Thiersch Grafts Research Articles

Epithelial grafting for vitiligo requires ultraviolet A phototherapy to increase success rate

Phototherapeutic techniques were introduced into medical practice by the ancient Egyptians. It is considered a cornerstone in the management of resistant vitiligo; yet, failures are very well known. Recently, the introduction of surgical techniques provided a major development in the management of vitiligo and replaced other conventional unsuccessful therapies. The aim of this work is to find out if phototherapy, which failed to resolve the vitiligo problem in patients, is still required in the treatment strategy after epithelial grafting of the same cases. Twenty-five vitiligo patients, nonresponding to classic phototherapy, were treated surgically. Ultrathin Thiersch grafts and suction blister grafts were used. Phototherapy using ultraviolet A (UVA) bulbs in combination with psoralen or khellin was used postoperatively immediately after take of grafts onto recipient sites. In spite of reactivation of depigmentary effects at grafted areas, phototherapy acted as a stimulator for melanocytic proliferation and function and as an immunosuppressant, halting the melanocytic destructive process. The application of UVA phototherapy resulted in successful treatment in the patients receiving it. The success of epithelial grafting in patients with vitiligo can be increased by UVA phototherapy.

Sphincter replacement grafts

An anal sphincter replacement graft can be carried out when sphincter lesions occur after unsuccessful conservative or other treatment. Today, two different techniques are used to take over the function of the sphincter. The dynamic gracilis graft can be carried out if a non-atrophied,well innervated m. gracilis is present. This technique is carried out on patients whose incontinence is the result of a trauma,pudendopathy or imperforate anus. It can be extended to the construction of a neo-anus after abdominal resection. The artificial anal sphincter is used whenever the previous method fails or can not be used due to a non-vital, denervated or the lack of the m. gracilis. Older methods such as non-stimulated gracilis, glureus or Thiersch grafts are not commonly used.

Isolierte Verbrühungen und Verbrennungen an Händen im Kleinkindesalter*

Every year about a hundred children with burns and scalds are hospitalised in the Burns Unit of the University Children's Hospital in Zürich. 15% of these patients are children between 1/2 to 4 years old with isolated burns and scalds of their hands. The experience gained in the treatment of 53 such children during 4 years is described. The burn healed spontaneously in 31 patients; in 22 cases Thiersch grafts had to be used. In the follow-up treatment compression suits and special splints to prevent secondary contractures were employed. The results of this treatment using splints and compression suits are discussed.

Long-Term Therapy of Second and Third Degree Burns in Children Using Jobst-Compression Suits

Thirteen children, aged between 2 1/2 and 14 years, with full-thickness burns are presented. These children were treated with compression suits according to the method developed by the Jobst Institute in Toledo, Ohio. The material manufactured in Switzerland is described and the advantages and disadvantages of this material are discussed. Group I comprised 8 children who were fitted out with the suit directly after the burns had healed. These were all scalds covering 11 to 30% of the body surface and necessitating Thiersch grafts. Group 2 comprised 5 children who were only fitted with this suit 3 months to 2 years after the original accident. By that time they had all developed massive, hypertrophied scars, limiting flexion and extension of the joints. In the first group the skin colour rapidly returned to normal, the development of hypertrophic scars was not marked and these scars had a definite tendency to regress. Nine of ten affected joints either became normal or showed a considerable improvement in function. In the second group, 19 of 25 affected joints had become normal one year after the suits had been fitted and four showed definite improvement. Here the scars regressed, although admittedly slower than in the first group. The children appeared to wear the suits without discomfort or trouble.

JAMA 75 Years Ago

To the Editor:— In the Journal's reprintings from 75 years ago two recent issues have recounted procedures which today would fall under the heading of plastic surgery. The first was Cosmetic Surgery of the Nose from Aug 20, 1892, and reprinted in the Aug 21, 1967, issue. The second, on the topic of Thiersch's grafts from Sept 10,1892, was reprinted in the Sept 11, 1967, issue. Each of these was written originally in the first person, and it was difficult to understand why the authors' names were not given when reprinted. From a visit to the library I found that the first had been written by John B. Roberts, MD, of Philadelphia, one of the leading general surgeons of the day, with a special interest in correction of deformities of the face. I succeeded Dr. Roberts as professor of maxillary surgery at the Philadelphia Polyclinic, in 1920. This hospital later

Bacteriology of chronic otitis media. Results of analyses from the ear canal and from the operative cavity.

SURGERY of the chronic has aroused considerable interest during the last few years, and many new techniques have been developed to obtain a more permanent and satisfactory end result by operative intervention. During the past decades, up to 1960, the general trend was to make an open mastoid cavity, possibly covered with Thiersch's grafts, full-thickness grafts, or left uncovered. Bacterial examination of the discharge was not considered absolutely essential since, even if the postoperative cavity became infected and remained so, there was a free outlet for discharge into the external meatus and out of the ear. During the last five years the attitude of ear surgeons has changed essentially owing to their discontent with open mastoid cavities. In most clinics particularly interested in ear surgery, the operation is now completed with reconstruction of the drum and meatus, and the mastoid cavity is excluded from meatal connection by various means.

Behaviour of intracerebral autografts of mouse tail skin pre-treated with a single application of 20-methylcholanthrene.

THIERSCH grafts of tail skin from 30 mice of various strains and both sexes were implanted intracerebrally in an attempt to produce an expanding, space-occupying, intracranial lesion, and to investigate its effect on the surrounding brain, with particular reference to ‘cerebral oedema’. The autografts, which were cut with a Castroviejo keratome set to a thickness of 0.2 mm, measured approximately 3 mm × 1 mm. Immediately after removal they were inserted into the right cerebral hemisphere with a blunt probe, through a small hole made over the lateral aspect of the skull with a dental burr. All operative procedures were performed under ‘Nembutal’ anaesthesia.

Surgical Uses of Charged Gold Leaf

<h3>To the Editor:—</h3> It was exciting to learn of the revival of interest in the surgical uses of gold leaf as described by Gallagher and Geschickter (<i>JAMA</i><b>189:</b>928 [Sept 21] 1964). In reviewing the literature they speak of the scant references to the use of gold for any purpose. I first learned of the protective, adhesive, and antiseptic properties of goldbeater's foil in 1925 when I was surgical assistant to the late Dr. George H. Semken. He introduced me to its use as the covering for both the donor and the recipient sites in Thiersch grafts and larger split-skin grafts. The extensive cancer dissections (in which he was a pioneer) frequently required skin grafting for complete closure of denuded areas; for these procedures he always had available a book of sterilized gold-leaf foil and a thin, broad, flat brush of the type used by sign gilders. The static charge

IT IS WORTH LOOKING AT CLOTHES.

We both missed the diagnosis in these two patients, but if we had examined their clothes we would probably have got it right. So we report them to make the point that it is sometimes worth looking at clothes as well as the bodies they hang on. Polonius said, apparel oft proclaims the man. We want to add, and, not very oft, proclaims his disease. Case 1. —A photographer, aged 29, attended in April, 1961, with crops of painful ulcers on his legs (Fig 1). The ulcers had started three years previously, after both legs had been skin grafted for burns following a motorcycle accident, and had recurred at intervals ever since. Because they were painful and would not heal, they were treated with Thiersch grafts. The excised tissue showed: Sloughs, with occlusion and necrosis of blood vessels and cellular infiltration with granulation tissue at the floor of the

The Human Haarscheibe, Its Structure and Function

The human haarscheibe (Hs), first described by F. Pinkus (1), was stained supravitally with methylene blue, and the report included a description of the supravital methylene blue stain and a discussion of the innervation, microscopic structure, and phylogenetic significance of the structure. Tamponi (2) studied it scrupulously in whole-mount Thiersch grafts stained with methylene blue. Without knowing the work of Tamponi, Kawamura (3) reexamined this structure and regarded it as a touch receptor organ. The purpose of this paper is to call attention to the significance of the Hs which occurs in about every fifth hair group on the trunk (4).

A clinical and histological investigation into the fate of epithelial elements buried following the grafting of “shaved” skin surfaces: Based on a study of the healing of split-skin graft donor sites in man

Summary Histological and clinical evidence is submitted that:— 1. The rate of quality of healing of split-skin graft donor sites is improved by the application of Thiersch grafts. 2. The burying of epithelial elements in the operation of shaving and skin grafting is followed routinely by the formation of microscopic epidermoid cysts, but that these undergo spontaneous dissolution within a year in the vast majority of cases. In only 3·4 per cent. of patients did clinically persistent epidermoid cysts require operative removal. 3. Following the application of Thiersch grafts to areas of partial thickness skin loss, some host sweat glands regenerate to discharge their secretion to the surface, but most do not: the latter, though continuing to survive and function, probably have their secretion internally resorbed into the local circulation. Under the same circumstances only a minimum number of hair follicles survive as functional units.

Simple Method of Cutting Full-Thickness Skin Grafts of All Sizes and Shapes

THE FREE transplantation of full-thickness skin grafts has the advantage over the tubed and pedicle flap method in that it saves much time in the course of operative treatment. This method of free transplantation is indicated in cases in which all conditions are aseptic and in which the stuffing of unnecessary subcutaneous fat is not desired. Thiersch and Reverdin grafts can be used without hesitation on clean granulating areas, but full-thickness grafts can be used only on aseptic and even surfaces of host tissue. The main advantages of the full-thickness grafts over Thiersch and Reverdin grafts are that they have good functional and resistance powers and produce excellent cosmetic results. The greater the thickness of the graft, the less will be the changes in pigmentation. One may say that there is danger of necrosis in the use of free full-thickness grafts, but this could be avoided by proper technique and

ARTIFICIAL VAGINA

THE SURGICAL creation of an artificial vagina still intrigues the medical profession. In the past 135 years, countless and tedious methods have been devised only to be discarded because of the magnitude of the procedure and/or the inability to cope with the serious complications. Dupuytren in 1817, Villaume in 1829, and Amussat in 1832,1made a simple opening between the bladder and rectum but could not satisfactorily maintain its caliber. Eventually, methods and materials for lining the pouch were outlined. Free skin flaps, strips of vaginal mucosa from other patients, intestinal wall from both the small and large bowel, hernial sac lining, guinea-pig intestine, peritoneum, fetal membranes, and, lately, Thiersch grafts have been utilized. Heppner, Gersung, Baldwin, Schubert, Graves, Wharton, Falls, Counsellor, and Frank contributed techniques to this end. While all these methods were initiated by the dissection of the area between the bladder and rectum, their greatest differences

Congenital absence and traumatic obliteration of the vagina and its treatment with inlaying thiersch grafts

A brief review of the operative procedures for the correction of congenital absence or traumatic stricture of the vagina is presented. Some of the disadvantages associated with pedicle grafts and the risk involved in using any part of the intestinal tract are stressed. The McIndoe procedure is the operation of choice by reason of its simplicity and practicability. I have added certain modifications to this procedure which seem to me to be sound and useful.Five patients with congenital absence of the vagina and two with traumatic stricture of the vagina were treated successfully and without mortality by this method.

BALLOON TAMPON AFTER RADICAL MASTOIDECTOMY

Twenty-five years ago I was taught to pack every radical mastoidectomy cavity with iodoform gauze. This procedure was carried out for many weeks and months, gave untold suffering to the patient and tried the patience of the surgeon. After that came the use of stents, mostly those made from paraffin or some form of wax. They were a decided improvement and are still much used. In skin grafting it has been a problem to hold the grafts in place. Dench used small Thiersch grafts held by tiny pellets of cotton dipped in an antiseptic powder. This method has merit but is time consuming and laborious. It occurred to me that it is much simpler to use a sterilized finger cot and blow it up with air from a syringe, tying off the neck with silk and doubling it over so that air may be well retained. After the grafts are

OPERATION FOR RETENTION OF AN ARTIFICIAL EYE AFTER EXENTERATION OF THE ORBIT

It was Bartisch¹who introduced the medieval and Arlt²the modern method of exenteration of the orbit. To overcome this dreadful deformity, Axenfeld³suggested the operation in which the conjunctiva, lids and hair lines are preserved. Later the conjunctiva and lids are sutured. Other surgeons, Küster,⁴Busache,⁵Rollet,⁶G. Worms⁷and Romano Catania,⁸used mucous membrane grafts, skin flaps, Thiersch grafts and sliding skin flaps to obviate the deformity without the introduction of a prosthesis. Few surgeons, however, have attempted to correct this deformity so that an artificial eye could be worn. Pólya⁹conceived the idea of introducing artificial bone into the orbital cavity and suturing the lids over it. In this manner a support is obtained for a prosthesis. Probably the best known procedure is the operation devised by Golovine,¹⁰in

RECOVERY OF SENSATION IN DENERVATED PEDICLE AND FREE SKIN GRAFTS

The literature on the recovery of sensation in transplanted skin is extremely scanty. In 1899, Stransky1reported a few observations in eleven cases of pedicle flaps and Thiersch grafts in which he described a return of tactile sensibility as early as ten days after transplantation. Dubreuilh and Noel2made a few incomplete observations in eleven cases of Wolfe grafts, and found that superficial sensation recovered in about a year. Williams3described the presence of impaired sensation in a Thiersch graft thirty years after operation. Davis and Traut4made the brief statement that recovery of sensation begins at the periphery of all types of skin grafts in four or five weeks, and that tactile sensibility is restored first, followed by pain and temperature sense. Their method of testing and specific cases are not described. While recovery of sensation is not of major importance in the late results

The Management of the Swollen Arm in Carcinoma of the Breast

The terms “brawny arm” and “lymphedema” have been given to the swollen arm which may complicate the inoperable, recurrent, or postoperative case of mammary cancer. Referring to those patients who have been subjected to radical mastectomy and have subsequently developed this unfortunate sequel without recurrence, Halsted coined the term elephantiasis chirurgica (surgical elephantiasis). In about 10 per cent of those with advanced mammary cancer edema of the arm occurs on the side of breast involvement. Lymphedema is more common where recurrence has followed surgery and is most frequently observed as a sequel to the radical operation, even if there has been no return of the disease (25 per cent). Brawny arm was formerly considered due to compression of the axillary vein by tumor tissue, and this view may be substantiated in certain cases. The axillary vein, however, may be excised in most instances without causing more than transient edema of the arm. This swelling is soft, in contrast to the brawny induration which is a result of lymphatic obstruction. The extirpation of the axillary lymph nodes and vessels is not wholly responsible for stasis. This complication arises when the smaller lymphatics about the shoulder have been occluded by the infiltration of tumor tissue or the fibrosis following irradiation, or postoperative infection. Halsted was convinced that postoperative infection was responsible for lymphedema when there was no recurrence of the disease. For this reason he advised loose approximation of the skin edges and Thiersch grafts in all cases where radical mastectomy was performed. He argued that necrosis of the edges of the incision followed the closure under tension and necrosis led to infection of the operative field. A low-grade streptococcal infection will cause a fibrosis of the lymph channels and once this is present in the skin there is a predisposition to subsequent attacks. A vicious circle is established.

Subcutaneous plates and knives for cutting large thiersch grafts for plastic surgery, designed at the suggestion of Mr. D. H. Gillies

Subcutaneous plates and knives for cutting large thiersch grafts for plastic surgery, designed at the suggestion of Mr. D. H. Gillies

A NEW THIERSCH GRAFT RAZOR

Plastic surgery is exacting in all its requirements; always so as to technic, often so as to instruments. Skin grafting is exacting in both regards. The greatest difficulty one has in cutting Thiersch grafts is in procuring a satisfactory cutting instrument. I have devised a knife that is simple and inexpensive and that serves the purpose well, giving a sharp edge at all times. It can be made in a few minutes, if necessary, from materials procurable anywhere. From the guard of a Durham Duplex safety razor, I removed the teeth from the left side at the line where the teeth join the body of the guard. This straight edge was then beveled, and the outer end was also beveled to facilitate the removal of the grafts from the knife. This completes the instrument. A guard which has a wider surface than the one ordinarily supplied may be provided.