Skin Grafting in Burns

Author(s): 
Chester N. Paul, MD, FACS

The definitive history of the transplantation of human tissues, or animal tissues for that matter, is shrouded in the mists of antiquity. Numerous authors referred to tissue transplantation centuries before the birth of Christ. Fata writes that the earliest recorded plastic surgery operation was done by a surgeon named Sushruta (or Susruta) in India perhaps as early as 700 years B.C.1–3 Sushruta is considered the father of plastic surgery in India and is credited by some as being simply “the father of surgery.” There is some evidence that reconstruction of the nose was considered as early as 1500 BC, perhaps even as early as 2500–3000 years BC.4,5 The operations by Sushruta, which are considered to be the first recorded plastic surgery operations, involved the transplantation of full-thickness pieces of skin in addition to fully intact noses from one individual to another.

It seems as though removal of the nose was a form of corporal punishment reserved for crimes such as theft and adultery. The Brahmin Koomes Caste undertook the repairs of the subsequent defects.6 Why these operations were in the hands of the brick layers is not clear. The donors of the skin grafts and perhaps donors of the entire nose were possibly slaves.7 One can assume slaves were used as the number of other willing nose donors was likely limited. It may also be assumed that the operations were fair undertakings requiring at least 4–5 large assistants, not including the surgeon, to convince the slave to voluntarily participate. Lack of willing donors, asepsis, modern anesthesia, and the ultimate problem of rejection—it can be assumed that results would have been less than stellar. Amputation of the nose was practiced until at least 1983 in Afghanistan and Pakistan, according to Ang.5

In his article “Ancient Egyptian Medicine,” Bryan credits the Ebers Papyrus as containing the first written record of the treatment of burns per se.8 Not only were the medications to be used in burn treatment discussed, but also their timing.

The early forages in India involving skin and tissue transplantation seemed lost to history for thousands of years only to resurface in Western medicine in the 1800s. Credit for publishing the first description of a successful grafting technique using free skin grafts to treat wounds is given by multiple authors to Swiss surgeon, JL Reverdin, although earlier attempts at skin transplantation by other surgeons are mentioned, including Cooper in 1817 and Buenger in 1821.7 Reverdin, however, received the most credit. During that time he was an intern or house physician in Paris, France. He published his technique of “Greffe Epidermique” in 1869.6,8–10 Reverdin’s published account may have been a seminal first step in skin grafting. However, Reverdin’s grafts were miniscule affairs, probably no larger than 1 mm to 2 mm and were taken by lifting the skin to be grafted with the point of a scalpel. Ollier in Paris or Lyons, France emphasized the importance of the dermal and epidermal transplantation throughout the literature in 1872.8,11,12 Ollier reported on and coined the term “dermoepidermic” grafting in 1871.6

It is not entirely clear who deserves credit for the first skin graft used in the treatment of burns. Reverdin is credited by some as applying small grafts to an old burn ulcer as early as 1869, but his works did not appear in published form until 1871.11 Some authors give credit to George David Pollock of London5,9,13 who published a series of articles dealing with the subject in 1870.8

References: 

1.    Fata J. Nasal Reconstruction, Principles
and Techniques. Available at: http://www.emedicine.com/plastic/TOPIC365.HTM. Accessed April 2, 2006.
2.    Chari PS. Susruta and our heritage. Indian J Plast Surg. 2003;36(1):4–13.
3.    Sharma S, Unruh H. History of adult
transplantation, Available at: http://www.eMedicine.com/med/TOPIC3497.HTM. Accessed June 1, 2006.
4.    Davis JS. Address of the President: the story of plastic surgery. Ann Surg. 1941;113(5)641–656.
5.    Ang GC. History of skin transplantation. Clin Dermatol. 2005;23(4):320–324.
6.    Chick LR. Brief history and biology of skin grafting. Ann Plast Surg. 1988;21(4):358–365.
7.    Hauben DJ, Baruchin A, Mahler A. On the history of the free skin graft. Ann Plast Surg. 1982;9(3):242–245.
8.     Klassen HJ. History of Burns. Rotterdam, The Netherlands: Erasmus; 2004.
9.     Haynes FW. The History of Burn Care. In: Bostwick JA, ed. The Art and Science of Burn Care. Aspen Pub: 1987: 3–9.
10.     Reverdin JL. Greffe epidermique. Bull Soc Chir Paris. 1869;23:147.
11.     Herman AR. The history of skin grafts. J Drugs Dermatol. 2002;1(3):298–301.
12.     Integra Products. Skin Graft Knives, Padgett Instruments. Available at: www.Integra.com.
13.     Freshwater MF, Krizek TJ. Skin grafting of burns: a centennial. A tribute to George David Pollock. J Trauma. 1971;11(10):862–865.
14.     Lanz O. Over transplantaties. Ned Tijdschr Geneegkd. 1907;51:1333–1337.
15.    Tanner JC Jr, Vandeput J, Olley JF. The mesh skin graft. Plast Reconstr Surg. 1964;34:287–292.
16.     Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma. 1970;10(12):1103–1108.
17.     Janzekovic Z. The burn wound from the surgical point of view. J Trauma. 1975;15(1):42–62.
18.     Janzekovic Z. The treatment of burns, excision of burns. Burns. 1977;15:61–66.
19.     Heimbach DM. The results of early primary excision. J Trauma. 1981;21:732–734.
20.     Feller I, Tholen D, Cornell RG. Improvements in burn care, 1965 to 1979. JAMA. 1980;244(18):2074–2078.
21.     Green H, Kehinde O, Thomas J. Growth of cultured human epidermal cells into multiple epithelia suitable for grafting. Proc Natl Acad Sci USA. 1979;76(11):5665–5668.



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