Dobrev, M.

Stoyanov, S.

English

Varna Medical University Press: Journals

FREE SKIN PLASTY IN TRAUMATIC LESIONS OF THE LIMBS M. Dobrev, S. Stoyanov One of the most effective methods in treating traumatic skin defects is the t imely performed free skin grafting (skin plasty) . I t s scope of application i n the routine surgical practice is steadily increasing. Over a period of five years, free skin grafting was resorted to in 350 pa-tients — 275 men and 75 women. I t was used mostly in hand injuries — 270 patients or 73.40 per cent. Of the total number of plastic repairs, 58 fal l to the thumb, and 54 — to the index finger. S k i n plasty of the thumb and in-dex was done in a total of 112 patients, which makes 32 per cent of the total number of patients operated on, and 43.60 per cent of traumatic hand lesions where skin plasty was indicated. S k i n plastic repairs in the leg rank second after the hand in terms of frequency. T h i s particular type of skin plasty was applied on emergency indications in case of l imited skin defects, or else, as a planned intervention in case of rather extensive involvement. I n planned operations the skin defect was resurfaced following removal of necrotic t is-sue zones, and provided a suitable bed for the donor skin was present, e. g. clean and pink granulations. U s u a l l y , a dermatome was used in skin transplan-tation at thickness 0.3—0.4 m m . The same skin-graft thickness is advised by other authors too ( 1 , 3, 5, 6 ) . A slightly thicker skin graft (0.5 mm) was used only in case of resurfacing defects on the palm and volar aspect of the fingers. The types of traumatic lesions where free skin grafting was resorted to are outlined in Table 1. T a b l e 1 Type of injury Fingers Wrrst Forearm Arm Foot sole Leg Thigh Total Amputation Crush injury Skin defect Contused-lacerated wounds Incised wounds 68 24 86 31 19 2 9 8 7 3 3 4 4 2 2 3 1 1 II 1 OO GO 8 12 19 8 7 2 3 3 86 63 120 49 32 Total 228 39 15 5 11 54 8 350 The free skin graft was perforated with a thin scalpel or large size needle. After graft suture, a grease-impregnated dressing was usually applied for eight days. To secure an even pressure on the transplant, as wel l as its ful l s u r v i -106 M. Dobrev, S. Stoyanov v a l , the dressing was applied in the form of a cushion. Ful l -thickness skin was used mainly to resurface the bottom of the interdigital commissure (web space), as recommended by other authors ( 2 , 4, 7, 8 ) . The reason for abstaining from its ut i l izat ion elsewhere is the uncertainty in terms of complete s u r v i v a l . F o l l o w i n g reposition and f ixation of the bone fragments in open frac-tures requiring s k i n defect coverage through free skin plasty (mainly in the hand), we resort to plastic repair w i t h resurfacing the defect using free s k i n , prelevated w i t h the aid of scalpel or dermatome. One of the problems related to this particular type of skin plasty is the continuity of intervention, requiring a great amount of time and patience. Because of that many surgeon discard the method, and embark on s k i n de-fect coverage using skin material from the neighbourhood (adjacent or local skin flaps). Many authors recommend skin defect coverage by local s k i n flaps exclu-sively ( 9 , 10). We adopted such a policy whenever the site of damage and the condition of the adjacent skin allowed i t . S u r v i v a l of the split-thickness s k i n was certain in 347 cases of the series. T h i s is attributed to its capacity to withstand considerable mechanical and other impacts. I n many instances the skin covering is restored to the extent rendering it hardly distinguishable by appearance from the normal s k i n . Ne-crosis developed, and secondary skin plasty was nesessitated in three patients only. T h i s is attributed to the failure to abide by the rules of s k i n grafting. P a r t i a l necrosis of the free skin graft was observed rather frequently, although secondary skin plasty was not mandatory. I n some patients remo-v a l of the ensuing cicatricial necrosis had to be done, but the f inal outcome of skin repair was favourable in a l l instances. Rough scarring subsequent to free skin plasty was not recorded. Adequate granulations and the taking of a sufficiently bulky graft are among the factors responsible for the high per-cent skin graft survivals . Under the same aspect, we feel that avoiding any tension in the suture edges is likewise essential. Suturing of the wound ed-ges under tension was avoided in order to preclude complications, such as lacking apposition of the edges, suturing material cuts, scar necrosis and the l ike . The size of the skin graft was never smaller than the defect. Thus ten-sion of the transplant was obviated. Another condition is the application of appropriate immobilization. T h i s rather simple operation has already be-come popular among the medical staff of the c l inic in delivering emergency medical aid to patients under outpatient conditions. T h i s holds true mainly for cases with defects on the distal phalanges, or guillotine amputation of digits. I n many instances the intervention was conducted under local ane-sthesia. I n 61 per cent of patients free skin plasty was performed w i t h i n the first 24 hours. The question of carrying out in- or outpatient treatment was decided by the surgeon in charge. I n most of the patients skin plasty was done in fresh wounds, following primary surgical treatment, under conditions of complete hemostasis. S k i n plasty application greatly contributes to avoid certain complications, and along w i t h that enables to preserve the function of the injured part of the l i m b , to preclude the development of irregular and rough scarrings, defor-mations or serious inflammatory processes. Under the aspect outlined, the role played by antibiotics, administered to a great number of our patients, should be by no means underestimated. Free skin plasty in traumatic lesions of the limbs 107 We have no experience whatsoever w i t h the method of leaving the graft without suture, as recommended by some authors, nor w i t h homotransplan-tation (9 , 10). I n patients in poor general condition, the areas of the extensive wound surface, prepared first for operation, were the first to be covered — thus com­plete restoration and s u r v i v a l of the transplanted skin grafts was secured. The transplants were taken exclusively with a dermatome. S k i n grafting procedures play a very important role in the complex treat­ment of patients w i t h traumatic lesions of the l imbs. I t is a matter of inter­ventions assuming a particular importance when due consideration is given to the fact that the skin defects involve mainly the extremities, and not i n ­frequently — the working and weightbearing surfaces of digits, sole and am­putation stumps. R E F E R E N C E S 1. A H д p у с о н, М. В. и др. Орт. травм, протез., 1972, 7, 78. — 2. В и с о т с -с к а я , В. И. Орт. травм, прот., 1975, 11, 75. — 3. Г р и г о р ь е в, М. Г. Орт. травм, протез., 1973, 1 , 7 . — 4. Д и м и т р и е в , Г. И. и д р . Орт. травм, прот., 1972, 7, 7. — 5. Е д и н а к , Б. И. Орт. травм, прот., 1972, 7, 11. — 6. К и р и ­л е н к о , А . В. Орт. травм, прот., 1976, 5, 15. — 7. К л а с с е н, Г. Я . и др. Орт. травм, прот., 1972, 7, 15. — 8. К о в и н с к и й, И. Т. и др. Орт. травм, прот., 1972, 1, 85. — 9. Р у с а к о в, А . Б. и др. Орт. травм, прот., 1973, 7, 56. — 10. С и-н и л о, М. И. и др. Орт. травм, прот., 1973, 7, 44. СВОБОДНАЯ К О Ж Н А Я ПЛАСТИКА ПРИ Т Р А В М А Т И Ч Е С К И Х П О Р А Ж Е Н И Я Х КОНЕЧНОСТЕЙ М. Добрев, Ст. Стоянов Р Е З Ю М Е Свободная кожная пластика находит все более широкое применение в хирурги­ческой практике. За пятилетний срок в Клинике ортопедии и травматологии — Варна, свободная кожная пластика была применена у 350 больных. Она осуществлена преимущественно при травматических кожных дефектах руки — у 257 больных (73,40%). Большой и ука­зательный палец являлись чаще всего поврежденными — у 112 больных. Это составляет 32% общего числа больных и 43,60% травматических поражений руки. Срочно свободная кожная пластика применена у 6 1 % больных. Кожный трансплан­тат забран дерматомом или скальпелем. Этот вид операции применяется при открытых переломах конечностей, кожных дефектах и ампутациях. Реже прибегалось к кожной пластике по соседству. У всех больных кожная пла­стика была успешной. Только у трех из них наступил некроз, что потребовало проведе­ния повторной кожной пластики. Свободная кожная пластика приобретает особенно большое значение в клиниче­ской практике, принимая во внимание, что дефекты кожного покрова располагаются преимущественно на конечностях. 

FREE SKIN PLASTY IN TRAUMATIC LESIONS OF THE LIMBS

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FREE SKIN PLASTY IN TRAUMATIC LESIONS OF THE LIMBS

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Varna Medical University Press: Journals