Skin Grafting in Burns
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
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.
As the art and science of skin grafting developed it became clear early on that allograft skin, while a good temporary burn covering, was not a long-term solution to treating burns. The same is true of attempts at xenografting. Immune reactions were not found to be the cause of allograft rejection until the 1940s.4 As grafting of larger burned areas was undertaken, methods to provide broader coverage of the excised bed were needed. Often the amount of normal skin available to act as graft donor sites was a limiting factor. The concept of “meshing” the skin graft to allow it to stretch for greater coverage was not new. A hand held device for this very purpose was devised and reported by Lanz,14 a German surgeon, as early as 1907.4,14 Improvements in these hand held devices followed, but of these, the hand cranked double roller graft mesher developed by Tanner and Vandeput15 was the most significant. Current graft meshers function in a remarkably similar fashion today.
The timing of surgical intervention and grafting in burns had previously been an area of spirited debate. Burned tissue was originally allowed to slough off due to auto digestion, sub-eschar infection, and bacterial digestion severing the attachment of dead tissue to the subjacent viable tissue. Subsequent skin grafts were then applied to the remaining granulating wound bed. Major burns have been plagued with invasive infections and malnutrition as the eschar was allowed to slough throughout history. Early excisions of dead burn tissue with immediate closure, application of dressings, or grafts had been advocated as early the late 1800s.
Remarkably, this technique did not become the standard of practice in the burn community until the latter 20th century. Many authors promoted the concept of excising dead tissue followed by application of skin grafts, but it was left to Zora Janzekovic to present an integrated concept of early burn excision followed by immediate skin grafting. Janzekovic presented her revolutionary work in the mid 1970s when she published her technique of shaving off layers of dead tissue until a viable base of living tissue was reached, which was followed by immediate skin grafting. The shaving of multiple thin parallel layers of the burn until healthy tissue is reached is known as tangential excision.16–18 While the term “tangential excision” is not technically accurate, it is the term most often used in current surgical literature. This original presentation solidified the concept of early excision and grafting in the burn community. The efficacy of this technique was confirmed in a groundbreaking study by Heimbach.19 This seminal study confirmed that early excision and grafting of burns lower costs, shortened hospital stays, and lowered burn mortality—a goal that has been sought since burn care was first undertaken.20 In the burn community today, the principle of early excision and grafting of very deep to full-thickness burns is considered the standard of care. Another appealing approach to autologous skin coverage of excised burn wounds surfaced in l979. In that year Green, Kehinde, and Thomas21 published their success in growing epidermal cells in tissue cultures.
This technique has been further refined and it is now possible to grow large sheets of the patient’s epidermal cells in tissue cultures. These cells can then be transferred to the prepared burn wound to provide autologous epidermal coverage. Although a fascinating approach to burn healing there have been many clinical draw backs and this technique has not found universal acceptance in the burn community.21
Over the last 25 years there has been a slow but steady increase in the art and science of burn care. Improvements in lowering both mortality and morbidity continue to be made. Amazingly, effective techniques using artificial created skin substitutes are nothing short of fantastic.
Giant strides have been taken concerning the care of burn victims since the first attempts at tissue transplantation were made in India, centuries before Christ. Burns that resulted in death a decade ago are now being salvaged with improved quality of life. New techniques are emerging on a regular basis. Moving forward, perhaps new drugs or the fruits of gene technology may one day make the entire concept of surgery for burns archaic; one can only hope.