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Wound healing for surgeons
592
BRITISH JOURNAL OF PLASTIC SURGERY
Surgical Management of the Burn Wound. By David M. Heimbach and Loren H. Engraw. Pp. 176 with colour photographic illustrations. (New York: Raven Press, 1984.) Price $93.50. The pr&cis to this book states that its primary intent is “to aid general and plastic surgeons with general wound management of burns of all sizes according to the area of the body involved.” The authors have certainly succeeded in this task, and acknowledge the part played by anaesthetist and nursing staff in their regime-including an excellent contribution from each. With few reservations a plea is made for early surgery in any burn which is considered unlikely to heal in three weeks whatever its extent. The first three chapters consider general factorspatient selection, excisionai techniques, wound closure. Individual areas of the body are then discussed separately in greater detail. It soon becomes evident that this book is not written from an armchair, but by practising and practical surgeons who themselves have met problems in looking after burn patients and try to present at least some of their solutions to others. The lavish use of superb colour clinical photographs illustrates, emphasises and elaborates the points made in the text. A great deal of practical detail is included, the photographs showing the application of techniques in individual patients. Each chapter ends with a list of maxims summarising and emphasising important aspects of the section and these are all of great practical value. Being American in origin some of the materials and instruments suggested are not available in Europe. This is particularly the case with Biobrane which is used extensively as a skin substitute. Some of the techniques suggested might be considered less acceptable, e.g., the use of skeletal traction and the elaborate splinting used for the grafted hand. Also although the authors recognise the superiority in many instances of sheet grafting, mesh grafting appears to be used extensiveiy. Many would criticise its use in smaller injuries. This book is for the specialist in bum care. The surgical and nursing technioues involved cannot be learned from a book, good a< this one is. It should, however, be readily available to all concerned in the surgical care of the burn patient. ANNE 3. SUTHERLAND
Guillaume Dupuytren: a surgeon in his place and time. By Hannah K. Barsky. Pp. xii -i-29.5 with 24 illustrations. First Edition. (New York: Vantage Press Inc. 1984.) Price US $14.95. Most of us, I suspect, have compiled a highly personal and emotively unscientific list of “hero figures”, some of them contemporary, others long since dead, who have in some way influenced our study, understanding and practice of surgery. Dupuytren’s name has always been near the top of my list, so that I opened this book with high expectations of enjoyment and educational enrichment. It looked good, it was a convenient size, nicely printed, it appeared to have been carefully researched over several years and although Mrs Hannah Barsky herself is not a doctor, her late husband, Dr Arthur J. Barsky, was a distinguished American plastic surgeon whom I had met on several occasions and whose book on Plastic Surgery was in the 1950’s the best book available for the trainee in plastic sur-
gery along with David Matthew’s smaller book “The Surgery of Repair”. Mrs Barsky had obviously taken great pains to collect background information so that she could, as explained in the words of the publishers of the book jacket, “. . paint a fascinating picture of his time and the people he knew-the people who shaped the arts. the sciences and even the governments of the day”. In a burst of hyperbole, the publishers added that “. each of these people and events is wonderfully related to the character and development of the grand master himself in skillful blend of fact, speculation and anecdote”. But as I began to read the book I soon became increasingly troubled and irritated for my reaction to the book bore no resemblance to that of the publishers’ blurb on the book jacket. Little new has been added to what we already know of Dupuytren’s childhood, early general and medical education, surgical career and the medico-political infighting of the day. In the chapters devoted specifically to Dupuytren’s work and life, the content, stripped of its padding, is thin and the style of writing not particularly inspiring. The remaining chapters that deal with the cultural, scientific, and political background are as incomplete and disjointed as the background notes that we find in the programmes distributed at orchestral concerts. Names are dropped like confetti (for no obvious reason), “purple passages” of prose fill page after page, speculation and anecdotal tales run riot. Nowhere are we given any deep insight as to whether this background influenced Dupuytren or not or any inkling of his personal views on the social upheaval that was taking place at the time. In my view, the authoress set herself an extremely difficult task. A writer, just like a painter or a musician, cannot always pull off a masterpiece or even a good piece of writing. In the same way, a surgeon does not always perform superlatively well. This is not a happy book: I would certainly not buy a copy or even give one to a friend. But Dupuytren has not lost his place in my list of surgical heroes. MICHAEL
N. TEMPEST
Wound Healing for Surgeons. Timothy E. Bucknall and Harold Ellis. Pp. 344. (Bailliere Tindall, 1984.) Price E19.75. This book gives a general outline on a broad canvas with some areas of considerable detail reflecting the special interest of the authors of those chapters. The twenty authors are either authorities in their field or diligent bibliographers. Only one is not a surgeon and only one works out of the United Kingdom and thus the book is intelligible to surgeons and readable. Grammar, vocabufary and style are British and attractive except for one chapter which has more personal pronouns than one would ever expect in a textbook. The special value of the book is that the healing of tissues and organs are considered separately to include skin, gut, nerves, vessels, serosae, bones, tendons, liver, bile ducts, pancreas and spleen. The book is suitable for the surgeon who is preparing for examinations, or who has left that phase of learning behind and now wishes to know what has happened in wound healing in the past twenty years, without recourse to the literature. It serves this function well. The diagrams are clear but sometimes are labelled with irritating ciphers requiring translation below. The photographs are monochrome and generally good.
593
BOOK REVIEWS The shortcomings of the text for a plastic surgeon are the inadequacy of information on dressings and their effect on wound healing, what contributes to the quality of a scar or influences pigmentation. Scar hypertrophy and keloid formation are inadequately covered as is the effect of irradiation on healing. There is a good index. The bibliography offers plenty of relevant further reading. ROY SANDERS
Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face. ASPRS Vol. 23. Edited by Bernard L. Kaye and Gilbert P. Gradinger. Pp. xiii+ 377. Over 400 illustrations (photographs and line drawings). (St. Louis, Toronto: The C. V. Mosby Company, 1984). Price&85.50. In the preface to this volume the editors define problems “As those conditions that the patient brings to the surgeon prior to surgery” and complications “As those unfavorable conditions that result after surgery”. They express the hope that study of these may reduce the latter. They also aim to describe some of the latest techniques in aesthetic facial surgery. It must be admitted that they largely succeed and the distinguished contributors to this symposium have given freely of the fruits of their experience. Inevitably in a multi-author work there is some unevenness but not sufficient to spoil the overall effect. The first section on patient selection and patient dissatisfaction is perhaps the most tantalising and in some ways the most disappointing. Herein lies the key to success in this type of surgery and the opening chapter on “learning to say no” is potentially the most important. Important not only in setting the tone of the book, but as a contribution to the management of the patient whose aspirations are incompatible with reality. Regrettably this chapter is too superficial in its exposition and is marred by the use of aphoristic jargon beloved of advertising agencies, for example “Beauty is skin deep but ugly is down to the bone”. This is followed by the startiing observation that “We can recall certam unattractive yet charming, talented and prominent women of the world such as Eleanor Roosevelt, Golda Meir. Indira Gandhi and Margaret Meade, who became truly more attractive as they grew older.” This is gratuitously offensive. untrue and irrelevant. There seems to be a generahsed confusion amongst some aesthetic surgeons and their patients that the surgical amelioration of ageing of the skin is synonymous with the creation of beauty. If any should harbour this misconception, perusal of the excellent photographic records produced in this book will expose the fallacy of their views. One is reminded of the backhanded compliment paid by a husband to his w&e after attending a large social function “My dear, you were the most beautiful woman there-my God they were an ugly lot”. Nonetheless it would be wrong to condemn entirely the opening section and indeed. one can only agree with the editorial comment at the end of it: “The younger surgeon will benefit from reading and rereading it (Part one) as he gains more experience in handling aesthetic surgery patients. The experienced Plastic Surgeon will benefit from this section by comparing his techniques with those authors, broadening or modifying them as he sees fit.” It is to be hoped that there will be a future sym-
posium which will discuss more fully this aspect of aesthetic facial surgery. The sections that follow deal with forehead and brow; procedures in mid and full face, which includes useful accounts of the piatysma-SMAS cervicofacial rhy~idectom~. blepharoplasty, surgery of the neck, earlobes, chin and finally “surface surgery”. The latter section describes chemical peel and dermabrasion and a combination of these two methods. The range of techniques described and discussed is far greater than those undertaken by the majority of plastic surgeons in this country. Nonetheless it is a commonplace that what America does today Britain will do tomorrow and that the undoubted explosion of interest in this type of surgery will result in a wider application of techniques, medico-legal problems and commercialism. This volume will be a valuable contribution to the literature. It will. hopefully, caution and calm the over enthusiastic beginner and will interest and support the established practitioner. In the midst of this maelstrom of “aesthetic” activitychapters of surgery, cosmetic surgery clinics. beauticians, protile plastics, bustography and all the rest. it is worth quoting the words of the famous art critic Eric Newton, .. ..I beauty cannot be described, therefore it cannot be defined. It cannot be measured either in quantity or quality, therefore it cannot be made into the basis of a science. It has always proved impregnable to the frontal attacks ofthe aestheticinns."
Reference E. Newton (1950). The Meuning o/‘Beuuty. Longmans Green & Co. London. 1. P. BENNETT
Manual on the AO/ASIF Tubular External Fixator. By G. Hierholzer, Th. Riiedi, M. Allgiiwer and J. Schatzker. Pp. 100 with 104 figures. (Berlin. Heidelberg, New York and Tokyo: Springer-Verlag, 1985). Price DM 86. This well illustrated book is, as the title states. a manual of the A0 external fixation system. Although it lists chapters on biomechanics and biological principles, it is essentially a book describing the techniques used to apply this tubular system in which there are essentially three confi~uralions: a single bar, a frame and a trapezoidal system. The book itself is clearly laid out with figures of excellent quality. I found the text sometimes a little dithcult to follow and this may be a result of t~dnsIation, There are a number of interesting points raised by the authors. particularly the use of an interfragmentary screw in conjunction with the single bar to ensure accurate fracture reduction. Also the authors recommend removing the system at 6 to 8 weeks and then applying a patella tendon bearing plaster or internally fixing the patient-s fracture. Consensus is apparently being reached that external fixation devices should be left for a nlininlum of 6 weeks and then removed. although there are strong dissenters from this view. The authors recommend as close an application as possible of the device to the bone in order to ensure stability. In plastic surgery. in which a flap is to be raised, this idea may just not be possible and hence some degree of stability must be compromised. This book certainly fulfils its main purpose of describing in
BRITISH JOURNAL OF PLASTIC SURGERY
Surgical Management of the Burn Wound. By David M. Heimbach and Loren H. Engraw. Pp. 176 with colour photographic illustrations. (New York: Raven Press, 1984.) Price $93.50. The pr&cis to this book states that its primary intent is “to aid general and plastic surgeons with general wound management of burns of all sizes according to the area of the body involved.” The authors have certainly succeeded in this task, and acknowledge the part played by anaesthetist and nursing staff in their regime-including an excellent contribution from each. With few reservations a plea is made for early surgery in any burn which is considered unlikely to heal in three weeks whatever its extent. The first three chapters consider general factorspatient selection, excisionai techniques, wound closure. Individual areas of the body are then discussed separately in greater detail. It soon becomes evident that this book is not written from an armchair, but by practising and practical surgeons who themselves have met problems in looking after burn patients and try to present at least some of their solutions to others. The lavish use of superb colour clinical photographs illustrates, emphasises and elaborates the points made in the text. A great deal of practical detail is included, the photographs showing the application of techniques in individual patients. Each chapter ends with a list of maxims summarising and emphasising important aspects of the section and these are all of great practical value. Being American in origin some of the materials and instruments suggested are not available in Europe. This is particularly the case with Biobrane which is used extensively as a skin substitute. Some of the techniques suggested might be considered less acceptable, e.g., the use of skeletal traction and the elaborate splinting used for the grafted hand. Also although the authors recognise the superiority in many instances of sheet grafting, mesh grafting appears to be used extensiveiy. Many would criticise its use in smaller injuries. This book is for the specialist in bum care. The surgical and nursing technioues involved cannot be learned from a book, good a< this one is. It should, however, be readily available to all concerned in the surgical care of the burn patient. ANNE 3. SUTHERLAND
Guillaume Dupuytren: a surgeon in his place and time. By Hannah K. Barsky. Pp. xii -i-29.5 with 24 illustrations. First Edition. (New York: Vantage Press Inc. 1984.) Price US $14.95. Most of us, I suspect, have compiled a highly personal and emotively unscientific list of “hero figures”, some of them contemporary, others long since dead, who have in some way influenced our study, understanding and practice of surgery. Dupuytren’s name has always been near the top of my list, so that I opened this book with high expectations of enjoyment and educational enrichment. It looked good, it was a convenient size, nicely printed, it appeared to have been carefully researched over several years and although Mrs Hannah Barsky herself is not a doctor, her late husband, Dr Arthur J. Barsky, was a distinguished American plastic surgeon whom I had met on several occasions and whose book on Plastic Surgery was in the 1950’s the best book available for the trainee in plastic sur-
gery along with David Matthew’s smaller book “The Surgery of Repair”. Mrs Barsky had obviously taken great pains to collect background information so that she could, as explained in the words of the publishers of the book jacket, “. . paint a fascinating picture of his time and the people he knew-the people who shaped the arts. the sciences and even the governments of the day”. In a burst of hyperbole, the publishers added that “. each of these people and events is wonderfully related to the character and development of the grand master himself in skillful blend of fact, speculation and anecdote”. But as I began to read the book I soon became increasingly troubled and irritated for my reaction to the book bore no resemblance to that of the publishers’ blurb on the book jacket. Little new has been added to what we already know of Dupuytren’s childhood, early general and medical education, surgical career and the medico-political infighting of the day. In the chapters devoted specifically to Dupuytren’s work and life, the content, stripped of its padding, is thin and the style of writing not particularly inspiring. The remaining chapters that deal with the cultural, scientific, and political background are as incomplete and disjointed as the background notes that we find in the programmes distributed at orchestral concerts. Names are dropped like confetti (for no obvious reason), “purple passages” of prose fill page after page, speculation and anecdotal tales run riot. Nowhere are we given any deep insight as to whether this background influenced Dupuytren or not or any inkling of his personal views on the social upheaval that was taking place at the time. In my view, the authoress set herself an extremely difficult task. A writer, just like a painter or a musician, cannot always pull off a masterpiece or even a good piece of writing. In the same way, a surgeon does not always perform superlatively well. This is not a happy book: I would certainly not buy a copy or even give one to a friend. But Dupuytren has not lost his place in my list of surgical heroes. MICHAEL
N. TEMPEST
Wound Healing for Surgeons. Timothy E. Bucknall and Harold Ellis. Pp. 344. (Bailliere Tindall, 1984.) Price E19.75. This book gives a general outline on a broad canvas with some areas of considerable detail reflecting the special interest of the authors of those chapters. The twenty authors are either authorities in their field or diligent bibliographers. Only one is not a surgeon and only one works out of the United Kingdom and thus the book is intelligible to surgeons and readable. Grammar, vocabufary and style are British and attractive except for one chapter which has more personal pronouns than one would ever expect in a textbook. The special value of the book is that the healing of tissues and organs are considered separately to include skin, gut, nerves, vessels, serosae, bones, tendons, liver, bile ducts, pancreas and spleen. The book is suitable for the surgeon who is preparing for examinations, or who has left that phase of learning behind and now wishes to know what has happened in wound healing in the past twenty years, without recourse to the literature. It serves this function well. The diagrams are clear but sometimes are labelled with irritating ciphers requiring translation below. The photographs are monochrome and generally good.
593
BOOK REVIEWS The shortcomings of the text for a plastic surgeon are the inadequacy of information on dressings and their effect on wound healing, what contributes to the quality of a scar or influences pigmentation. Scar hypertrophy and keloid formation are inadequately covered as is the effect of irradiation on healing. There is a good index. The bibliography offers plenty of relevant further reading. ROY SANDERS
Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face. ASPRS Vol. 23. Edited by Bernard L. Kaye and Gilbert P. Gradinger. Pp. xiii+ 377. Over 400 illustrations (photographs and line drawings). (St. Louis, Toronto: The C. V. Mosby Company, 1984). Price&85.50. In the preface to this volume the editors define problems “As those conditions that the patient brings to the surgeon prior to surgery” and complications “As those unfavorable conditions that result after surgery”. They express the hope that study of these may reduce the latter. They also aim to describe some of the latest techniques in aesthetic facial surgery. It must be admitted that they largely succeed and the distinguished contributors to this symposium have given freely of the fruits of their experience. Inevitably in a multi-author work there is some unevenness but not sufficient to spoil the overall effect. The first section on patient selection and patient dissatisfaction is perhaps the most tantalising and in some ways the most disappointing. Herein lies the key to success in this type of surgery and the opening chapter on “learning to say no” is potentially the most important. Important not only in setting the tone of the book, but as a contribution to the management of the patient whose aspirations are incompatible with reality. Regrettably this chapter is too superficial in its exposition and is marred by the use of aphoristic jargon beloved of advertising agencies, for example “Beauty is skin deep but ugly is down to the bone”. This is followed by the startiing observation that “We can recall certam unattractive yet charming, talented and prominent women of the world such as Eleanor Roosevelt, Golda Meir. Indira Gandhi and Margaret Meade, who became truly more attractive as they grew older.” This is gratuitously offensive. untrue and irrelevant. There seems to be a generahsed confusion amongst some aesthetic surgeons and their patients that the surgical amelioration of ageing of the skin is synonymous with the creation of beauty. If any should harbour this misconception, perusal of the excellent photographic records produced in this book will expose the fallacy of their views. One is reminded of the backhanded compliment paid by a husband to his w&e after attending a large social function “My dear, you were the most beautiful woman there-my God they were an ugly lot”. Nonetheless it would be wrong to condemn entirely the opening section and indeed. one can only agree with the editorial comment at the end of it: “The younger surgeon will benefit from reading and rereading it (Part one) as he gains more experience in handling aesthetic surgery patients. The experienced Plastic Surgeon will benefit from this section by comparing his techniques with those authors, broadening or modifying them as he sees fit.” It is to be hoped that there will be a future sym-
posium which will discuss more fully this aspect of aesthetic facial surgery. The sections that follow deal with forehead and brow; procedures in mid and full face, which includes useful accounts of the piatysma-SMAS cervicofacial rhy~idectom~. blepharoplasty, surgery of the neck, earlobes, chin and finally “surface surgery”. The latter section describes chemical peel and dermabrasion and a combination of these two methods. The range of techniques described and discussed is far greater than those undertaken by the majority of plastic surgeons in this country. Nonetheless it is a commonplace that what America does today Britain will do tomorrow and that the undoubted explosion of interest in this type of surgery will result in a wider application of techniques, medico-legal problems and commercialism. This volume will be a valuable contribution to the literature. It will. hopefully, caution and calm the over enthusiastic beginner and will interest and support the established practitioner. In the midst of this maelstrom of “aesthetic” activitychapters of surgery, cosmetic surgery clinics. beauticians, protile plastics, bustography and all the rest. it is worth quoting the words of the famous art critic Eric Newton, .. ..I beauty cannot be described, therefore it cannot be defined. It cannot be measured either in quantity or quality, therefore it cannot be made into the basis of a science. It has always proved impregnable to the frontal attacks ofthe aestheticinns."
Reference E. Newton (1950). The Meuning o/‘Beuuty. Longmans Green & Co. London. 1. P. BENNETT
Manual on the AO/ASIF Tubular External Fixator. By G. Hierholzer, Th. Riiedi, M. Allgiiwer and J. Schatzker. Pp. 100 with 104 figures. (Berlin. Heidelberg, New York and Tokyo: Springer-Verlag, 1985). Price DM 86. This well illustrated book is, as the title states. a manual of the A0 external fixation system. Although it lists chapters on biomechanics and biological principles, it is essentially a book describing the techniques used to apply this tubular system in which there are essentially three confi~uralions: a single bar, a frame and a trapezoidal system. The book itself is clearly laid out with figures of excellent quality. I found the text sometimes a little dithcult to follow and this may be a result of t~dnsIation, There are a number of interesting points raised by the authors. particularly the use of an interfragmentary screw in conjunction with the single bar to ensure accurate fracture reduction. Also the authors recommend removing the system at 6 to 8 weeks and then applying a patella tendon bearing plaster or internally fixing the patient-s fracture. Consensus is apparently being reached that external fixation devices should be left for a nlininlum of 6 weeks and then removed. although there are strong dissenters from this view. The authors recommend as close an application as possible of the device to the bone in order to ensure stability. In plastic surgery. in which a flap is to be raised, this idea may just not be possible and hence some degree of stability must be compromised. This book certainly fulfils its main purpose of describing in