Reverdin and Other Methods of Skin-Grafting
Boston Medical and Surgical Journal
The ancients well understood the art of bridging over skin defects by the use of the plastic flap. The earliest mention of the procedure, employed in rhinoplasty, is found in the Ebert papyrus, dating about 1500 b.c. Galen and Celsus wrote upon plastic surgery, as did also Antyllus and Paul of Aegina. It was among the natives of India, however, I hat the operation reached its highest development in ancient times. From the Ayurveda (c. 100 b.c.) we learn that plastic flaps were turned on to the
... ose from the cheek, and later from the forehead. Some attempts also at plastic work about the ears were made. The operation was probably quite commonly performed, for ears and noses were amputated in those days as a punishment for crime. There seems to have existed among the Brahmins a certain caste, the Koomas, or potters, which considered the repair of mutilated features its especial province. Besides using the pediculated flap, from the cheek or forehead, they would sometimes vary the procedure, as Susruta tells, by slapping the skin of the buttock with a wooden shoe until it wras quite congested, and then, with a leaf cut to proper shape as a pattern, cutting out a piece of skin with its subcutaneous fat, transplanting it and sewing it into place, uniting it to the freshened edges of the defect. lip and nose, expounded the method which was then in general use. Whereas the Indian method provided that the pediculated flap be taken from close at hand, so that it need only be rotated on its pedicle to cover the defect, the Italian or Tagliacotian allowed for the taking of the flap from any portion of the surface of the body, provided only that it could be brought and fixed in close enough approximation to the area to be covered. For this sort of rhinoplasty the left upper arm was usually chosen, and on its anterior aspect two parallel cuts eight inches long were made down to the fascia, four inches apart. The strip thus formed was separated up from the fascia by blunt dissection, and under it was carried a sheet of oiled paper, to prevent formation of adhesions. After a week or more, when the under surface had granulated in thoroughly, the upper end of the strip was cut across, the arm brought up to the face and fixed by straps, and the flap sewed into place. Tagliacozzi had a few followers who reported successful cases, but rhinoplasty gradually sank into disuse and in course of time began to be considered impossible or fabulous, and his success was declared apocryphal. Reneaulme de la Garanne (1712) tried to rehabilitate it, proposing to simplify the operation by sewing into the defect a fresh flap immediately after cutting, without waiting for it to granulate. But the " investigators " of the eighteenth century were satisfied with writing Latin dissertations on the improbability of the operation's ever having been performed. Finally-, at the end of the eighteenth century, the Paris Academy of Surgery expressed the accepted opinion when it declared that the operation was impossible. eeverdin graft. In the latter half of 1869 M. J.-L. Reverdin, a young Genevan (interne in the Hôpital Necker in Paris under Guyon), noticed, as Billroth had done, the occurrence of islands of epithelium in the midst of the granulations of ulcers. Accepting Billroth's explanation for the occurrence of these islands from proliferation of the epithelium of deep-lying portions of skin glands, or of scattered bits of the basal layer of epithelium, by chance uninjured by the destructive force, he recognized the importance of aiding epidermatization of ulcers by the artificial implantation of new islands to serve as centers of growth. Accordingly, in a patient who had lost the skin of his thumb, he tried the experiment of planting on the granulations two small bits (of about 1 sq. mm.) of epidermis lifted from the skin of the upper arm by the point of a lancet, without drawing blood, and held in place by a strip of diachylon plaster. These took root, and from them, and from other grafts applied later, the epithelium spread to the margin of the ulcer. He called this " epidermic grafting," and on Dec. 8, 1869, he presented a paper on the case to the Société Impériale de Chirurgie. Reverdin had demonstrated that detached particles of living epidermis not only retained their vitality for a certain time, but that when laid upon a granulating surface, they were capable of entering into permanent union with it, and of actively proliferating toward the formation of new epithelium.