIe up and
NEW
SERIFS VOL.XLIII, No. 2
Brown, et al.-Grafting
around unti1 no cyanosis appears in the If this continued graft during activity. pressure is negIected, there may even be smaI1 hemorrhages under, and into, the graft. If the graft is directlv over the shin or ankIe, it ihouid be further protected with padding for several weeks. A Iate source of annoyance in some patients is the coIIection of sebum in and under the graft; this occurs first as smaI1 raised lumps and, where recognized, these shouId be evacuated by fine openings over them. If this is not done, these areas may become infected as an ordinary pimpIe and the pus may dissect under the graft and actually cause some surface 10~s.~
of Leg Ulcers
A merican
Journal
0CSurgrry
447
Percentages of cures are misleading because it is recognized that many patients may develop another uIcer at any time; however, it is probabIe that a11 patients can be kept we11 if they wiI1 report for treatment. REFERENCES BROWN, J. B., and BLAIR, V. P. The repair of defects resulting from fulI thickness loss of skin from burns. Surg., Gynec. 0 Obst., 60: 379-390, 1935. 2. BROWN, J. B., BLAIR, V. P., and BYARS, L. T. The repair of surface defects, from burns and other causes, with thick split skin grafts. South. M. J., z&408-415, 1935. 3. BROWN, J. B., BYARS, L. T., and BLAIR, V. P. A study of uhzerations of the Iower extremity and their repair with thick spfit skin grafts. Surg., Gynec. @TObst., 63: 331-340, 1936. 4. BROWN. J. B. The covering of raw surfaces. Internat. Abst.‘Surg., 6 107:5-I 16 1938.
I.
BROWN,
M.D.,
VILRAY
Professor of CIinicaI Surgery, Washington University School of Medicine
P.
BLAIR,
M.D.
Professor of ClinicaI Surgery, Washington University SchooI of Medicine
AND LOUIS
T.
BYARS,
M.D.
Assistant in Clinical Surgery, Washington University SchooI of Medicine ST. LOUIS, MISSOURI
F
ROM a study of a group of patients sent into the hospital for repair of. uIceration of the Iower extremity, it appears that, where a Iarge amount of skin has been Iost, the best repair wiI1 be by the repIacement of norma skin. Nineteen different causes of uIceration have been found, but there is a surprisingIy smaI1 percentage of varicose uIcers. The Iongest duration of continuous uIceration was twenty years, in a woman who had dressed three huge open areas every day over this entire period. Another ulcer was open and cIosed for forty-four years. If there is complete circular loss of skin, spontaneous epitheIization is greatIy retarded, and there may be a compIete Iack of growth from the Iower epitheIia1 edge. If just a little bridge of normal skin is left through the fuII Iength of the leg, spontaneous epitheIization may occur very rapidIy and occasionaIIy give a permanent bearing surface. There is, however, a tremendous individua1 variation in the rate and possibIe extent of surface heaIing in these patients. Some patients never produce any rea1 granuIations on the uIcer bed, but continue to have a dirty gray or yeIIow glistening base. AIthough this base may never be made clean, it may be excised and successfu1 grafting done. More troublesome is the Iesion that has deveIoped an excessiveIy thick, dense scar, the remova of which carries one down to bone or tendon; and perhaps stiI1 more hazardous for a successful repair is the occasional Iesion that has a deep edema under the uIcer base, 452
suggesting possibIy the beginning of an eIephantiasis. Spontaneous heaIing of permanence cannot be expected in uIcers due to arterial disease or to excessive radiation. Various microscopic pictures of the uIcer edge may be found. There may be a marked activity of epithelium as evidenced by excessive keratinization and indicating a stimuIus to epitheIia1 proliferation by the wound itseIf but with no success whatever in covering the defect. This type of benign activity might be the most responsive to conservative methods of treatment such as eIastic adhesive strapping, if the tota area is not too prohibitive. Another type of edge may show practicaIIy no epitheIia1 activity and no tendency for deep invasion. From these types any degree of epitheIia1 activity up to squamous ceI1 carcinoma may be found. The “scar” epitheIium that covers these defects spontaneousIy under conservative treatment may give a permanent bearing surface in some instances, especiaIIy if the area is not too Iarge, but it is not normal skin and can be easiIy traumatized with resultant recurrent ulceration and very slow healing. This epitheIium creeps across the scar base, does not contain hair or glands and does not have norma derma to attach it to the base. Slight infection or trauma may cause widespread denudation of this thin, Aat “scar” epitheIiaI growth. Free thick spIit grafts are suitable for the repair of leg ulcers for the following reasons : (I) They can be obtained in Iarge amounts
New SERIES VOL. XLIII. No.
L
Brown,
et al.-Grafting
rapidIy and easiIy. In one patient 128 square inches were covered and in another aImost the entire Iower Ieg was covered at
A
of Leg UIcers
A rnerican Journal of Surgery
443
in some instances, or in patients unsuited for any other type of repair. These were used once in this series after failure of a
B
FIG. I. A, complete circuIar Ioss of skin one and one-half years folIowing burn. There is excessive keratinization around the edges but no effort to bridge across in heaIing. B, compIete heaIing in one operation for each leg in which the area was excised and the defect covered with thick spIit grafts.
singIe operations. (2) They may be gotten of suitabIe thickness to give norma appearance, and a norma bearing surface that wiI1 withstand trauma. (3) The donor area from which they were taken heaIs rapidIy without deformity. (4) They can withstand transpIantation into a contaminated fieId. (5) B ecause of genera1 ease of handIing this graft, Iarge areas, incIuding unstabIe surrounding scar epithelium, are more apt to be grafted. This is especiaIIy important where an entire Ieg may have to be covered before the patient is through. (6) The postoperative care both for the patient and for the surgeon is reIatively easy. (7) Any secondary operations can be done early. (8) The use of any type of fuI1 thickness graft is not thought necessary, and, on an infected heId, it is not practica1. QuaIifications of this choice of thick spIit grafts may, of course, be made: (I) Pinch grafts or smaI1 deep grafts may advantageousIy be used without hospitalization
spht graft because of a mistake in technique. (2) DoubIe pedicIe or sIiding flaps may be used, in osteomyeIitis cases, to insure a thicker covering over the tibia. (3) Individual preference of the surgeon for some type of fuI1 thickness graft which, if successfu1, wiI1, of course, give as satisfactory a resuIt as the thick spiit graft.3 It is unnecessary to mention that any causative factors shouId be controIIed if possibIe before grafting. Improvement in circulation and contro1 of infection are probabIy the most important earIy steps. If the patient comes in with a dirty wound and surrounding area, he is usuaIIy given soap, water, and a brush and asked to do the best he can in the bathtub. Ointments or coId cream may be used if necessary to Ioosen crusts and heavy keratin deposits, and gentIe surface debridement is carried out. Continuous wet dressings either of sahne or Dakin’s sohrtion are then kept on the area, with the patient in bed and the
454
American
Journal
of Surgery
Brown,
et al.-Grafting
Ieg eIevated most of the time. It is perhaps best to use some mild application at the time of each dressing, such as 5 per cent
We11 now
of Leg Ulcers
FEBRUARY, 193~
being judged by its appearance. However, if the IowIy pyocyaneus is known to be present, it is best to delay operation until
five years.
gentian violet or other of individual choice. Very fine mesh bandage gauze or oId linen placed next to the wound is of greater benefit than the usual coarse mesh dressing gauze. In extensive areas and in badly infected wounds, the continuous saIine bath is used for one to three hours a day. EIastic pressure bandages are frequently used and this pressure may improve the entire aspect of the leg within twenty-four to forty-eight hours. These preIiminary pressure dressings may even be substituted for bed rest over several days’ time.3 No patient is operated on if there is any evidence of cellulitis or edema anywhere, and patients have been kept in bed as Iong as three weeks before operation. It is, of course, hoped that the ulcer might be sterile, but it is doubtfu1 if one of any size is ever entirely free of contamination. Routine preoperative cuhures are not done, the readiness of the wound for grafting
this is controlIed, for it is extremely harmfu1 to the growth of free skin .grafts. It is also very important that any active ringworm infection be controlIed. LocaI preparation is done with soap, water, ether, and 2 per cent iodine. The uIcer edge and base are excised down to a suitabIe bleeding surface, by undercutting (never scraping) with a knife, care being used not to expose bone or tendon; any adjacent thin “scar” epithelium is removed with the knife and the resultant defect is bound firmIy with saline gauze after any necessary bIeeders have been tied with very fine silk. Granulations must be very carefully removed if there has been recent healing over exposed bone or tendon; and, if a deep avascular base persists in spite of deep removal, it may be better to risk putting grafts directly on this rather than exposing bare bone or tendon by stilI further dis-
NEW SERIES VOL. XLIII,
No. L
Brown,
et aI.-Grafting
section. Grafts wiI1 grow on bone covered with periosteum but not where it has been stripped.
of Leg UIcers
A merican
Journal
of Surgerg
dsjj
or basted aIong the edges with running more running mattress sutures sutures; through the surface of the graft bind it
FIG. 3. A, this uker hid been open and closed for forty-four years foIlowing trauma .1 : P .r, r 1 , 7. 3 1 ‘T so unrn:1 aearn ,_~.L at tne rime or a mule-leg. B, neawx m_one operar*on anu remamea from other cause.
In long standing uIcerations there may be such a thick scar formation that a bIood suppIy to a graft cannot be maintained and, even though the graft Iooks viabIe at the first dressing, it may be progressiveIy lost. If this situation can be recognized, much troubIe may be avoided by being sure to remove compIeteIy the avascuIar scar. If it is over a Iarge surface, smaI1 areas can be done at one time rather than make the procedure too formidabIe. Thick spIit grafts up to three-fourths the thickness of the skin are obtained, usuaIIy with the aid of the suction retractor, from the same or opposite thigh, if possibIe in one piece Iarge enough to cover the whoIe defect. The graft is appIied directIy to the base, sIightIy overIapping the edges, and whipped
down to the bed of the defect. If more than one graft is used, their edges are overIapped. MuItipIe stab hoIes are cut in the graft to aIIow for drainage. Several Iayers of wet gauze are smoothIy appIied, tubes for irrigation are incorporated, good firm pressure is obtained and a dressing is appIied. Postoperative Care. The origina dressing is kept wet with saIine introduced through the irrigation tubes. After a good many observations we have concIuded that the use of the continuous wet dressing gives a better chance of “take” than a dry or a grease dressing, but, occasionaIIy, if the uIcer bed is cIean enough, a simple grease-gauze pressure dressing is used. After four days the first dressing is done, the sutures are removed and the over-
456 ‘4me&an
Journal of Surgery
Brown,
et al---Grafting
lapping edges trimmed away carefully. One per cent siIver nitrate, 5 per cent gentian violet or some other miId antiseptic is
A
of Leg UIcers
FEBRUARY, ,939
stances of infection, if an active light is begun immediateIy and carried on over severa days, much surface area can be
B
FIG. 4. A, smaII ulcer recurrent
for thirty years in the scar epitheIium over an old osteomyelitis scar; patient had had trouble in securing empIoyment because of it. B, at one operation the whole scar area was removed and covered with a thick spIit graft with compIete heaiing resulting. We11 four and onehalf years.
gentIy painted over the edges and surface. The graft and surrounding areas are usualIy found so clean that wet dressings are no longer necessary and one or two Iayers of fine mesh gauze impregnated with 4 per cent xeroform, 5 per cent scarIet red or 5 per cent zinc oxide are appIied. A good firm pressure dressing is put over this and any necessary joint lixation is continued. If there is fluid, pus, or bIood under the graft, it is evacuated through new small openings; if there is evident Ioss of any area with a gross amount of pus around it, the dead graft is trimmed carefuIly away; if there is BaciIlus pyocyaneus infection present, the whole surrounding area is washed with soap and water. In these in-
saved. Antiseptics are used IocaIIy, fine mesh gauze is appIied smoothly over the whoIe area, and a wet dressing is reapplied. Adequate irrigation with Dakin’s solution or saline is maintained to insure continual and the dressing is carefuIIy wetness, changed each day. After a few days, in clean cases and as soon as infected cases have become clean, the usual grease gauze or steriIe cold cream is used over the area, and, after suitable padding is in pIace, an elastic bandage is applied. WaIking should be prohibited for two weeks and activity curbed for another week or two after this. The patient is sent home with the elastic bandage in place to be worn whiIe up and
NEW
SERIFS VOL.XLIII, No. 2
Brown, et al.-Grafting
around unti1 no cyanosis appears in the If this continued graft during activity. pressure is negIected, there may even be smaI1 hemorrhages under, and into, the graft. If the graft is directlv over the shin or ankIe, it ihouid be further protected with padding for several weeks. A Iate source of annoyance in some patients is the coIIection of sebum in and under the graft; this occurs first as smaI1 raised lumps and, where recognized, these shouId be evacuated by fine openings over them. If this is not done, these areas may become infected as an ordinary pimpIe and the pus may dissect under the graft and actually cause some surface 10~s.~
of Leg Ulcers
A merican
Journal
0CSurgrry
447
Percentages of cures are misleading because it is recognized that many patients may develop another uIcer at any time; however, it is probabIe that a11 patients can be kept we11 if they wiI1 report for treatment. REFERENCES BROWN, J. B., and BLAIR, V. P. The repair of defects resulting from fulI thickness loss of skin from burns. Surg., Gynec. 0 Obst., 60: 379-390, 1935. 2. BROWN, J. B., BLAIR, V. P., and BYARS, L. T. The repair of surface defects, from burns and other causes, with thick split skin grafts. South. M. J., z&408-415, 1935. 3. BROWN, J. B., BYARS, L. T., and BLAIR, V. P. A study of uhzerations of the Iower extremity and their repair with thick spfit skin grafts. Surg., Gynec. @TObst., 63: 331-340, 1936. 4. BROWN. J. B. The covering of raw surfaces. Internat. Abst.‘Surg., 6 107:5-I 16 1938.
I.