Skin Grafting in Burns

Chester N. Paul, MD, FACS

Further developments in skin grafting occurred in the late 1800s. In 1886, a German surgeon named Carl Thiersch articulated several lasting improvements in the technique of skin grafting. His techniques included using a straight razor to excise long thin strips of skin containing some dermis and applying them to a freshly debrided granulation tissue bed.6,9,11
While numerous articles were published in the late 1800s and into the 1900s, the value of many articles is difficult to determine in retrospect. In many cases details were scant and articles were published that did not define whether they were applying autografts or allografts, or whether the grafts were full- or partial-thickness.

The interest in the use of skin grafts to treat burns declined somewhat in the beginning of the 20th century. Utilization of larger skin grafts that yielded poorer results proposed by Triesch appeared to renew interest in using smaller grafts. The term “pinch graft” was applied to a refinement of the Reverdin technique published by John Staige Davis of Johns Hopkins University in 1914.4,6,8 Davis refers to this in an interesting and extensive monograph published in 1941.4 Advancements in the technical aspects of skin grafting and the scientific understanding of grafting continued to progress albeit slowly. Initial grafts were obtained free handed with long, thin, bladed knives. Finochietto developed an improved knife for controlling the depth of skin harvest in 1920; multiple improvements in surgical burn knives followed. Braithwaite, Watson, Goullian, and Corbett are names still associated with knives used to harvest skin and remove burned tissues today.6,12

Some early burn surgeons became extremely adept at these free-hand procedures. According to Haynes, a famous picture was published by Dr. Brown of the University of Washington, St. Louis, in which he was able to harvest an entire intact strip of skin from the axilla to the ankle.9 Even today burn surgeons will attest that this is a truly remarkable feat.

The introduction of the mechanical dermatome was a significant advancement in burn treatment. Although cumbersome and bulky, the first device was invented by Humbly of England and introduced in 1930s. The introduction of the hand powered rotating drum dermatome by Padget and Hood 9 years later was also a significant advancement. The first powered dermatome was invented by Dr. Brown. According to several authors, Brown conceived of the instrument while being held prisoner by the Japanese during the World War II.8 Brown introduced the instrument in 1948 in conjunction with an engineer named Barron. Several other dermatomes (hand-, air-, and electric-powered) are currently available to burn surgeons, including the Zimmer electric dermatome, which is widely used throughout the United States.


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