293

SIMPLE PLASTIC PROCEDURES IN GENERALSURGERY

By F. T. MoORIE, F.R.C.S., F.R.C.S.E.Plastic Surgeon, King's College Hospital, London; Surgeon, Plastic Unit, East Grinstead

Plastic surgery deals with the restoration ofparts of the body destroyed or deformed as theresult of congenital defect, trauma, surgical ex-cision or disease. It should have for its mainobject the restoration of function. It should alsobe the aim of the surgeon to secure a good cosmeticresult. In all cases the principle of restoration oftissue in kind-bone for bone and skin for skin-is of paramount importance.

It is the purpose of this paper to describe simpleprocedures used by plastic surgeons and withinthe scope of all general surgeons.

Plastic surgeons have developed a techniquewhich can rightly be called atraumatic. It is quiteimpossible not to inflict damage to tissues if un-suitable instruments are used. Many generalsurgical instruments such as haemostats, tissueforceps, retractors, needles and suture materialare much too heavy and deny any feeling or touchto the surgeon. The greatest care possible shouldbe taken when it is necessary to handle tissues.Maingot has taught for years that further advancesin abdominal surgery will come from the freeadaption of plastic technique to abdominaloperations.

Closure of a Skin IncisionIt is pertinent at this point to describe the

method used by plastic surgeons to completeclosure of a skin incision. The instruments usedare lightweight forceps of the Mclndoe type,dural hooks to retract the skin, the mosquitopattern artery forceps which pick up only thebleeding point, and suture materials of fine silkon atraumatic sharp needles. Only by' greatdelicacy in handling tissues can the ensuing tissuereaction be reduced to a minimum. Repeatedsponging is avoided and haemastasis is secured bytying bleeding points with fine catgut or silk. Alldeep spaces are obliterated by accurate approxima-tion of the tissues in layers. The skin suture may

be continuous or interrupted but each stitch mustproduce eversion of the edgesoof the wound. It is

FIG. I.-Detail of stitching technique.

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

POSTGRADUATE MEDICAL JOURNAL

important that the stitch should be just sufficientlytight to secure approximation of the wound. Tootight a stitch causes unnecessary stitch marks, andif the stitches are spaced too closely together theskin edges will be ischaemic and healing will bedelayed.The needle enters the skin at not more than

i in. from the edge and passes into the deepertissues, securing a slightly greater ' bite' untilthe needle reappears I in. from the other skinedge (Fig. i).

It is a cardinal rule in plastic surgery thatclosure of a skin defect must not be achieved undertension, because the resulting scar stretches andif it does not lie parallel to the normal skin creaseshypertrophy or keloid formation may occur. Upto about the age of three, scars on the whole be-have satisfactorily and rarely become keloidal.From three to 17 years of age scars are prone to bedisappointing. Certain patients older than 20,particularly those with red hair or deeply pig-mented skin, tend to produce very unsightly scars,especially if the direction of the scar crosses thenormal skin creases.

Closure of Smali Skin DefectsRemoval of tissue, including skin, for example

following excision of a rodent ulcer, may leave adefect that cannot be closed easily by direct suturethat obeys plastic principles.The closure of all small defects , involves

mobilization of the wound margins and ' ad-vancing ' the tissues to cover the defect. The sizeof defect that can be closed by this simple methoddepends on the elasticity of the skin, after under-mining the skin for an area approximately five tonine times greater than the defect. There areareas in the body where loss of skin cannot'bemade good by simple 'advancement' flaps'orextensive undermining and suture. An example isthe lower limb, where the skin is relativelyinelastic, and if it is stretched its viability is con-siderably impaired. Similarly defects situated nearthe eyelids, mouth and nose will cause distortionof the surrounding tissues if sutured undertension. This may lead to subsequent ectropionand exposure of the globe, or to asymmetry ofthe mouth and dribbling.

Most small defects of the skin can be resolvedinto three main geometrical figures, namely acircle, a triangle and a rectangle. An irregulardefect can be resolved by paring the skin edges toform a combination of two or more of these figures.The surrounding skin must be widely under-mined for a total area of between five and ninetimes the area of 'the defect. Fig. 2a, b, c, dillustrates the method of closing these defects.

Small puckers or dogears may be produced atthe corners of the closed incision. This re-dundant skin is carefully excised so that the finalincision is flat though slightly prolonged.An important step in every operation is the

mechanical approximation of the divided tissuesto obliterate dead spaces and minimize theultimate scar. If the skin is approximated and thedeep tissues ignored, exudates and haematoma willaccumulate in the remaining dead space and inviteinfection; this will delay healing and the surfacescar, regardless of the care with which the skinwound mav have been closed, will stretch because

X I )l \-.

iZZiIJ t S

... .... ... ..

:..0:... . . . . ..... ..

4 *. . -;

FIG. 2.-Methods of closure of defects (the stippledareas indicate areas of- undermining); (a) Tri-angular defect. (b) Rectangular defect. (c)Rectangular defect, altemative method with tri-angular excisions at each end. (d) Circular de-fect. Note final excision of dog ears.

294 May I1952copyright.

on May 9, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.28.319.293 on 1 May 1952. D

ownloaded from

9MOORE: Simple Plastic Procedures in General Surgery

of insufficient support. In other words, the sub-cutaneous tissues must be carefully united inlayers.A good scar may be secured if:-i. The skin is incised vertically and not at an

angle.2. The incision lies parallel to the normalgrain' or natural creases of the skin.3. The incision is of adequate length so that

unnecessary retraction and tissue manipulation isavoided.

4. Haemostasis is absolute.5. Dead spaces are obliterated.6. Stitches are not inserted under tensioni.7. Infection is avoided.Stitches are only a method of fixation, bringing

the two cut surfaces into the closest appositionuntil healing has begun. Early removal of stitches,particularly on exposed areas of the body, is im-portant, as unsightly stitch marks will ruin anexcellent scar. Pre-operative and post-operativeirradiation of the skin may be necessary to securethe best result.

Closure ofRaw Areas with Skin GraftsIn the surgery of trauma and, indeed, as a

result of a planned surgical operation, a skin defectis not uncommon. Sometimes a wound maybreak down leaving a raw area which takes a longtime to heal by secondary intention. Primary' closure ' of large skin defects with skin grafts is asimple problem. Special training is unnecessaryand little skill is required.

Skin grafts of most use to general surgeons fallinto two categories:

I. Pinch grafts.2. Split skin grafts.

Pinch GraftsThe resurfacing of denuded areas by the use of

small 'pinch' grafts is the oldest and simplestmethod of skin transplantation. It involves nospecial preparation, is easy of execution and can bedone under local anaesthesia. The dressings andinstruments are not elaborate and the after care isnot irksome. These minute transplants will' take 'on any raw surface and under conditions contra-indicating the use of other more complicatedmethods; indeed, they will often survive even inthe presence of considerable suppuration. Further-more, should a portion of the grafts fail, it is nogreat calamity since the loss can easily be remediedby a repetition of the process.

Technique. The granulation tissue is preparedfor grafting by the application of gauze soaked innormal saline and this is changed four-hourly. Alight pressure dressing is applied. After three tofour days pale, heaped up granulations with a

heavy infection can be made to flatten out and be-come cherry red in colour, the surface resemblinga well-cut lawn.A word ofwarning is necessary. Local measures

alone are not enough to prepare a granulating areafor skin grafting if the haemoglobin is below 6oper cent. Blood transfusions must be given. Inmy experience a raw area is safe to graft when theskin edge is beginning to grow in or epithelialize.No mention has been made of the use of anti-biotics to help sterilize the raw area. It is acontroversial subject and it is largely a matter forpersonal preference, but I prefer to withhold theapplication of all antibiotics unless there is aspecial reason.The grafts are obtained from an area of skin

bordering the lesion. A small island of epidermisis raised on the point of a cutting needle, and witha sharp knife, such as a B.P. No. ii, a cone ofskin 4 to 5 mm. in diameter is cut off and trans-ferred to the granulating a'rea, raw surface down-wards. The graft consists of epidermis and partof the dermis (Fig. 3a, b). If the graft hasbeen properly cut a slight ooze of blood takesplace in the crater.

FIG. 3.-(a) Cutting a pinch graft. (b) Section ofgraft.

Care must be taken to avoid cutting these graftsat a deeper level, otherwise permanent scars willbe left on the donor area and the thick layer ofconnective tissue on the base of the graft willinterfere with its viability. The closer the graftsare placed the better, since the proliferation fromtheir edges is limited, so the more numerous thegrafts the more rapid the healing.

After the grafts have been placed a layer oftulle-gras is laid over the area. Above this areplaced a few layers of gauze wrung out of saline

MOY 1957- 295

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

296 POSTGRADUATE MEDICAL JOURNAL May 1952

solution. -These in turn are covered by two orthree layers of dry gauze, the whole being held inplace by a bandage or adhesive plaster. If the areathat was grafted was dirty a change of dressing isrequired every 24 to 48 hours, depending upon theamount of discharge. If the base was clean thedressing is left undisturbed until the part iscompletely epithelialized.

Split Skin or Razor GraftsApplication of grafts of this type is simple and

rapid. The grafts may be obtained in any size,limited only by the available donor surface and bydexterity of the operator. Owing to their thinnessand comparative avascularity they are capable ofreceiving nutrition through direct osmosis fromthe surrounding lymph spaces. The donor areaheals quickly and spontaneously without seriousscarring. The grafts are subject to discolorationwhich may render their use objectionable on ex-posed parts, particularly on the face.

Technique. The donor area is preparect anddraped in the normal manner.The cutting of the graft requires no great skill

provided a flat surface is presented to a knifethat is really sharp. Even in the hands of expertsthe cutting of a graft can be an impossibility witha blunt knife.

If the thigh is to be the donor area an assistantsupports the fleshy part of the thigh with the kneebent slightly so that as far as possible a flat skinsurface is presented to the surgeon. The bestknife for the infrequent user is undoubtedly theHumby pattern in which the thickness of the graftcut is largely controlled by adjustment of a rollerprotecting the cutting edge. By light pressure with

I//

ii

FIG. 4.-Cutting a Thiersch graft from the thigh.

a flat board placed parallel to the cutting edge ofthe knife, the skin surface is tightened andflattened. By smooth cutting movements ratherlike slicing ham, a graft may be cut keeping thegraft board about I in. to i in. in front of themoving knife edge (Fig. 4).

COTTON WOOL- -ij Y%( 'Zt

:5KIEGALF( ii-(r -< ->ff ; e

~4.7

t'

IN PI1b !.' I;

'FIG. 5.-Dressing for free graft.

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

May 1952 MOORE: Simple Plastic Procedures in General Surgery 297

The split skin graft is spread on to tulle-graswith the raw surface outwards, and transferred tothe recipient area. The whole is secured bystitching the graft and tulle gras to the skin aroundthe defect (Fig. 5). The after care and dressingshave already been described and are the same asthat given for pinch grafts.The donor area is covered with tulle - gras

dressings and liberally protected with cotton wool;the dressings are secured with a sterile bandage.

I do not think flaps and tubed pedicle graftscome within the scope of this subject. Somegeneral surgeons have had experience of theirapplication, and the following remarks do notapply to them. The results following the use oftubed pedicles and flaps is often very disappointingto the surgeon and may be disastrous in in-experienced hands. It takes considerable trainingand experience for the plastic surgeon to obtain asound working knowledge of what to do,and whatnot to do. For instance, the Imre flap used on theface to repair defects situated around the lowereyelid appears relatively simple. So it is, if the tipof the flap survives (and it is easily lost), if haemo-stasis is perfect (and it is difficult to secure), ifthe stitching is not so tight as to cause a necrosisof the skin edge, if the flap is designed big enough,if the incisions lie in the same direction as normalskin creases and, finally, if the subject is old andhas an abundance of loose skin that can bemobilized to replace the defect. The scales areweighed heavily against the surgeon who, withoutprevious training, attempts what may appear tohim a simple procedure.

However, a scalp defect is frequently en-countered, and it is often necessary to move thescalp by carefully designed flaps to cover a duralor bony defect.

Special AreasScalpThe scalp is almost completely inelastic, and

this feature governs any plastic repair in this area.Very small defects are often impossible to close bydirect suture. Neither will extensive underminingof the adjacent scalp allow the tissues to be ad-vanced over the defect. The use of advancement' flaps ' depends on the elasticity of the tissue;because the scalp will not stretch defects in thisarea must be closed by flaps. The abundant morecomplex blood supply of the scalp makes the useof very large flaps a relatively safe procedure. Theflap should be designed with its base towards themain blood supply of the scalp and its size shouldbe four or five times greater than the defect. Thegreatest and most frequent mistake is to design toosmall a flap so that the defect is incompletelycovered.The scalp flap is elevated completely, leaving

pericranium intact. It is then rotated and sewninto its new bed. It is possible that a ' dog ear'will form when the scalp flap is moved into itsnew position. This is of no importance at thisstage, the object of raising a flap being to cover aspecified defect. ' Dog ears' are easily trimmedout at a later date. There is obviously a raw areaor secondary defect from the site where the scalpflap previously lay. This is covered by a split

),, '

hr.li :)-rf). r- fi:i>.r,i - , . . . j; * \ ';

FIG. 6.-Closure of scalp defect with rotation flap.Skin graft to secondary defect.

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

POSTGRADUATE MEDICAL JOURNAL

t' ri'.:ffi ;1 ,1'II #-ff..tfI wffII I4)ft"$fX'4Av:P1f>e!ts 4-y f

t: r, 'r> ifFIG. 7.-Free skin graft to eyelid. (a) Lesion on upper eyelid requiring wide

excision of eyelid skin. (b) Ecision completed. Defect held widely openwith anchor sutures. (c) Split skin graft applied to defect with stent mouldand fixed by overtying of anchor sutures. (d) Pressure dressing.

298 MOY I1952

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

MOORE: Simple Plastic Procedures itn General Surgery

skin graft secured with a few interrupted finestitches (Fig. 6). As an emergency measure it isjustifiable to use hairy scalp flaps to close fore-head defects involving bony loss. The hairy scalpcan subsequently be returned to its originalposition and repair of the forehead defect achievedby a secondary free graft.

FaceThe surgery of the face presents special prob-

lems since the result is visible to all. A cleanlaceration inflicted with a sharp knife can be con-verted into a hideous scar by the surgeon whocloses the wound in a clumsy fashion. If skin hasbeen lost in an accident or necessarily removed inthe excision of malignant disease, closure of thedefect is achieved by adding tissue from thevicinity or covering the raw area by a free graft.The use of adjacent tissues implies closure bylocal flaps. Their use requires special training andthey cannot be described satisfactorily in a shortpaper.A defect that is too large to be covered by simple

methods is best closed by the application of asplit skin graft. The surrounding tissues arethereby not distorted and the chaotic sequelae oftight strangling sutures are eliminated, so that indue course the surgeon will face a problem un-obscured by avoidable scarring and distortion oftissues. There are many defects on the facewhich it is not proposed to discuss, because Iconsider them entirely within the province of theplastic surgeon. Lesions of the upper or lower lipsnot exceeding one-third of the width can readilybe closed by excising a complete V section of thelip including skin, muscle and mucous membrane.The raw areas are united in layers securing ac-curate union of mucous membrane, muscle andskin. The cosmetic effect is satisfactory. Morecomplicated repairs involving the Abbe orEstlander flap or the Gillies ' fan flap ' require thefull plastic armamentarium for their satisfactoryconclusion.

Lacerations of the eyelids, particularly thoseinvolving the lash edge, present a special problem.The multitudinous methods of repair, each withits enthusiastic advocate, testifies to the difficultyin obtaining a satisfactory result. Scars lyingvertical to the lash edge tend to contract giving anotched deformity. Full thickness defects of theeyelids present special technical problems which isoutside the scope of this article.

Skin losses of the eyelids which are larger thancan be closed by some obvious simple method arebest covered by a thin split graft. The skin graftis most satisfactorily applied to the raw area on astent mould. A small piece ofstent ofsuitable size isrendered soft by immersion in hot water. When

workable it is moulded to the shape of a sausageand applied to the defect and cooled with coldwater. It is then dried and a split skin graft ofsuitable size is wrapped on to the mould, rawsur-face outwards. The mould with its skin coveringis then secured to the raw area bv stitches insertedinto the cut skin edge, the long ends of which aretied over the mould. A light pressure dressing isapplied and the dressing left undisturbed for threeto five days. Subsequent dressings are carriedout as for any other free graft (Fig. 7a, b, c, d).

NeckThe most important plastic procedure in the

neck which comes within the scope of the generalsurgeon is the technique for breaking a verticalscar which has contracted and is limiting move-ments of the neck. This is the Z-plasty and it isof use only if the scar is lineal and tends to pro-duce a web. The surrounding tissue must besufficiently vascular to withstand the procedure.It is carried out as follows. With the scar under-tension, the proposed incisions are marked out.The longest line of the Z is the scar itself. Thearms of the Z begin at each end of the scar and aremarked out at an angle of 600 to the scar andabout two-thirds of its length (Fig. 8). The in-cisions are made following the pattern, and thetwo broad based triangular flaps thus formed areundercut and fully mobilized. The position of

FIG. 8.-The Z-plasty

MlaY I952 299,copyright.

on May 9, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.28.319.293 on 1 May 1952. D

ownloaded from

36o POSTGRADUATE MEDICAL JOURNAL May 1952

the flaps is then transposed so that the tip of oneflap is sutured at the opposite side of the base ofthe other flap. The Z-shaped incision is sutured,but the long line of the scar now lies transverselyacross the original scar pull.

ChestSkin defects of the chest wall sometimes arise

during resection of a carcinoma of the breast.Complicated flaps are not practical and the defectshould be closed in the simplest manner. Theincision is sutured as far as possible and the re--maining area is covered with a split skin graft.Primary healing is secured and the donor areais healed within ten days. The technique forcutting the graft and subsequent dressings havebeen described.

A~

1~VI 4~L4 A ,.,,.........

F D l i of skin betwen ntu i

FIG. 9.-Diagram illustrating death of skin between two longitudinal incisions.

AbdomenGreat care is rightly given to closure of the

abdomen following laparotomy, but a number ofpatients subsequently develop ventral herniae.This is more common in patients who have beensubjected to more than one laparotomy. Somesurgeons advocate that the abdomen should be re-opened through an incision parallel to the previousincision, but not through the same incision if-the same exposure is required as at the previousoperation. This practice may lead to sloughing ofthe skin of the abdominal wall between the in-cisions and is associated with a very high in-cidence of hernia (Fig. 9). The old scar should be,excised and the wound extended into normaltissue and the skin undermined extensively untilnormal rectus sheath is found. The peritonealcavity is then opened through normal tissue. Ifspeed is the sole consideration a transverse in-

cision is indicated when the pre'vious incision wasparamedian in type.

Relaxation incisions if used at all should beclosed by the application of a skin graft. The extratime taken to do this is rewarded by healingobtained in the shortest time.

Lower LimbProbably the commonest problem in the leg

which besets the general surgeon is the treatmentof varicose ulcers. The following remarks are notintended to cover the entire subject but to describesome methods of use in this controversial field.I am fully aware that some surgeons consider thatskin grafts have a very limited use and the ulcermay recur in spite of ' new skin.'

Varicose ulcers are seen in all stages of chronicity

and sizes, with or without visible varicose veins.Oedema of the foot and leg may be increased bylocal infection. Many patients do not seek reliefuntil pain or profuse offensive discharge from theulcer denies them sleep or the company of theirfellow men. Skin grafts have no place in the un-treated varicose ulcer. The varicose veins must beligated or injected, the superadded infection andoedema must be controlled. A lengthy period inbed may be indicated according to the severity ofthe ulcer, and it may take several weeks to achievea very slowly healing ulcer. Recent ulcers withlittle surrounding fibrosis and with a soft red basecan be successfully healed by pinch grafting theraw area. This can sometimes be accomplished onan out-patient. The larger more indurated ulcerwith extensive scarring in the base and surroundingtissues is a different problem. Even if healing isobtained by the application of pinch or split skin

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

May 1952 MOORE: Simple Plastic Procedures in General Surgery 301

~Z.

... ..

FIG. io.-The whole lower lip was re3ected for an epithelioma. Both cheeks were extensivelymobilized and an attempt made to secure union in the midline under tension. The result wascatastrophic. The wound broke down and a fistula formed in the midline. The new' lower lip'was totally inadequate and was stretched as a tight band beneath the upper lip. Dribbling wasconstant, mastication and phonation were difficult. A repair was performed in which theprevious 'flaps' were returned to their normal position and tissue was used where it could bespared, that is from the nasio-labial region. The dotted lines indicate the method ofreconstruction.

grafts, the healed ulcer surface remains unstableand easily breaks down. A wide excision of theulcer and surrounding scar tissues is indicated,the resulting raw area being 'covered with a splitskin graft. Even after healing, the ulcer diathesisremains and the limb must be permanently sup-ported by elastic bandages or stockings, appliedbefore getting out of bed. The ulcerated leg witha severe periostitis and endarteritis is in most casesunsuitable for the methods described above, andthe services of a plastic surgeon should be soughtto consider the possibilities of a cross leg flap.The general surgeon, having read so far, will

feel that I have allowed him a very limited field inplastic surgery. If Maingot's predictions are rightand an atraumatic technique is adopted for generalsurgical procedures, a much greater field may be-come available. The following cases are discussedto impress upon all surgeons ambitious to do re-constructive work that an atraumatic technique isessential.

FIG. ii.-The longitudinal contracted scars crossing themetacarpo phalangeal joint creases have resulted inlimitation of extension. The patient stated that thejoints of his hand had a wider range of movementbefore the operation for removal of the palmarfascia for Dupuytren's contracture.

L L11- l l l E-l l I a jR,., l -11 I i z X!^- . . I

s , , - .-* 11 M M- m.U . *....i....mS.. ..- . l -w ,EXs , -.. s--

................ ... i . ....E1

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

30 :F>()2;'lPOSTGRADUATE MIEDICAL JOURNAL May I952

Case I (Fig. io)Large resections for cancer of the mouth must

not be repaired by any method of which thesurgeon has had no previous experience. Wideresection of the growth, yes, but attempted re-construction of the oral sphincter without tcch-nical equipment or knowledge, no.

If the wound does not break down following ill-considered repair the unfortunate sufferer mayhave a new disease. If the cheeks had beenwidely used in the repair, mastication may be im-possible and dribbling a daily nuisance. Many old

:T

FIG. I2.-This man lost a small full thickness section of his lower lip in an automobileaccident. A repair was carried out by a tubed pedicle flap. The flap remained unsightly,anaesthetic and the man was troubled with persistent dribbling. A repair of theEstlander type (shown in dotted outline) would have given a better result, with retainedsensation and, therefore, without dribbling. The c03metic result would also have been better.

men for whom this type of operation is performedwish for little -more than to be able to smoke,drink, eat, talk and sleep. If their oral sphincter isdestroyed their last days will be a misery.

Case 2(Fig. ii)Incisions in the palm of the hand should never

be made longitudinally across a joint crease.These incisions may heal with contraction of thescar which prevents full extension of the involvedjoints. The worst examples are to be seen follow-ing unwise incisions for acute infection of the handor for Dupuytren's contracture. They are in-excusable. The surgery of Dupuytren's contrac-

ture is difficult enough without vitiating a possiblygood result by ill-placed incisions.

Case 3 (Fig. 12)Frequently the general surgeon may be tempted

to repair a skin defect by local flaps or a tubedpedicle flap. It is not enough that the tubedpedicle flap is eventually transplanted to the re-cipient area; the point is that the tubed pedicleflap should be really necessary and that it shouldmerge with its surroundings. Repair must havefunction as its main aim for if this is not achieved

on account of an ill-judgcd type of repair, theseries of operations will have been pointless.The three case photographs which follow are

shown to illustrate problems that can only besolved by ' plastic' surgery.

Case 4This woman had an extensive basal celled

carcinoma of her forehead involving the lefteyelids, left ear and extending across the nose(Fig. 13). The whole mass was excised includingmuch of the left frontal bone, the left eye and partof the left ear. The defect was covered by a largehairy scalp flap. One month later, the scalp flap

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

MOORE: Simple Plastic Procedures in General Surgery

Fic. 13-.Extensive basal-celled carcinoma of forehead, before and after treatment.

.i

I/

FIG. 14.-The relief of pruritus vulvae by radiation has, in some cases, resulted in a radiation der-matitis. This must be treated by excision which gives immediate and lasting relief. Thedefect resulting from excision of all affected tissues is satisfactorily closed by using two largerotation flaps.

MqY1952 303

14

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from

304 POSTGRADUATE MEDICAL JOURNAL May I952

....*. eSRjo.'...- \:

I.....' ;sl8lj.>:,'1.....

...t

N -

FIG. I5.-(a) An attempt had been made to remove the growth by the intra-oral route threemonths previously. A large malignant ulcer was present on the alveolar ridge, the baseinvading the skin of the submental region. (b) The patient on discharge, 14 days after wideexcision of the growth and immediate repair. Function of the mouth was excellent and theresult cosmetically acceptable. As this patient had not worn dentures for several yearsmastication with the remaining half mandible was satisfactory.

was returned to its normal position and the bedit had occupied was closed by grafting the rawarea with a split skin graft. This two-stage opera-tion was necessary to allow the orbit to fill up andacquire a suitable bed for skin grafting.

Case 5 (Fig. I4)The widespread use of radium and X-rays as

therapeutic agents has resulted in a considerablenumber of cases of radiation dermatitis. Manyof the minor burns heal and remain healed, butthe ulcerative type, once established, demandscomplete excision. Pain, itching, ulceration anddischarge combine to make the sufferer's life un-endurable. Deformity from contraction is some-times present. If the burn is on the face the un-pleasant and disfiguring appearance is sufficientto make the patient seek relief. Lastly the realpossibility of epitheliomatous change cannot everbe excluded, and for this reason total excision isindicated.Case 6 (Fig. I5a, b)

This unfortunate patient, aged 67, was referred

to the Plastic Unit, East Grinstead, suffering froman intra-oral carcinoma ulcerating through thetissues of the chin on to the skin. It was grosslyinfected. Wide excision of the tumour mass, in-cluding half the mandible, left a large defect.Immediate repair was achieved using a full thick-ness ' fan' flap to reconstruct the corner of themouth and lower lip. A neck flap which includedplatysma closed the remaining sub-mandibulardefect. This patient was able to return to herhome I4 days after operation with the slight dis-ability that is associated with hemi-resection of themandible-the remaining half of the mandibleswinging towards the side of injury when themouth was opened.

AcknowledgmentsI wish to thank Mr. Gordon Clemetson for the

photographs, Mr. Robin Dale, F.R.C.S.E., for hisdiagrams, Mr. C. R. McLaughlin, F.R.C.S.E., andcolleagues at East Grinstead for the considerablehelp they have given me in the preparation of thisarticle-

copyright. on M

ay 9, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.28.319.293 on 1 M

ay 1952. Dow

nloaded from