Free skin grafting

Abstract

Our interpretation of fundamental factors involved in free skin grafting have been presented with the aim of extending the usefulness of this simple operative procedure. These fundamental factors involve theoretic and factual considerations of epithelial and secondary tissues. The epithelial and cardiac tissues we believe are the most important fundamental tissues in the body; the epithelial tissues keep us wet animals, the cardiac tissues circulate this wetness. Barring specific disease, these tissues will survive at the expense of all other tissues in order to serve the body and work for body needs until the last remote chance of repair is gone. We make use of the vital characteristics of the type of epithelium we are dealing with, the epidermis (ectodermal epithelium), in determining the time to operate, our operative procedure and postoperative care. The time to perform a free skin graft operation is when the patient can withstand a simple operation; we are not concerned with the ability of the epidermis to survive. It will survive if applied to a suitable base properly and at the expense of the body if need be. Establishing a minimum of body economy as to blood count, hemoglobin, etc., leads to needless delay in free skin grafting. Loss of vital fluid incident to this delay causes degenerative processes in vital organs. The plane of body efficiency is lowered and the patient reverts to the picture of starvation. We classify granulation tissue in the category of free skin grafting as useful, useless and pernicious. It is useful in the first stages of its appearance when the collagenous tissue base is minimal; useless at a later date because a better base can be obtained if the granulation and collagenous tissues are removed; pernicious still later because the healthy appearance of the firm, flat granulations belie the thick layer of strangling collagenous tissue beneath. The reason why the granulations are firm and flat is because the collagenous tissue is at a late stage of maturity, the bed is strong and firm and the capillaries are partly occluded by organizing immature scar. The epidermis has no direct blood supply. It lives on overflowing springs of tissue fluid. This fluid filters through a delicate white fibrous tissue feltwork of the dermis to the epidermis. Our operative procedure is designed to provide optimum conditions for the body to reconstruct from secondary tissue something similar to this fine feltwork which has been lost. For this reason the firm, heavy blanket of secondary tissue found lying on the major supply of necessary nutrition is removed. This allows the body to reconstruct something of secondary tissue, more in keeping with the missing, delicate veil of primary tissue. We believe that success in free skin grafting depends upon the internal fixation of the graft to the host by a physiologic glue, the clot. We do not believe that it depends upon the external pressure of bandages in an attempt to achieve the same result. General, special, local and refrigeration anesthesia are used. As to thermal anesthesia, we follow the method suggested to Dr. Eastman Sheehan and ourselves by Dr. Frederick Allen, i. e., to apply ice bags continuously for two hours prior to operation over the donor site and the area to be skin grafted. We have not been able to sterilize granulating areas surgically by any means other than by their total destruction with a corrosive agent. Since we do not use granulation tissue for skin grafting, its loss is of no moment. Donor sites are unbandaged except for a single layer of gauze which is placed over the wound. Postoperative care, except for general supportive measures, is confined to means of protecting the grafts. A variety of methods may be used.