SKIN PLASTICS

From Big Medical Encyclopedia

SKIN PLASTICS — operation of substitution of the defects of skin which arose later wounds, burns or operative measures.

History

To. by the item to recovery of a nose it was applied in Ancient Egypt and Ancient India for many years B.C. Plastic surgeries using To. items are described in A. Tsels's works. In 1597 in Bologna there was a treatise on plastic surgery of G. Tagliacozzi, in Krom the method of change on a leg of the skin rag taken on an upper extremity for substitution of the cut-off parts of the face, in particular for a rhinoplasty is described. To. the item gained further development in works of domestic scientists. Yu. K. Szymanowski in 1865 published the fundamental guide to plastic surgery of «Operation on the surface of a human body». In 1869 Zh. Reverden proved and made free skin transplantation. Russian surgeons P. Ya. Pyasetsky (1870), A.O. Yatsenko (1871), S. M. Yanovich-Chaynsky (1870), etc. was improved free To. item. Method K. the item a round skin stalk on the feeding leg which was widely used in plastic surgery developed in 1916 P. Filatov.

In 1930 Douglas (V. of Douglas), and in 1937 Dragetedt and Wilson (L. Dragstedt, H. Wilson) offered a method K. the item perforated skin rags which was improved during the Great Patriotic War B. V. Parin (1943), Yu. Yu. Dzhanelidze (1945), H. N. Blochin (1946). A new stage in development To. the item began after creation of a dermatome by Pedzhett (E. S. Padgett, 1939), M. V. Kolokoltsev (1947 — glue, 1952 — electric disk), allowed to make To. the item the split skin transplants of various thickness (see. Dermatomas ).

Distinguish primary and secondary (early and late) To. item. Primary it is carried out in the next few hours after wound, secondary — after formation of granulations (early To. item), ulcers it is also long not healing wounds (late To. item). Depending on a source of skin allocate autoplasty (see), homoplasty (see) and a heteroplasty (see. Heteroplasty, xenoplasty ); on sovr, the nomenclature a homoplasty — an alloplasty, a heteroplasty — xenoplasty.

Indications

To. to the item it is shown at the wounds which are followed by extensive defects of integuments (e.g., at scalped wounds of a shin, a brush, etc.), at once after surgical treatment or in later terms, after formation of granulations when it is not possible to impose on a wound secondary seam (see). To. the item is applied also to closing of the defects formed after excision of vicious hands, new growths, tubercular damages of skin at plastic surgeries in maxillofacial surgery, at operations for elephantiasis and malformations of extremities (e.g., syndactylias). Especially broad use To. received the item at treatment of burns for closing of the granulating wounds, after necretomies.

Contraindications

To. to the item it is contraindicated at serious condition, exhaustion of the patient, elevated temperature and considerable bacterial pollution of a wound.

Preoperative preparation

Preoperative preparation during the carrying out secondary To. the item has enormous value for engraftment of a transplant. It includes good high-calorific nutrition of the patient with enough proteins and vitamins, hemotransfusion, and also preparation of area of defect of the fabrics which are subject to closing. At it is long not healing wounds and ulcers preparation to To. the item includes clarification of a wound surface from necrotic fabrics, elimination of pathogenic microbic flora and acute inflammatory process. With this tselyo apply treatment by bandages with various antiseptic solutions, streptocides, antibiotics and enzymes taking into account staging of process of healing of wounds. Granulations and hems exsect, carefully process a bottom of an ulcer or wound. To. the item of fresh wounds is carried out after full-fledged surgical treatment.

To. the item is carried out under local or general anesthesia.

Methods

Are offered the following methods K. the item — free, not free on the feeding leg and combined. At free To. items completely separate sites of skin from the donor site and replace to area of defect. Distinguish at free skin transplantation change by the split and full-layer skin transplant.

Free skin plastics

Zh. Reverden (1869) replaced small sites of epidermis of 2 — 6 mm to the granulating surface 2 . S. M. Yanovich-Chaynsky (1870) replaced skin transplants the sizes 4 — 12 mm 2 , the containing epidermis and a part of a derma, for the first time with success having applied this method K. the item for closing of defects after gunshot wounds. Davis (J. S. Davis, 1914) replaced the skin transplants including up to 3/4 all thicknesses of skin. Tirsh (To. Thiersch, 1874) offered To. the item the thin split transplant containing only epidermis. Small thin strips of epidermis cut off a special knife and replaced to the granulating wounds. Ollye (L. Oilier, 1872) made plastics transplants of the big sizes, to 4 — 8 cm 2 , later it applied for To. the item transplants in all thickness of skin. V. P. Blair and Brown (J. Century of Brown, 1929) applied a manual way of splitting of skin, with the help to-rogo them it was succeeded to receive dermoepitelialny transplants of various area 0,3 — 0,4 mm thick. Was widely adopted dermatomny To. the item split calibrated, i.e. in advance planned thickness, a transplant. In our country To. items are devoted by the split dermatomny transplant works of H. N. Blochin, B. A. Petrov, M. V. Kolokoltsev, E. I. Shumilkina, T. Ya. Aryev, A. K. Tychinkina and other surgeons. At dermatomny To. items stack thin skin transplants on previously prepared wound surface and cover with a compressing bandage. On second day surely make careful change of a bandage in order to avoid the shift of a transplant by the dried bandage. Thicker dermatomny transplants apply to the purposes K. the item on a face, palmar surfaces of brushes, in joints and bottom surfaces of feet. The site of skin used for plastics (donor) is covered with a sterile bandage; it can be reused for To. the item in 8 — 10 days, and if necessary repeatedly that especially important at treatment of extensive burns.

B. A. Petrov (1950), Moul (R. Mowlem, 1952) and Jackson (D. Jackson, 1952) after extensive burns applied to closing of wounds To. the item tape-like alternating split auto-and gomotransplantatam. To. by the item it was made at the end of the 3rd week after a burn. Auto-and gomotransplantatam all wound surface was closed. Gomotransplantata slowly resolve, autografts, gradually expanding in the parties, cover granulations. Apply thin rags 0,1 — 0,2 mm thick; they are replanted better, than thick, do not demand fixing to edges of a wound and almost retractions are not exposed. At an insufficient stock of skin, at extensive burns of Gabarro (P. Gabarro, 1943) the «branded» way K offered. the item — the small rectangular transplants placed on a wound surface with various intervals.

Full-layer free To. item. Lawson (G. Lawson, 1870) and A.S. Yatsenko offered (1871). Sizes of transplants of 2 — 4 — 6 mm 2 . F. Krause in 1893 applied for To. the item transplants to 20 — 25 cm 2 .

P. Ya. Pyasetsky (1870) for the best engraftment immersed skin transplants in holes which previously made in granulations. This «submersible» method of skin transplantation was improved later by Brown (W. Braun, 1920) and Alglavom (P. Alglave, 1927). Brown replaced small epidermal transplants a needle under granulations. Alglav immersed full-layer skin transplants under granulations or in the holes created by a scraping of granulations. The perforated rag sieve is applied to closing of big defects of skin. Douglas put circular notches in the beginning in the field of a transplant then the skin rag otseparovyvat, leaving round sites of skin for epithelization of a donor wound. Dragstedt and Wilson on a skin transplant made linear cuts. The donor wound was sewn up tightly. Creation of openings in a transplant promoted good drainage of a wound and allowed to increase the area of a transplant.

One of versions full-layer free To. the item is replantation on a wound of the skin rags which are completely torn off at the time of an injury, the offered V. K. Krasovitov in 1935. The method of replantation of skin rags across Krasovitov at scalped wounds of the head, extremities with success is applied in an urgent surgery. At pollution scalped skin is washed with soap and a brush in running water, oil stains delete with ether then the skin rag is immersed in solution of Rivanolum.

Hypodermic cellulose is deleted by means of a dermatome, the skin rag is dried up and replaced to a wound. Replantation of skin is admissible during 6 hours after wound, however the methods allowing to extend considerably terms of preservation of viability of the separated skin rag are developed.

Not free skin plastics

Fig. 1. The diagrammatic representation of mobilization of edges of a wound by use of additional (aperient) cuts during the closing of various defects to» and (aperient cuts are designated by a dotted line, on the right or from below in drawings the type of seams after closing of defect is shown): 1 — the section parallel to edge of defect; 2 — small notches on each side from defect; 3 — the continued cuts at defects of an oval form; 4 — the cuts forming a movable rag; 5 and 6 — the continued cuts for closing of triangular and rectangular defects; 7 — 9 — options of cuts for closing of round defects.

Not free skin plastics includes plastics local fabrics and transplants from the remote parts of a body on the temporary feeding leg. To. the item is carried out by local fabrics by mobilization of edges of a wound or by means of additional (aperient) cuts (fig. 1). For the prevention of a tension of edges apply one or two parallel sections on them. Apply also small notches on all thickness of skin near a wound. At the big sizes of a wound apply movable figured ways K. item. Various options of slits are developed for closing of round defects and wounds of various form (oval, triangular, rectangular), and also movable rags for plastics of square defects — according to the offer Yu. K. Szymanowski (1864).

Fig. 2. Diagrammatic representation of consecutive stages of skin plastics counter rags: 1 — the defect of skin which is subject to closing; dashed lines designated future additional cuts; 2 — additional cuts are made; 3 — the dotted line planned places of crossing of skin crossing points at tops of rags; 4 — rags of an otseparovana to the basis; 5 — rags are moved: right (upper) to the left and from top to bottom, left (lower) — to the right and up, the directing stitches are put; 6 — defect is closed.

To. to the item counter movement of adjacent triangular rags it is recommended by A. A. Limberg in 1963; it is applied to closing of defects of skin after excision of the pulling together hems in joints of extremities, the person, small tumors of skin, and also at is long not healing wounds of an extremity. Triangular rags find from skin together with hypodermic cellulose so that corners of their tops were equal 30 — 45 or 60 °. Triangular rags with a corner 30 ° apply on a face where it is better than a condition of blood supply. On extremities recommend to apply rags with a corner 45 or 60 ° at which blood supply is better provided. Rags otseparovyvat and after a hemostasis mutually move and pull together seams without tension (fig. 2).

Fig. 3. Closing of extensive defect of skin of a back of the hand by means of a bridge-like rag (it is specified by an arrow) from integuments of a front surface of a stomach.
Fig. 4. The diagrammatic representation of closing of defect of skin of a cheek with a rag on the feeding leg (the Indian way): the rag (1) is taken near defect of a cheek, on a neck, on this place seams are visible (2); the feeding leg (3) is crossed after engraftment of a rag.

Bridge-like way K. the item consists in closing of skin defects by means of the bridge-like rags including skin and hypodermic cellulose. For closing of wounds of a brush or a forearm the bridge-like rag is found from integuments of a front or side surface of a stomach (fig. 3). To. items on a leg apply also to closing of wounds in joints by movement of a skin rag, adjacent to a wound (the Indian way). Rather seldom (generally at big ventral hernias) cutis-subcutis recommended by S. P. Shilovtsev is applied.

N. V. Almazova (1923) applied the combined methods Indian way for plastics of defects of fabrics on a face (fig. 4). This method K. items apply also to closing of defects of a stump of an extremity. The wound surface which is formed on site the moved rag is closed if necessary the split skin transplant. At Italian way the rag on the feeding leg is found in areas of a body, remote from defect. The method is applied more often to closing of skin defects on extremities (a brush, a shin, foot). The first stage of operation includes cutting out of a skin rag, mending of a donor wound and fixing of a transplant to edges of skin defect. At the second stage cut his leg (after engraftment of a rag). By means of the Italian method K. the item is possible to close skin defects of 45 — 70 cm 2 .

Apply to closing of more extensive defects combined To. items, at a cut close a bed of a rag the split transplant. One of ways combined To. the item is Tychinkina's method including three stages. Originally find a skin rag with the wide basis and otseparovyvat it from the subject fabrics. The wound surface of the feeding leg of a rag and all area of a wound of the donor site are closed the split skin autograft then the found rag is returned into place and fixed seams. In 2 weeks the rag is repeatedly separated from a bed, delete granulations on its inner surface and hemmed to the refreshed edges of defect. In 4 — 5 weeks cut the feeding leg. This method is especially shown during the closing of defects on the «working» surfaces of extremities»

the Way of plastics round skin stalk of Filatov was widely adopted at plastic surgeries in maxillofacial surgery for substitution of various defects of the person, on a brush, at fistulas of a throat, gullet, throat.

Fig. 5. The most frequent places of cutting out of a bucket-handle graft.
Fig. 6. Diagrammatic representation of a buffer stage of plastics bucket-handle graft: the bucket-handle graft is replaced by one end to a brush, the leg of a stalk at other end is pressed by a clip for the purpose of a training of blood circulation.

N. A. Bogoraz applied a bucket-handle graft to creation of a penis. The bucket-handle graft can be formed in various areas of a body (fig. 5). For formation of a rag carry out two parallel sections so that length 3 — 4 times exceeded width of a transplant. After separating the skin wound is sewn up, create a stalk by imposing of noose silk sutures of a rag. Especially carefully create edges and legs of a stalk, without allowing a tension of seams. In 12 — 14 days one of the feeding legs of a stalk is cut and replaced to area of defect if the stalk is located near defect. At an arrangement of a stalk at considerable distance from defect the end of a stalk is replaced to a brush or a forearm in the beginning, and through a nek-swarm time other its end is replaced to area of defect. Before migration of a stalk carry out test for assessment of a condition of blood supply, drawing the basis of the remaining leg a thin rubber plait. Also the training of blood supply of a stalk by crossclamping of a leg 2 — 3 times a day is applied, gradually increasing time of an applying a tourniquet or clip of 5 min. to 2 hours during 2 — 4 weeks (fig. 6). On a brush do the semi-lunar section corresponding to the sizes and a form of the end of a stalk. Possibly closer to the basis of a stalk tsirkulyarno cut integuments, excise cellulose throughout 1,5 — 2 cm then cut the end of a stalk, immerse and fix it catgut seams to a bottom of a wound of a brush. On skin of a stalk and a wound of a brush impose noose silk sutures. The second leg of a stalk is cut in 6 weeks and make plastics of defect. Implantation of one leg or serially implantation of both legs of a stalk near defect with the subsequent plastics of defect can be applied to closing of defect in the beginning.

For rhinoplasty (see) figured stalks are offered: four-web-footed, in the form of a letter «T», a cross with formation of three stalks on one end, etc.

Depending on the purposes of plastics make a full or partial raspravleniye of a stalk for closing of defect. The skin hem is excised along a stalk, the section is deepened, cut concentric unions and slits cut and partially or completely excise hypodermic cellulose.

During the performance of rhinoplasty the stalk is completely exempted from hypodermic cellulose, keeping feed vessels. During the carrying out a meloplasty with the cosmetic purpose for recovery of contours, and also at plastics of bottom surfaces of foot hypodermic cellulose is left in necessary quantity. For a tamponade of bone cavities use a distal part of a stalk after excision of skin. The proximal site of a stalk is straightened and applied to closing of skin defect.

The average duration of plastics the migrating round bucket-handle graft is equal to 3 — 6 months. It includes five stages: formation of a stalk (2 — 4 weeks), migration of a stalk on a brush (4 — 6 weeks), transfer of a stalk from a brush on defect (4 — 6 weeks), cutting off of a stalk from a brush and a rasplastyvaniye on defect (3 — 6 weeks) and korrigirovany legs (3 — 6 weeks).

A lack of plastics a bucket-handle graft, except duration, is distinction in color of skin of a stalk and skin around defect that matters during the carrying out plastic surgeries (see) on a face. L. M. Obukhova with the cosmetic purpose suggested to make a deepitelization of a stalk at face lifting. After excision of an epithelium there is a gradual formation of a thin flat pinkish hem. The stalk accepts the coloring close to complexion.

V. P. Filatov offered, except typical, a so-called acute stalk with one feeding leg. One end of an acute stalk remains free or can be used for closing of defect; thanks to good blood supply such stalk is used also for creation of difficult transplants.

Later To. items and on area of a skin transplant apply a bandage a donor wound, to-ruyu for the prevention of drying and simplification of change recommend to moisten with fir balm. Seams remove on 6 — the 8th days

Outcomes

the Most frequent complications To. items are suppuration, a partial or full necrosis of a transplant. They are observed at a tension and insufficient vascularization of a transplant. According to most of authors, engraftment of skin transplants comes in 90 — 96% of cases.

See also Incompatibility immunological , Burns , Plastic surgeries .



Bibliography: Aryev T. Ya. Thermal defeats, L., 1966; Blochin H. H. Skin plastics, M., 1955, bibliogr.; B at r and and N F. The atlas of plastic surgery, the lane from Czeches., t. 1 — 3, Prague — M., 1967; In and l of e with about in S. P., D m and t r and e-in and 3. E. and To r at of l and to about in E. I. Primary and delayed skin plastics at damages of a brush and fingers, M., 1973, bibliogr.; Dzhanelidze Yu. Yu. Free skin transplantation in Russia and the Soviet Union, L., 1952, bibliogr.; Zoltan Ya. of Cicatrix optima, the Operational equipment and conditions of optimum healing of wounds, the lane with Wenger., Budapest, 1977; To about l of e with N and to about in I. S. and In and x r and e in B. S. Operational treatment of deep thermal burns, M., 1962, bibliogr.; Kolokoltsev M. V. A dermatome and its use at free skin transplantation, Gorky, 1947; L and m e r A. A. Planning of mestnoplastichesky operations on a body surface, L., 1963, bibliogr.; P and r and B. V N. Skin plastics at traumatic damages, M., 1943; Petrovb. A. Free skin transplantation at big defects, M., 1950, bibliogr.; Petrovsky B. V. and Krylov of V. S. Mikrokhirurgiya, M., 1976; Povstyanoyn. E. Plastic surgery of burns, M., 1973, bibliogr.; You chink and on A. K. Kozhnoplasticheskiye of operation, M., 1972, bibliogr.; Filatov V. P. Plastics on a round stalk, Vestn, oftalm., t. 34, No. 4-5, page 149, 1917; X and t r about in F. M. Defects and cicatricial fusions of a throat, cervical department of a gullet, throat, trachea and technique of their elimination, M., 1963, bibliogr.; Szymanowski YU. K. Operations on the surfaces of a human body, Kiev, 1865; Itsenko A. S. To a question of transferring or an inoculation of the separated pieces of skin to granulyatsionny surfaces, a yew., SPb., 1871; BohmertH. Hautersatz bei Verbrennungen mit Spalt-hautnetztransplantaten und Xenotrans-plantaten, B., 1974, Bibliogr.; B r ii with lene r H. Stiellappenplastik bei chronischen Unterschenkelwunden, Lpz., 1970, Bibliogr.; Chintz G. Grefa de piele libera, Bucure§ti, 1974, bibliogr.; Douglas B. Sieve graft-stable transplant for covering large skin defects, Surg. Gynec. Obstet., v. 50, p. 1018, 1930; Padgett E. C. Calibrated intermediate skin grafts, ibid., v. 69, p. 779, 1939; Reconstructive plastic surgery, ed. by J. M. Converse, v. 1, Philadelphia, 1977; R e v e of d i n J. - L. De la greffe epidermique, Arch. gen. Med., t. 19, p. 276, 555, 703, 1872.


D.F. Skripnichenko.

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