1Postgrad. med. J. (September 1967) 43, 587-591.

Plastic reconstruction and skin cover afterinjuries and burns

C. R. McLAUGHLINM.A., M.B., F.R.C.S.E.

Consultant Plastic Surgeon,Queen Victoria Hospital, East Grinstead

THE PURPOSE of this paper is to summarize, for thebenefit of busy surgeons in Casualty and AccidentDepartments, the role of plastic surgery in relationto injuries-including bums-in which the patienthas suffered a serious breach of the 'skin envelope';and also to consider certain aspects of facialinjuries.

It is not easy to cover so wide a subject in a smallspace, and technical details can only be given forsome of those procedures which lie reasonablywithin the compass of an Accident Department;but at the same time it is possible to hint at morecomplex procedures which may be carried out in anappropriate specialist unit.The normal physiology of the body demands

integrity of the skin envelope, and any seriousbreach in this may endanger life as well as health.In all serious burns and in many other injuriessuch a breach occurs, and the patient with a largeexposed area suffers a double danger: on a systemicscale there is the hazard of a generalized infectionwhere the entry of organisms can cause bacteraemiaor septicaemia; and at the same time, particularlyin burns, there is a gross disturbance of the body'sbiochemical balance. The local effects, also, areoften serious; these include infection, oedema andpain. They do not necessarily endanger the patient'slife but they are certainly a menace to comfort andoften to function.

BurnsIt will not be possible within the compass of this

paper to consider the general management of theburned patient; nevertheless it is important to notethat skin cover is extremely relevant to the survivalof any patient with extensive burns; and until thebreach in the skin envelope is repaired, his life maybe in danger. We must now consider how best torepair this breach. The ideal procedure of coursewould be early primary grafting, but this is onlypossible where the burn itself can be excised withinthe first 4 or 5 hr. Primary excision is possible inonly a surprisingly limited number of burns wherethe extent is small and the limits well-defined. One

should beware of attempting primary excisionwhere it is hard to assess the depth of the burn;this is notably true of the flexor aspect of the palmand fingers, particularly with electrical burns wheredepth is often impossible to assess precisely.However, given a small self-limited burn, such asmay be caused by contact with hot metal, earlyexcision and grafting as a single procedure withinthe first few hours is feasible and should not beoverlooked.

Delayed graftingIn a vast majority of cases, early grafting being

impossible, the surgeon must wait until nature,aided by later surgery, has established a raw areawhich will receive a graft. Sloughs of burned skintend to be slow to separate and seldom does naturalseparation take place within the first 21 days. Inunfavourable cases this period will be very muchlonger, and commonly in electrical burns it takes5 or 6 weeks for separation to occur. It is also note-worthy that when burns have been treated by openexposure (and this is an excellent method in well-chosen cases) the dry eschar which has formed ismuch slower to separate than the moist slough ofthe covered burn. Thus it is clear that the timingboth of spontaneous slough separation and of thesurgical procedure of desloughing is important.The extensive removal of large sloughs is a majorprocedure even if the operation seems simple. It isessential that the general fitness of the patientshould be assured and this usually involves a bloodtransfusion, if not before, at least during a procedurewhich can otherwise lead to dangerous exsanguin-ation. For this and other reasons, speed during theoperation is also imperative, as the duration bearssome relation to the blood loss.Much has been written of the advantages of

chemical agents for desloughing, but these havebeen found on the whole to be disappointing, andwhen effective are extremely uncomfortable for thepatient, and thus are badly tolerated.

It is most important to have clear criteria of whatconstitutes 'clean' granulations and emphasis has

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often been placed on precise bacteriology. This isnot the whole answer and indeed culture reportsshould be used mainly to confirm clinical judgementand not to take its place. We must now considermethods of making the patient fit for surgery. Justas blood transfusion is important in the earlyresuscitation of the badly burned patient, so it mustnot be overlooked 3 or 4 weeks later when de-sloughing is contemplated. It is easy to have beenmisled by the early haematocrit values and toforget that the total mass of circulating red cells isinvariably reduced by a severe burn; this latentanaemia declares itself increasingly after the firstweek. During these early weeks the patient shouldbe on a high protein diet, but there is little to begained by special drugs such as cortisone.The second part of the problem is to prepare the

raw area locally so that it is sufficiently clean for aThiersch graft to be applied with a good expectationof a successful 'take'. This problem has receivedmuch attention, but a good deal of confusion stillexists in the minds of young doctors. Many centresfor the treatment of burns rely on the use ofprophylactic systemic antibiotics given over a longishperiod and this cannot be readily condemned,though its advantages are a little uncertain. Thereis certainly a place for the use of topical antibioticswhere a particular organism shows signs of beingtroublesome, and certain organisms (notably Ps.pyocyanea) are notorious for causing the failure ofgrafts. In some cases an antibiotic solution made upin suitable strength (such as chloramphenicol,1 part in 400 in normal saline) can be applied as anold-fashioned cold compress on gauze, the latterbeing covered with sterile jaconet to keep the dressingmoist. However, this method should only be usedfor a limited time to avoid colonization of thegranulations by resistant organisms. The use ofso-called local antiseptics is of very doubtful valuethough there has been a considerable vogue forsuch substances. However, we can reasonably saythat those antiseptics which kill organisms are veryapt to kill the tissues, or at least to cause the patientsa degree of pain which they will not readily tolerate.In many cases straightforward attention to simplesurgical hygiene, the use of a bath containing hypo-chlorite (or Dettol), and the application of a blanddressing are the first requirements. Everyone isanxious to select a dressing which does not adhereand so does not cause pain and bleeding when it ischanged, and tulle gras in its various forms has hada great vogue. While there is no objection to thismaterial during the first week or two, it is apt in thelater stages to cause progressive maceration of thewound. As it happens, ordinary gauze is probablythe best material to use next to a wound that hasbecome a little indolent. The choice of blandmedications to apply on the gauze is very wide.

For many years plastic surgeons have favoured amixture of eusol and liquid paraffin in equalquantities. These two substances are, of course,not miscible, but pharmacists can produce anemulsion. In either form this combination iseffective, since the paraffin is satisfactorily blandand the eusol (which is, of course, sodium hypo-chlorite) is reasonably effective as a hypertonicsolution which encourages a healthy exudate, andis one of the few acceptable local antiseptics. Interms of simple hygiene the use of a bath is to belooked on with considerable favour, and thetheoretical objection of faecal and other contamin-ation is usually outweighed by the advantages ofsimple mechanical lavage.

The scope of surgical desloughingIn excising sloughs it is important to reach tissues

which are manifestly viable; with fat this is difficultto assess, though in children the fat is notably morevascular than in adults. It is usually wise in deepburns of the abdomen and thighs to carry thedesloughing down to the deep fascia, as this is oftenthe first layer that one can be sure is safely viable.As regards the type ofgraft to be used, split skin

from the patient himself is, of course, the firstchoice. Homografts whether taken from relativesor a cadaver will in few circumstances last longerthan 3 weeks, and their use is thus distinctly limited.It is, however, possible to store the patient's ownautografts taken at one operation so that they canbe applied, if necessary without an anaesthetic, at arather later stage when the condition of the rawareas is more satisfactory. This applies when onepart of the burn is surgically more advanced thananother. In the extensively burned patient, properpriority must be given to those areas which merit it;attention to the face, and above all to the eyelids,must come first. The hands are of special impor-tance, and great attention must also be paid tothose parts of the limbs which undergo flexion.

Technique of cutting skin graftsThere can be no excuse these days for a young

surgeon being unable to cut a split skin graft ofreasonable size. This is essentially a simple pro-cedure and just as much part of the emergencysurgeon's repertoire as passing a catheter.Only two pieces of equipment are required; the

first is one of the modern skin grafting knives, withan adjustable guard to control the thickness of thegraft. Perhaps the ideal design (Cobbett, 1967,personal communication) is a knife with a guardwhich oscillates but does not rotate (since rotationtends to roll a very thin graft up like a blind, whichcan be awkward) (Fig. 1). The other requirementis a bevelled wooden board to hold the skin tautand flat in front of the knife. The best areas for

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FIG. 1. Skin grafting knife with mobile guard. Theguard does not rotate but stays pressed steadily on theskin while the knife glides to and fro.

cutting grafts are in the inner aspect of the thighand upper arm, and the assistant should so hold thelimb as to present a flat surface of maximum width(Fig. 2). The most useful graft is roughly half the

FIG. 2. The patient's thigh presented flat, supported bythe assistant's hand below it. In favourable cases thisgraft may be 3 or 4 in. wide and extend the full lengthof the thigh.

full thickness of the skin approximately 15/1000 in.)The cut skin is spread on tulle gras at full stretch,and the donor surface is itself dressed with tullegras.

In any badly burned patient the surgeon will haveconsiderable difficulty in finding sufficient donorareas to obtain the skin he wants, but if the skin istaken with skill it is possible for any one area toprovide a second graft quite soon. It may surprisesome readers that in specially favourable cases

three lots of thin skin have in fact been cut withina total of 3 weeks from the same area. If homograftsare being used it is important that they should belaid on alternately with the autografts, so that thelatter can spread and replace the homografts asthese are progressively rejected. There is a goodreview of these problems by Wallace (1966).

Degloving injuriesPatients who are injured in road traffic or

industrial accidents frequently suffer what isconveniently called 'degloving' of upper or lowerlimb. Here there is sudden loss of skin as in a burn,but the problem is simpler and the systemic effectsare usually less severe. A good deal of judgementis required in deciding whether to return the flapof skin which has been stripped back; this obviouslyshould not be done if the skin is manifestly dead.However, it is sometimes possible by severe trimmingto retain the proximal part of the traumatic skinflap and use it to cover part of the exposed tissues.Where skin is totally detached it can, in rare cases,be filleted and returned as a full-thickness Wolfegraft. This does not have many applications outsidethe scalp.

Compound fractures of the legThe problem of treating limb fractures which are

not only compound but are associated with anactual loss of adjacent skin is a complex andfascinating one. There is a good review (Brown,1965) which deals with the lower limb and discussesthe alternatives. In these cases the scope of debride-ment must be correctly assessed. The only simplegeneralization is that all viable tissue must beretained, and tissues which are almost certainlydead must be sacrificed. If muscle does not bleedit should usually not be retained, and bony frag-ments when loose and detached from periosteumare seldom worth keeping, being in fact very proneto end up as sequestra. If the area of skin which hasbeen lost is small then it may be possible to closethe wound by primary suture. This, however, mustnot in any circumstances be done under tension;also every precaution must be taken against localhaematoma formation and local sepsis. Any ofthese will lead to disruption of the wound, and theposition then will be worse than if primary suturehad not been attempted. In difficult conditions it isbest simply to apply a Thiersch graft to the softtissues. Elaborate repairs using flaps, whether localor from the opposite leg, are very risky and canseldom be justified. It has been fashionable to carryout so-called 'relaxation incisions' in a somewhatcrude form to allow primary closure, but again thisis seldom justified, and grafting of the secondaryraw area is essential. In some cases the best alter-native is delayed primary suture at about 6 days.

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If the local conditions are extremely unpromising,then delayed suture must be discarded and thepatient treated by the secondary application ofskin grafts to the tissues when they develop healthygranulations. Grafts can, of course, take on peri-osteum and they will also take on cancellous bone.The one surface that is hopeless to graft is the barecortex. Provided the fracture is properly im-mobilized it is surprising how often the wound canin fact be re-surfaced entirely by Thiersch grafts.Even if this is only a provisional cover, it is never-theless well worth carrying out, and the wholeproblem of secondary cover can be left to expertsat a later stage.

Facial injuriesIn relation to facial injuries there are some

special factors, and these may be summarized asfollows:

(1) Any residual scarring is likely to be offen-sive, at least to the patient.

(2) The blood supply of the face is for the mostpart superb, and wide excisions are seldom necessary.

(3) There is an absolute obligation to curettetar-ingrained surfaces whether abrasions or lacera-tions. If this is not done the patient will have apermanently pigmented scar and may well guessthat this was due to the neglect of the originalsurgeon!

(4) As regards facial fractures, those involvingthe nasal bones are the most likely to be compound.

(5) A closed fracture in the orbital area mayseriously involve the dura, the eye or its relatedmuscles. (Fractures of maxilla and mandible willnot be considered here as they lie outside the scopeof this paper.)We may now examine these local factors more

closely. It is often impossible to get a good cosmeticresult when repairing a facial laceration at the timeof injury. It is, of course, obligatory to carry outthe repair meticulously as though it were in factthe final operation; but a disappointing result doesnot necessarily reflect on the surgeon. Gentle hand-ling, using fine instruments and sutures, is impera-tive. Hypertrophy of the scar may be aggravated bysmall retained fragments of foreign material, andthese are very easily missed. In cases of true (orapparent) keloid formation it is wise to wait up to6 months before carrying out a secondary excisionand suture. Owing to the excellent viability of thefacial skin, it is usually sufficient to remove a meremillimetre or two of the skin margins prior to primarysuture, unless the edges are torn in an irregular way.A casualty surgeon must always assume that a

patient who has been injured by contact with amodern road has in fact got tar tattooed into hiswounds. This is hard to detect at the time wherethe tar is concealed by blood, but it is absolutely

FIG. 3. Patient with heavily tar-ingrained scars shownfollowing primary surgery, which clearly did not includeadequate curetting.

essential to treat it properly, as there is often nochance of recovering later the opportunity initiallymissed (Fig. 3). Apart from soap and water and ascrubbing brush, the best instrument is a steelspoon such as Volkmann's and this must be pliedruthlessly even though the process appears to betraumatic. Each raw abraded surface and eachdeep fissure must be curetted in turn, so that thereis as little chance as possible of these ugly tattoosappearing later.

Turning to nasal fractures, simple early reductionis important and for this manipulation the bestinstrument is Walsham's. It may be necessary aftercorrection of the fracture to pack the nose, and inrare cases to insert short rubber tubes to maintain anotherwise blocked airway. Surgery to the septum,in any definitive sense, it not possible until monthslater. Splinting of a badly fractured nose mayappear difficult, and there are two methods available.It is usually sufficient to apply plaster of Paris inthe form of a triangle with an extension on to theforehead. The size of this triangle can be roughlyestimated by first cutting a piece of lint to fit thenose (Fig. 4). This method has the advantage thatthe fracture can be finally manipulated through theplaster as it dries. In very bad cases where the nasalbones have collapsed, the proper procedure is tocut out two lead plates about 1 x i in. which willlie on each side of the fracture. Their upper endsmust reach above the level of the inner canthus.Two holes are punched in the lead plates which are

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FIG. 4. Plaster of Paris nasal splint in position. Thelower piece of strapping at cheek level has beenomitted to show the design of the plaster.

then transfixed by a wire suture mounted on asharp needle. This is passed (say) from left to rightthrough the upper holes and back through thelower ones, in the form of a mattress suture. Whentied firmly but not tightly, this wire will maintainthe bony fragments in a reasonably accurate positionand can be left for a week.

Note: As regards fractures around the eye, it is importantif possible to obtain the advice of an ophthalmic colleague.It must always be remembered that the injury which fracturedthe orbital ring may have caused serious damage to the globeor to the optic nerve, and it is usually not difficult to make arough assessment of vision prior to surgery.

A suspected fracture of the malar bone should beconfirmed by X-ray. It is important, unless chemosismakes this impossible, to test the patient for diplopiaby asking him to follow one's finger and say if hehas double vision. The fractured malar should bereduced by one of the recognized routes (either the

upper temporal route, through the temporal fascia,or, in selected cases where the antrum is collapsed,by a Caldwell-Luc approach). If the fractureremains unstable, and a gap still be felt in the regionof the fronto-malar suture, then open wiring atthis point may be indicated. Happily a properreduction of the malar or orbital fracture alongthese lines is usually, but not invariably, sufficientto cure the diplopia. If it remains then it must beseen by a specialist as early as possible.

Note: In connection with severe nasal fractures we mayconsider for a moment the problem of cerebro-spinalrhinorrhoea. This is usually an indication that there is amaxillary fracture in addition to a nasal fracture, and suchcases should be treated by experts. It is, however, useful torecall that primary treatment by accurate reduction andimmobilization almost invariably cures the leak of CSFwithin a matter of hours, and the intervention of a neuro-surgeon is seldom called for. With proper surgery plusantibiotics the incidence of meningitis is virtually nil inthis context.

ConclusionsIt can be seen from this necessarily brief summary

that reconstruction and skin cover in relation tobums and injuries presents many problems. Someof these patients should clearly be dealt with byexperts, but such experts are not always immediatelyavailable, even these days. The main purpose ofthese clinical suggestions, necessarily made in asomewhat didactic form, is that the surgeon on thespot should do nothing and omit nothing which willcomplicate the later treatment. A mistake in theprimary treatment, such as failing to curette a tar-ingrained face, or perhaps closing a compoundfracture under tension so that the whole woundbreaks down, may make the subsequent treatmentnot merely difficult but impossible.

AcknowledgmentI am grateful to Mr P. Broadbery, A.R.P.S., A.lI..P., for

the photographs.

ReferencesBROWN, R.F. (1965) The management of traumatic tissue

loss in the lower limb, especially when complicated byskeletal injury. Brit. J. plast. Surg. 18, 26.

WALLACE, A.F. (1966) The problem of skin cover in extensivebums. irit. J. plast. Surg. 19, 161.

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