NEW METHOD OF TUBE PEDICLE SKIN GRAFTING

MAXWELL MALTZ, M.D.

PIastic Reconstructive Surgeon, Beth David HospitaI

NEW YORK CITY

T HOSE who, by severe accident or disease, have been maimed beyond recognition and thus damned to a Iife

of misery, are most urgentIy in need of skilfuI pIastic surgery. Such deformity means socia1 and economic ostracism, with its inevitabIe deIeterious effect on behavior and character.

In cases such as these beauty cannot be restored. The pIastic surgeon can, however, restore normaIity to the features and make Iife IivabIe for the unfortunate individua1 who once again may find his pIace sociaIIy and economicaIIy. This cannot be done overnight. The greatest assistants to the surgeon are time, patience, and painstaking Iabor.

A burned chiId whose chin is fastened to its chest by a hideous scar, the victim of an explosion whose mouth is no Ionger human and whose eyeIids are turned out of their sockets, the wretched being whose ear has been torn away by a whirIing machine, the sufferer whose Iip has been destroyed by cancer, a baby born with a cIeft in the roof of its mouth---a11 these victims of ghastIy disfigurements can be aided by pIastic surgery, for a11 of these distortions can be reIieved by the mercifu1 art of transpIant- ing tissue.

The desire to be norma in appearance is as oId as history, and from the beginnings of time those affIicted with a facia1 dis- figurement sought surgica1 rehef to attain peace of mind. Therefore, contrary to popuIar beIief, pIastic surgery is not a modern invention. It is true that the restoration of features ravaged by the World War gave a great impetus to this branch of surgery and for the first time brought its more popuIar aspects to the attention of Laymen. But pIastic surgery had already been practiced for tens of

centuries before the war. Though its earIy practitioners may have been singuIarIy inept, it is as old as facia1 abnormality itseIf.

The Aryuveda, a sacred journa1 of the ancient Hindus, reveaIs the fact that marked efficiency in pIastic surgery through the use of skin grafts was attained in India more than 2500 years ago. In those days it served a curious cause. A distorted conception of justice provided that the noses of girIs of too amorous a disposition or of unfaithfu1 wives might be mutiIated by their irate fathers or husbands. Natu- raIIy enough, the victims of this brutaI Iaw sought the aid of surgeons who, it is recorded, were occasionaIIy summoned by the remorsefu1 fathers and husbands in an effort to atone for their momentary harsh- ness. Thus at first the art of pIastic surgery Aourished in India mainIy to correct nasa1 disfigurements infficted in the name of chastity, to heIp victims of a barbaric Iaw to Iive again the Iives of normaI human beings.

MutiIating the nose was aIso sometimes practiced on prisoners of war. One Indian potentate, a king of Ghoorka, having captured a hostiIe city, commanded that the noses of a11 the inhabitants, except those of infants and of aduIts who pIayed wind instruments, be cut off in order to remind them constantIy of his power. The conquered province henceforth was known as the City of Cut Noses.

Because it was apparentIy effective and easiIy performed, the mutiIation of the nose became eventuaIIy a stock punishment for various crimina1 offenses. It was simpIer and cheaper to disfigure a crimina1 than to keep him in jail. NaturaIly, this barbaric practice made much work for the corrective surgeons.

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These men, forerunners of the pIastic surgeons of today, operated in hoveIs. All around them was fiIth; GodIiness came

a prisoner by Tippoo, who cut off his nose and one of his hands. In this state he joined the Bombay army near Seringapatam, and is now a

FIG. I. Age 7. Right cheek, temple, and lower eyelid burned in fire. Contracture of scar produced hideous deformity with ectropion of right Iower Iid downward and outward.

before cIeanIiness. Their methods, of course, were crude, often brutal.

About 500 B.C., however, after constant experimentation with pIants, the tech- nique, Iater known as the Hindu method, of restoring the nose was deveIoped. This method consists of peeIing from the fore- head a strip of skin, one end of which is not severed. The strip is twisted so as to keep the outer layer-the epidermis-upper- most. It is then pIaced over the injured area and shaped to form a nose.

This Hindu method was described by two carefu1 observers in a Ietter to the GentIeman’s JournaI, London, for October, 1794. The operation which they witnessed was substantiaIIy the same as that evolved so many centuries earIier ! Their description is as foIIows:

“Cowasjee, a Maharaja of the caste of husbandmen, was a buIIock driver with the English army in the war of 1792, and was made

FIG. 2. Same case as Figure I. Preparation of tubed pedicle from right arm under general anesthesia. Two parallel incisions were made, creating a pedicle separated from the under- Iying tissues 2?$ inches wide and 6 inches Iong. Th e pedicle was transformed into a tube with raw surface outward by means of inter- rupted sutures of siIk. Roil of vaselinized gauze used to fiI1 hoIIow of tube. Wound dressed daiIy with vaselinized gauze after treatment with metaphen.

pensioner of the Honorable East India Com- pany. For about twelve months he remained without a nose, when he had a new one put on by a man of the brickmaker caste, near Poonah.

“This operation is not uncommon in India, and has been practiced from time immemorial. Two of the medica gentIemen, Mr. Thomas Cruso and Mr. James TrindIay, of the Bombay Presidency have seen it performed as foIIows:

“A thin pIate of wax is fitted to the stump of the nose, so as to make a nose of good appear- ance. It is then fIattened and Iaid on the fore- head. A Iine is drawn around the wax and the operator then dissects off as much skin as it covered, Ieaving undivided a small slip be- tween the eyes. This sIip preserves the circu- Iation tiII a union has taken pIace between the oId and new parts.

“The scar of the stump of the nose is next pared off. The skin is now brought down from

218 American Journal of Surgery MaItz-PedicIe Grafts

the forehead and being twisted half around, its edge is inserted into the raw stump so that a new nose is formed. A IittIe terra japonica is

into the light. Two SiciIian professors of the art, Branca and his son, have Ieft records of a number of cases of correcting exten-

FIG. 3. Two weeks Iater, second stage. ProximaI end of tube detached from arm, tube unroIIed and brought to point of repair of face with interrupted sutures of silk after scar of face was removed and everted Iid returned to normal anatomic position on face. PIaster of Paris cast appIied to chest and arm to prevent motion of skin flap. Wound treated daily for two weeks.

softened with water, and being spread on slips of cIoth, five or six of these are pIaced over each other to secure the joining. No other dressing but this cement is used for four days.

“It is then removed, and cIoths dipped in ghee (a kind of butter) are appIied. The con- necting slips of skin are divided about the twenty-fifth day, when a Iittle more dissection is necessary to improve the appearance of the new nose. For five or six days after the oper- ation, the patient is made to lie on his back; and on the tenth day, bits of soft cIoth are put into the nostrils to keep them open suffIcientIy.

“This operation is generaIIy successfu1. The artificial nose is secure, and Iooks nearIy as we11 as the natural one-nor is the scar on the fore- head very observabIe after a Iength of time.”

It was not unti1 the earIy Renaissance quickened the imagination of the civilized worId that pIastic surgery again emerged

FIG. 4. After two weeks cast removed, distal end of Asp detached from arm, arm brought back to norma position, repair of remaining defect in face completed with distal end of unroIIed tube. Picture shows resuIt eight months Iater.

sive Ioss of the substance of the nose by using fIaps of skin taken from the arm. Though their workmanship was compara- tiveIy crude, the resuIts of their operations appear to have been exceIIent.

It was the Renaissance, however, which produced the true father of modern pIastic surgery-the ItaIian, Tagliacozzi, who deveIoped methods which are stiI1 used in correcting facia1 defects.

A profound student of anatomy and human nature, TagIiacozzi heId the chair of surgery at the University of BoIogna. Though recognition came to him during his Iifetime, his work was constantIy impeded by the prevaiIing bigotry of the time. But to this Renaissance surgeon goes the indisputabIe honor of having contributed more to the study of restorative surgery than any of his contemporaries. Frequent use of skin from the arm for transpIanting to the face is the procedure for which he is chiefly remembered, and this technique is, in his honor, known as the ItaIian method,

NEW SERIES VOL. ?<LllI, No. I Maltz-Pedicle Grafts American Journal of Surgery 219

in

Of

contradistinction to the Hindu method ’ using a ffap of skin from the forehead. His methods were imitated by his

Such men branded him as an impostor and tried to discredit him. After his death his enemies succeeded in blackening his

FIG. 3. Burn of neck and left arm and axilla from fire, causing contracture of arm ax& and neck.

st udents and eventuaIIy gained ascendancy in the profession. There were, however, e\ ren in his own day, physicians who sup-

PC n-ted the cIergy in opposing Tagliacozzi.

FIG. 6. Same case as Figure 3. Prepared tube two weeks later. Cylindrical gauze supporting hoIIow of tube.

FIG. 7. Tube unrolled and brought to point of repair after scar of neck was excised. Cast keeps ffap immobile. Right arm used because Ieft arm and axiIIa were also scarred.

memory, and his methods lapsed tempo- rarily. Instead of transpIanted tissues, surgeons resorted again to primitive methods for remaking noses, using oil- cIoth, papier-machk, wood, or siIver.

Much that we know of TagIiacozzi’s work can be learned from his treatise on “The SurgicaI Treatment of MutiIations by Grafts,” pubIished in 1597, wherein he attributes his discovery of skin grafting to his knowledge of tree grafting. He discusses his method of repairing mutiIated Iips, noses, and ears, the pIace from which the skin graft is to be seIected, the quantity needed, and the method of joining it to the mutiIated parts. Though Iittle was known in his day of the psychoIogy of facia1 ap- pearance and of the effects of deformity on behavior, he explains, in the introduction to the treatise, that a beautifu1 face at- tracts, but an unsightly one 511s us with revulsion. He writes: “We restore, repair, and make whoIe those parts of the face which Nature has given but which Fortune has taken away, not so much that they may delight the eye but that they may

American Journal ot Surgery MaItz-PedicIe Grafts

FIG. 8. Result seven weeks Iater. Linear scar showing attachment of graft to neck stil1 visibIe.

FIG. IO. Same case as in Figure g. Showing tube brought to point of repair after preparation simiIar to that in two previous cases. Cast appIied to prevent motion of flap. Right arm used because Ieft arm was aIso burned.

FIG. I I. FinaI resuIt nine months Iater.

FIG. 9. Age IO. Face burned in fire, contracted scar producing downward and outward ever- sion of lower Iip and angIe of mouth, pIus distortion of chin.

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buoy up the Spirits and heIp the mind of the afIIicted. . . . We do this . . . as be- comes good physicians and disciples of that great Hippocrates.”

European surgeons were informed of the practice of this ancient art in India through a Ietter to the GentIemen’s JournaI aIready quoted. One of the first to adapt this infor- mation to the need of his cIienteIe was J. C. Carpue of London, who successfuIIy performed a number of simiIar operations in 1814. About the same time C. F. von Grafe in Germany successfuIIy empIoyed both the ItaIian and Hindu methods. SubsequentIy surgeons in France and America used the same methods. Ever since, surgeons have been perfecting and adding to the technique of the art of pIastic reconstruction.

Thus we see that pIastic surgery is probabIy as old as facial disfigurement. It is true; however, that never before was it practiced on so wide a scaIe as during and after the WorId War partIy because facia1 and bodiIy mutiIation exceeded a11 previous records and partIy because surgery had never before been abIe to cope so ade- quateIy with disfigurements.

Those injured in parts of the body other than the face offered the Iess serious prob- Iems, for their scars couId be covered by cIothing. But many others, with their features shockingIy mangIed, suffered the tortures of the damned. Fearing to con- front the worId again with distorted faces, they prayed for death. These men needed speedy reIief, if they were to escape ir- reparabIe psychic trauma. The surgeons working at the base hospitaIs on various head speciaIties united their ski11 in per- fecting oId methods and devising new ones to rebuiId these ravaged faces.

When the soldiers returned from Europe, their features reconstructed, they were abIe once more to find pIaces for themseIves sociaIIy and economicaIIy. Such adaptation wouId not have been possibIe had their faces stiI1 borne the ghastIy traces of their experiences in the War.

But times of peace aIso have their burden of accidents at home, in industry and on the highway and their corresponding need for corrective surgery by the utiIization of a skin flap.

Forehead flaps can be modified to suit each individual case. A flap can be taken from the neck or chest, from behind the ear, or from a more distant part, such as the arm, according to the Italian method, or even from the abdomen. But since the skin from these areas has to trave1 a con- siderabIe distance to reach its destination it is best for safety’s sake to do these pro- cedures in two stages. An attached trans- pIant from one of these sources is thus given the name of deIayed ffap.

A new procedure used with deIayed flaps was perfected by HaroId D. GiIIies of London during the World War. To insure the heaIth and success of the flap, he trans- formed its pedicIe into a tube by uniting its edges. It thus nourished itseIf in its own bIood, so to speak.

Though a distinct advance in the art of transpIanting skin, the tubed pedicIe has the disadvantage of curving on itseIf whiIe in tubed form and aIthough this tube is unroIIed when utiIized to cover a defect the tendency for the skin ffap to arch a bit remains. NaturaIIy this is more evident in narrower grafts. Here it is a definite dis- advantage when a defect of the face has to be repaired because it is difficult to make the arched skin grow ffat against the face. In addition, since it is necessary to cut into the fat of the tube in order to Aatten it out for use, a certain amount of injury to the tissue takes pIace in the smaIIer tubes.

To prevent this tendency for the ffap to cur1 the author has perfected a new technique in skin transpIanting by trans- forming the pedicIe into a tube with its raw surface outward instead of inward, the reverse of the GiIIies technique. With such raw surface outward the tube cannot grow together, and therefore no curIing of the skin ffap takes pIace. Besides, the raw

222 American Journal of Surgery Maltz-PedicIe Grafts

surface of the graft can be permitted to granuIate as much as is desired if a thicker graft is needed, thus obviating additiona surgery in the subsequent use of cartiIage fascia or fat.

It wouId appear that a tube with its raw surface outward is exposed to infection, but this is not vahd since proper care of the graft, Iike the proper care of any other

tissue in a surgical procedure, wiI1 avoid infection. *

The author has used this new method with success since 1933, presenting pre- Iiminary reports in 1934 and 1936.

*The interrupted sutures of silk forming the tube can be tied in such manner as to prevent union of the opposing edges of the wound. In such instances the stitches eventuaIIy “~~11 through” and the tube unrolls by itseIf by the time it has to be transpIanted.

THE maxiIIa is usually fractured by direct vioIence and this is often accompanied by damage to nasal, malar and IachrymaI bones.