Dalinde Hospital, Mexico City

Transcription

1 RESTORATION OF THE FACE COVERING BY MEANS OF SELECTED SKIN IN REGIONAL testhetic UNITS By M. GONZ~LEZ-ULLOA, M.D., F.A.C.S. Dalinde Hospital, Mexico City IT is the purpose of the present study to emphasise the need for restoring the facial skin by complete regions instead of by patches, the latter being often more conspicuous than the condition for which the correction was intended. Restoration by complete regions has two advantages: (I) To conceal the limits of the skin graft at the natural borders of each region (shadows, folds, hair) ; (2) to give each region such thickness and histological characters as are peculiar thereto. A B FIG. i Grafts applied to the face without considering expression, scar visibility, and lack of colour, texture, and thickness matching with the neighbouring areas. This manner of effecting cutaneous restoration by complete areas with a specific thickness will be called regional selective restoration, and the fragment of skin in definite size and characters for each area will be called regional msthetic unit. General Remarks.--After examining a large number of patients with facial restoration performed by us and by others, we feel that skin patches applied in the centre of one region or partially comprising two or more regions, without due regard for facial mobility, visibility of the scar in the graft periphery, or differences in colour, texture, and thickness as compared with neighbouring areas (Fig. I, A and B) must be avoided. Grafts of this nature, though no doubt

2 RESTORATION OF THE FACE COVERING 213 performed in good faith, evince, on the surgeon's part, a disastrous lack of skill and talent, as glaringly exemplified by the results. Such surgeons (including occasionally even ourselves) do but change one disability for another--the latter being sometimes even more disabling than the first. Except in the case of cutaneous defects which can be eliminated by gradual resection, restoration in visible areas should be accomplished by complete regions (Fig. 2), by " regional resthetic units " avoiding the defects of the anti-resthetic, anti-functional partial graft. It would seem that all surgeons of all times, everywhere, should have thought of this--so logical it appears to be--but the fact remains that no one puts it into practice as a regular and purposeful procedure. Every graft is integrated if attention is paid to the host area, to the method for taking and applying the graft, and to the post-operative care. This depends on a better knowledge of surface circulation, improved technical details, antibiotics, control of protein balance, electrolytes, etc., as well as on the utilisation of various dermatomes that make it possible, in one operation, to obtain skin of a selected thickness that is sufficient at least for one complete region of the face. The method to which this work refers, of utilising complete cutaneous regions of a similar thickness to that of the area which is to be replaced, allows for better surgery. The conditions for success depend on a careful study of the area that is to be repaired, on accurate planning of the size and thickness of the graft, and on a good knowledge of the surgery of skin transplantation. On considering the normal face of a middle-aged individual, several regions are observed which are limited by relief lines, folds, evident changes in cutaneous texture, or by the hair line. These regions, as studied in different individuals, have been systematised on a facial map which gives a natural division for the purpose of finding regional units and for starting the skin histological study and measurements. From each region skin specimens were removed to study (a) the thickness of the total skin and of each of its layers, (b) the histological composition. This investigation was carried out on the whole cutaneous surface of a newborn child, an adult woman, an adult male, and an elderly person. Our results from the investigation of the microscopical thickness of the skin isolated from the body have been previously reported (Gonzfilez-Ulloa et al., 1955). They did not show the dermatome thickness usable in surgery. In this paper we shall refer only to such data as are important for efficiently effecting skin transplantation on each specific group of facial regions. METHOD The face is covered by skin whose thickness is different in each region (Fig. 3). This characteristic determines the need for employing a similar cutaneous thickness for each specific region. The skin of the face, divided into regions, produces a map of " regional msthetic units " as shown in Fig. 4. These lines show the limit for the skin transplant, whether it be made as a graft or as a flap. Skin transplantation by graft is indicated when restoration comprises the skin only; by flap, when the destruction comprises subcutaneous tissue which has to be replaced. For reconstruction by means of a flap, instructions have already been given (Gonzfilez-Ulloa et al.,

3 REGIONAL /ESTHETIC UNITS OF THE FACE A--"/Esthetic Unit " of the Cheek. C--"/Esthetic Unit " of the Upper Lip. E--"/Esthetic Unit " of the Nose. FIG. 2 Except in the case of skin defects which can be removed by gradual excision, the restoration in visible areas should be made by whole regional areas which avoid most of the inconveniences of the partial~ anti-msthetic~ and antifunctional graft. 2z4

4 REGIONAL /ESTHETIC UNITS OF THE FACE B"--/Esthetic Unit " of the Mental Region. D--"/Esthetic Unit " of the Forehead. F--"/Esthetic Unit " of the Lids. FIG. 2 Except in the case of skin defects which can be removed by gradual excision, the restoration in visible areas should be made by whole regional areas which avoid most of the inconveniences of the partial, anti-msthetic~ and antifunctional graft. 215

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6 RESTORATION OF THE FACE COVERING ). Restoration by means of a graft is made with skin selected in thickness in " aesthetic units " of the whole region. I. How are " regional ~esthetic units " divided according to their thickness? According to their thickness (microscopically measured), " regional aesthetic units " are divided into: (a) Thick skin " aesthetic units " (2,000 to 3,000 /~); (b) medium skin "aesthetic units " (I,OOO to 2,000 t*) ; (c) thin skin " a:sthetic units " (500 to i,ooo/~). (a) The thick " resthetic units " are :- Cheek 2,900 Mental region 2,500 Nose (lobule) 2,400 kt Upper lip 2,300 (b) The medium " ~esthetic units " are :- Lower lip 1,9oo Neck. 1,8oo Nose (dorsum). 1,315 Ear (anterior-exterior) 1,26o v Forehead 1,0o0 (c) The thin " msthetic units " are :- Upper lid Ear (posterior-interior) 8oo Lower lid 70o FIG. 4 The covering of the face divided in regions produces a map of "regional msthetic units." These 2. From where should the skin be taken for the " cesthetic units "? There are, on the skin surface, extensive areas of thick skin with normal histological lines show the limits for transcharacter located in conspicuous areas of the body. plantation whether with grafts or flaps. These areas are good donors of facial " a:sthetic units." There are other areas with the same advantages as regards thickness and histological composition. However, these are more conspicuous than the former, because of their location on the anterior aspect of the body. The first areas we shall call AAA, the second AA (Table I). TABLE I Skin Donor Areas (Microscopically measured) Man, adult AAA AA Dorsal region 2,500 ~ Costal region 2,600 Lumbar region 2,I00 ~ Thigh (interior) 2,200 p Thigh (posterior). 1,9o5 ~ Abdominal region. 2,000 Infrascapular region 1,6oo ~ Thigh (exterior) 1,9oo Thigh (anterior) 1,8oo 3. What thickness should be given to the " regional cesthetic units "? For a restoration in which total function of the skin should be obtained, grafts are utilised that have a thickness as similar as possible to that of the skin that is to be replaced. These thick grafts do not contract, they slide over the deep layers, undergo less chance of pigmentary changes, and possess in their composition such glandular elements as will permit a more normal function and appearance in the skin that has to be transferred (Fig. 5). 3

7 218 BRITISH JOURNAL OF PLASTIC SURGERY The indications of several writers (Padgett, r939 ; Padgett and Soderberg, I942 ; Pavlowsky and Harris, I942 ; Padgett, z946 ; Beaux, I948 ; Corachan and Baquero, z95o ; Mir y Mir, I95I ; Bunnell, 1952) on the thickness of the so-called " whole-skin grafts" refer to dermatome thickness which is approximately 60 per cent. of the thickness of the skin as measured microscopically in isolated specimens. (See Table II and compare with the thicknesses shown in Fig. 6.) THE GRAFT ~ (includes all the elements of the skin) WHOLE-SKIN THICKNESS THE DONOR AREA <~ (with remaining epithelial elements to restore skin) SWEAT GLAND DEEPER THAN THE DERMIS SEBACEOUS GLAND FIG. 5 In a skin restoration in which the total functions of the skin are required, similar thickness should be used, leaving in the donor area sufficient epidermal elements to regenerate skin. According to the data obtained in the course of our study, it is possible to give the grafts a thickness similar to that of the area to be repaired, and, except in the donor area of the thick grafts, all areas will regenerate spontaneously, because of the existence, in the remaining dermal layer, of epithelial elements suitable for skin regeneration (see Fig. 5). Increase in the thickness of a graft makes the application of a good technique and good pre-operative and post-operative care compulsory, in order to secure a complete integration en masse, this being the purpose of an integral, a~sthetic, and functional skin restoration. The variation of thickness in different individuals, as well as sex variations and the irregularity of distribution of the epithelial elements of the cutaneous glands, observed in the course of our previous study (Gonzfilez-Ulloa et al., z955), made it necessary to find a factor, which can make the selective use of skin applicable to any average individual. The microscopically measured thickness of every skin was reduced to the lower round figure and 6o per cent. was obtained as the dermatome gauge indication (Table II).

8 RESTORATION OF THE FACE COVERING j2692\ I 2046 \f I! I / 1892 en ]M FIG. 6 Microscopic thickness of each " regional msthetic unit " of the face, and maximum thickness that can be obtained from the more suitable donor areas. TABLE n Regional 3Esthetic Units (Thickness and source of skin for transplantation) I. Thick Skin-- Cheek Mental region Nose (lobule) Upper lip 2. Medium Skin-- Lower lip Neck Nose (dorsum) Ear (anterior-exterior) Forehead 3. Thin Skin-- Upper lid Ear (posterior-interior) Lower lid in. (1,2oo p) (Or use a thin flap) o'o24 in. (600 p) o'o15 in. (375 ~) (Apply always over a hyperextended area) Dorsal region Costal region Thigh (interior) Lumbar region (Apply a thin graft over the donor area) The above-mentioned plus : Thigh (exterior) Thigh (anterior) Thigh (posterior) Infrascapular region Ear (posterior-interior) Arm (interior) Supraclavicular region (Or any of the abovementioned applied over a hyperextended area)

9 220 BRITISH JOURNAL OF PLASTIC SURGERY There are a great number of facial lesions that can be corrected by gradual resection. I believe this to be the elective treatment in cases where the scar can be concealed in facial folds or in shade or hair lines and no deformity is produced. Where this procedure is not feasible, the repair should be done by means of selected skin in "regional a;sthetic units." With the method described above, a~'sthetic inconveniences greatly decrease and skin function is fully restored. A single dermatome operation almost always makes it possible to secure the skin required for any facial region. The dermatome is gauged in three different thicknesses, 0"048, 0-024, and o-oi5 of an inch, depending on whether the region to be repaired is thick, medium, or thin. If two regions of different thicknesses are to be restored and the total area constitutes the size of a dermatome drum, I9o sq. cm., the section is made with the gauge of the thick graft. After the skin has been sectioned and the shape of each graft marked out on the dermatome drum, the excess is removed with the dermatome knife to give the thinner graft its requisite thickness. The region where the grafts are placed must be a recent surgical area, well vascularised. Careful h~emostasis is effected and the cutaneous borders are undermined in their periphery to enable suturing to be carried out without tension. The suture of one graft to another, in the limits of each region and with the neighbouring skin, is made with Dermalon 5-0. Sutures are withdrawn after forty-eight to seventy-two hours (such sutures should never be tight). Immobilisation of the grafted area is carefully effected. Secretions of the patient are diminished for forty-eight hours (atropine), feeding being by nasal or oral catheter. Administration of antibiotics, vitamins C and E, protein and electrolyte balance is effected according to the individual case. In grafting of the forehead, the bandage is applied without excessive pressure (danger of partial necrosis of the transferred skin from pressure against the frontal bone). In eyelid grafting, the repair is made separately (upper and lower). The area to be grafted is extended 60 per cent. more than is necessary, in order to avoid the occurrence of cicatricial ectropion. For nasal grafting an acrylic support is introduced in each nasal fossa to impart resistance to the cartilaginous structure, thus providing a sound base for fixing and applying pressure on the graft. A mould, similar to the above, is applied to the lateral portion of the dental arches in cases of skin restoration of the cheek, so that the graft may have contact throughout its surface and become wholly integrated. The same type of support and fixation is employed in restoring the skirt of the ear, which should be hyperextended as in the case of the eyelid. In lip grafting, immobilisation is secured by joining both lips together with several sutures (cotton yarn No. 40). These sutures are removed after forty-eight to seventy-two hours, at the same time as the graft sutures. When two symmetrical regions are affected (cheek, eyelids) it is advisable to make both repairs simultaneously. The procedure described above may be applied to relieve deformities resulting from cicatricial sequelae of burns or severe war injuries, necrotising acne, leprosy, and in all cases where a good a:sthetic and functional restoration of the facial skin is necessary.

10 RESTORATION OF THE FACE COVERING 22I SUMMARY The present study serves to emphasise the need for putting an end to the " age of skin-patch surgery," the results of which are often more regrettable than the original condition which they are supposed to correct. The method of selective regional restoration by means of "cesthetic units" is recommended, this method consisting of making cutaneous grafts of the same size, shape, and thickness as the whole region on which the repair is done. This procedure has two main advantages : (I) To conceal the borders of skin transplants in the natural limits of each region, and (2) to give each area the histological character and thickness that are peculiar thereto. The thickness of the facial skin and that of the donor areas best suited for replacing each region of the face is indicated. Technical details are given for securing a total integration of the cutaneous graft. REFERENCES BEAUX, A. R. (I948). Dia todd., 20, I647, BUNNELL~ S. (I952). " Surgery of the Hand," Philadelphia : J. B. Lippincott. CORACHAN, M., and BAQUERO, R. (I95O). Prensa todd. argent., 37,459. GONZALEZ-ULLoA, M., CASTILLO, A., STEVENS, E., and ALVA~Z FUERTES, G. (I954). Plast reconstr. Surg., x3, 3. GONZALEz-ULLOA, M., STEVENS, E., ALVAREZ FUERTES, G., and LEONELLI, F. (I955). Paper presented at the International Congress of Plastic and Reconstructive Surgery, Sweden. MIR Y MIR, L. (i95i). Act. dermo-sifilogr., Madr., 42, 66. PnDGETT, E. C. (I939). Surg. Gynec. Obstet., 69, (I946). Arner..7. Surg., 72, 683. PnDGETT, E. C., and SODERBERG, N. B. (I942). Dia todd., x4, 8. PAVLOWSKY, A. J., and HARRIS, M. M. (I942). Sere. todd., B. Aires, z, 7o9