842 BRIT. J. SURG., 1966, Vol. 53, No. 10, OCTOBER

As the result of the repeated emphasis by McCance and others of the importance of growth as a homeo- static factor in the newborn, much more emphasis is now being placed on the importance of starting milk feeding within 24 to 48 hours after operation. This can usually be achieved by some form of intubation of the stomach or intestine to allow the instillation of milk feeds into the normal alimentary tract below the level of the original obstruction.

As a cause of death in childhood, malignant disease is now second only to accidents. I t has been esti- mated that each year about IOO tumours occur per million children (Steward, 1966) or about 1200 tumours in children under the age of 14 years in the United Kingdom. Most of these are already far advanced at the time they first cause symptoms and perhaps 70 per cent are beyond our present methods of treatment by the time they are first recognized. Apart from tumours of the reticulo-endothelial and blood-forming organs, perhaps 80 per cent cannot be adequately treated by surgical excision alone. Amongst the many ways in which the present situa- tion might be improved, two stand out. First, im- provements in the forms of chemotherapy which are available and the more critical use of these drugs and, secondly, concentration of the patients in fewer centres so that a deeper experience in management and treatment can be accumulated. Steward (1966)

has reported that during 9 years in the Manchester region 21 children with Ewing’s tumour were treated by 17 different surgeons.

In addition to concentration of the patients, prefer- ably in children’s hospitals with access to suitable facilities for radiotherapy, there should be for Eng- land and Wales regional and national children’s tumour registries such as already exist in Scotland and Manchester. Through such registries informa- tion about the tumours of childhood, but not neces- sarily the patients, could be collected. From the analysis of such information the effects and value of current forms of treatment could be judged and much needed improvements might be devised.

REFERENCES EHRENPREIS, T., and SANDBLOM, P. (1949), Acta paediat..

Stockh., 38, 109. LAWRENCE, K. M. (1960), Post-grad. med. J., 36, 662. SHARRARD, W. J. W., ZACHARY, R. B., LORBER, J., and

BRUCE, A. M. (1963), Archs Dis. Childh., 38, 18. STEWARD, J. K. (1966), Br. med.J., I, 767. WATERSTON, D. J., BONHAM CARTER, R. E., and ABER-

DEEN, E. (1962), Lancet, I, 819. WILKINSON, A. W., HUGHES, E. A., and STEVENS, L. H.

(1969, Br. J . Surg., 52, 410.

18. YOUNG, D. G., and WILKINSON, A. W. (1966), Lancet, 2,

PLASTIC SURGERY BY T. GIBSON

DEPARTMENT OF SURGERY, WESTERN INFIRMARY, GLASGOW

THE scope of plastic surgery is not easy to define and it overlaps that of many other specialties. In select- ing topics for this review I have concentrated on those which seemed of most general interest and omitted those advances in technique which are of immediate value only to plastic surgeons; only the highlights have been sketched, giving, wherever possible, references to recent reviews rather than to individual papers.

IMlMEDIATE REPAIR OF OROFACIAL CANCERS

Although it is possible to reconstruct almost any defect resulting from ablation of malignant disease around the mouth and cheeks, this has often had to be a secondary procedure leaving the patient for weeks or months drooling uncontrollably, unable to eat adequately, or to speak intelligibly. Recently a number of techniques have been described which will permit primary closure of the defect and give as good a cosmetic and functional effect as a delayed repair. The secret lies in providing immediate lining for the buccal defect, since the skin cover can usually be readily achieved by local rotation or transposition flaps. There are two main techniques. For example, a flap of neck skin may be turned inwards below the mandible. By removing the epithelium over the site of the fold, the neck defect can be free-grafted and an oral fistula avoided (Kiehn and Des Prez,

1964). Neck flaps have the disadvantage of growing hair in male patients and McGregor (1963), alterna- tively, prefers the use of a forehead flap based on the temporal artery (Figs. 1-3). This can either be inserted through a slot just below the zygomatic arch and the

FIG. I.-Immediate pedicle flap reconstruction of intra-oral mucosal defects resulting from cancer ablation. The temporal flap (McGregor 1963) is designed as a ‘mirror image’ of the defect ta be repaired.’ (Figs. 1-3 reproduced by kind permission of the ‘British J’ournal of Plastic Surgery ’.)

GIBSON: WHAT’S NEW IN PLASTIC SURGERY 843

excess pedicle replaced later, or it may be prepared as an ‘island’ flap on a subcutaneous pedicle which is rerouted to the new site. As a refinement of this technique local flaps of tongue mucosa may be used to replace deficiencies in lip vermilion.

Excision of turnours of the maxilla has nearly always meant a permanent defect of the hard palate, many of which are not easily closed by obturators. Bakamjian (1963) has designed a local flap from the

quamous Carcinoma. Carcinoma excised. Temporal flap raised. Cheek tunnel made.

neck which incorporates the sternomastoid muscle and the skin overlying it, and which is inserted through a separate submandibular incision for im- mediate repair of the palatal defect.

INTRA-ORAL EXPOSURE OF THE JAWS The mouth has the reputation of being, bacterio-

logically, the most highly contaminated cavity in the body. For this reason operations on the jaws,

ral flap through

. S S G to scalp.

FIG. 2.-Transverse section of cheek showing diagrammatically how the temporal flap is passed through a cheek tunnel into the defect. A split-skin graft covers the donor site and the exposed under-surface of the pedicle bridge. Later the pedicle is divided and the excess returned to the scalp.

FIG. 3.-Temporal flap used after hemiglossectomy, hemimandibulectomy, and block dissection of neck glands in continuity for squamous carcinoma of floor of the mouth. A, Just before return of bridge segment of flap. 6, At completion of surgery. C, D, Intra-oral views of completed flap.

844 BRIT. J. SURG., 1966, Vol. 53, No. 10, OCTOBER

particularly the mandible, have usually been carried out through an external exposure and the greatest care taken not to enter the oral cavity, particularly when bone-grafts were being inserted. There has been a gradual realization in recent years, not only

that the intra-oral approach was just as safe, but that it provided far better exposure and left no visible scar. This has been responsible for a great increase in interest in the reconstructive surgery of both upper and lower jaws.

\

A B FIG. 4.-The intra-oral approach to the mandible. An incision from angle to angle in the buccal sulcus (A), with careful preservation

of the mental nerve, enables almost the whole of the body of the mandible to be exposed. (Converse, 1964.) (Figs. 4, 5 reproduced from ‘Modern Trends in Plastic Surgery-I’ by kind permission of Butterworths.)

A B

C D FIG. 5.-Micrognathia treated by intra-oral approach.for elongation of the body of the mandible. A, Extreme micrognathia with temporo-

mandibular ankyiosis resulting from forceps inlury at birth. 6, Profile view of the micrognathic patient. C, Improved contour obtained by elongation osteotomy and contour restoring bone grafting through the intra-oral approach. D, Improved contour following surgery. (Converse, 1964.)

GIBSON: WHAT'S NEW

The most important advance in intra-oral maxil- lary reconstruction has been the technique of primary bone grafting of congenital clefts of the palate (Johanson and Ohlsson, 1961; Rehrmann, 1964; Schuchardt, 1966). There exists a bony defect of the hard palate in congenital clefts and the effect of covering this with mucosa alone has often been the formation of a contracting bridge of scar tissue which drags the fragments inwards, collapses the alveolar arch, and leads in later life to underdevelopment of the maxilla and secondary prognathism of the mandible. I t is claimed that primary bone grafting of the defect at or before I year of age prevents this deformity. Johanson and Ohlsson (1961) bone-graft the whole length of the defect but many other workers feel that a bony bridge between the alveolar fragments, once these are properly alined, is sufficient. The bone rapidly becomes incorporated in the maxilla and anterior teeth frequently erupt through it in a more normal position than would otherwise have been achieved.

Reconstruction of the deformed maxilla is also being undertaken by osteotomies through intra-oral incisions. In this way a maldeveloped upper jaw may be brought into normal occlusion (Winstanley, 1965).

Many more malformations of the mandible are being reconstructed than ever before. Prognathism or retrognathism with an overshot, undershot, or open bite and unilateral cases with cross-bites can be readily corrected through an intra-oral exposure (Figs. 4, 5). These are not merely cosmetic operations; by careful dental planning the patient's teeth can be brought into occlusion and he can chew efficiently, often for the first time in his life. There are many techniques described. The prognathic mandible may be set back by excising precisely the right amount of bone from each side of the body (Converse, 1964) or by dividing the ramus on each side (Moose, 1964; Obwegeser, 1964). The micrognathic mandible can be advanced by a sliding-step osteotomy and a bone- graft; an additional bone-graft in front of the sym- physis will disguise the recessive chin (Converse,

Most operations on the body of the mandible, including the interosseous wiring of fractures and the removal of cysts, can be carried out more easily by the intra-oral route and external scars thereby avoided. Lesions on the ascending ramus, however, are usually best exposed through a skin incision (Osborne, 1964).

BURNS AND SCALDS There is nothing static in the treatment of burns

and the newcomer reading the world literature today might well be confused and bewildered by the many different methods, all of which have their sincere protagonists and many of which seem at first sight contradictory. Only the most important features can be reviewed here.

First-aid Treatment.-It has long been known that cooling is the only method of local treatment which will reliably relieve the pain of a recent burn. Claims are now being made that local cooling will also lower the mortality and prevent, in part at least, the development of shock due to burns. Ofeigsson (1965)~ impressed with the traditional methods of treating burns in Iceland by immersion

1964).

I N PLASTIC SURGERY 845

in or local application of cold water, has carried out many experiments in rats which show that a marked reduction in mortality and morbidity may be achieved in this way; the control rats had a mortality-rate of 60 per cent while of those cooled immediately after injury by water at 25' C. only 5 per cent died. Even when cooling was delayed for up to 45 minutes there was a significant reduction in the death-rate. Cooling to lower temperatures is undesirable and most of the rats immersed in water at oo C. died. One result of

FIG. 6.-Simple first-aid dressings for burns. Sheets of poly- urethane foam fixed with simple clip fasteners are comfortable to wear, protect the burn from outside infection, and are easily removed. (Kohn, 1963.) The reinforced backing originally described is no longer considered necessary. (Reproduced by kind permission of Dr. Y. Kohn, of the Department of Pathology, Queen Mary's Hospital, Roehampton.)

immediate cooling is to halt the burning process; burned skin remains at a potentially destructive temperature after injury and this is prolonged for some minutes if the area is clothed. Immediate im- mersion is the most effective and rapid method of reducing the skin temperature to safe limits and seems much preferable to the traditional method of wrapping in blankets or rugs which might have the opposite effect.

The reason why cooling decreases mortality is made clear by the work of King and Zimmerman (1965). In experimental animals they found that there is an extensive outpouring of serum from the damaged capillaries which appears within the first minute, continues at a rapid rate for 30 minutes, and then decreases slowly until it almost ceases after 3- 4 hours. Immediate cooling in water at 5" C. prac- tically abolishes this serum loss and thus minimizes the decrease in blood-volume which is responsible for much of shock due to burns. To be effective, however, it must be applied as soon as possible during the first 30 minutes after burning and con- tinued throughout this period.

It is not yet clear how these significant findings can be applied to human burns. When the patient reaches hospital the period during which cooling might have been beneficial has usually expired. There seems good reason for advocating immediate immersion in or repeated applications of cold water as a first-aid measure; but caution is required until the other effects of hypothermia in such cases have been evaluated.

846 BRIT. J. SURG., 1966, Vol. 53, No. 10, OCTOBER

The shadow of an atomic explosion influences much of the current thinking about burns, and a simple-to-apply first-aid dressing which is cheap and readily stockpiled would obviously be worth while. Kohn (1963) advocates sheets of polyurethane foam with simple clip fasteners to wrap around the burned part (Fig. 6). They are comfortable to wear, protect the burn from outside infection, and are easily removed.

Shock due to Burns.-Although the traditional- ists still support the view that shock due to burns is largely due to loss of fluid from the blood-stream and should be treated by intravenous fluid replace- ment, there are diverse opinions as to the relative amounts of plasma, plasma substitutes, electrolytes, and blood which should be given. Some believe, on the evidence of animal experiments, that fluid replacement can be accomplished by oral fluids alone. Since stockpiling of replacement fluids in case of an atomic blast is almost impossible, Jackson (1965) has carried out a controlled experiment to assess the treatment of shock due to burns in man by oral fluids alone. Using a half-isotonic solution of saline and bicarbonate, he found that burns up to 30-35 per cent of the body surface could safely be treated in this way, but the treatment is no easier and requires as much care and observation as intravenous therapy. Complications in a minority, such as continuous vomiting, an increased haematocrit, or peripheral vascular failure, had to be corrected by intravenous colloid.

Interest continues in the concept of burns ‘toxins ’, substances liberated in the burned skin which are alleged to cause the ‘toxaemia’ of shock due to burns. This is too large a subject to be discussed here. It has been well reviewed by Sevitt (1966), who con- cludes that most, if not all, of the so-called toxins in burns have been bacterial in origin.

Infection in Burns.-The wide range of avail- able antibiotics has completely changed the bacterio- logical aspects of the treatment of burns. No longer is the streptococcus the organism the most to be feared. Most attention is now centred on Pseudomonas aeruginosa (Ps. pyocyanea) which is resistant to most antibiotics and is the most common cause today of fatal septicaemia in burns. Kohn (1963) has investi- gated the spread of Pseudomonas in a burns unit and emphasizes that it is a contact, fomite, or ‘moist surfaces’ contaminant and is not primarily an air contaminant. He has found it in brushes, soap containers, mops, buckets, many antiseptic solutions, and in almost every sink trap which was examined. In such sinks it is often present around the plug-hole ready to be dispersed during scrubbing. With the changing pattern of cross-infection, this should be borne in mind when designing new bums centres; most of them are planned on the assumption that airborne infection is the main problem.

Jones and Lowbury (1965) have developed anti- sera which are able to protect mice from Pseudomonas septicaemia. Pseudomonas vaccines and hyperimmune plasma have been used with success in human burns (Feller, 1965), but there are many different strains of Pseudomonas and a completely polyvalent vaccine or antiserum has yet to be achieved.

Evaporative Water Loss and the Silver- nitrate Method.-In the stratum corneum of human skin there exists a barrier to the loss of body

water by evaporation (this is quite distinct from sweat evaporation, a process nicely regulated for thermostasis). Moyer (1962) first drew attention to the fact that burning destroys this vaporization barrier; however deep and waterproof the eschar appears, the amount of water loss through it is seventy to eighty times greater than from normal skin and is similar to that from a granulating surface. In extensive cases the water lost in this way may amount to 5 or more litres per day (Roe, Kinney, and Blair, 1964) and this means an expenditure of about 3000 calories to make good the energy loss in evaporation. Harrison, Moncrief, Duckett, and Mason (1964) point out the importance of this item in the increased catabolism of extensive burns.

Until the exact nature of the water-vapour barrier is known, there are only two possible substitutes, water-impermeable films and total immersion of the burn in physiological solutions. Films impermeable to water are also impermeable to pus and soon con- stitute the outer wall of an abscess. Moyer, Brentano, Gravens, Margraf, and Monafo (1965) therefore tried the effect of immersion in baths of Locke’s solution. The patients were comfortable, pain-free, ate well, and did not lose weight; sloughs separated rapidly and bloodlessly. But in spite of continuous filtration and changing, the number of organisms in the bath was astronomical within 24 hours and a number of invasive infections occurred. Continuously wet dressings have the same effect in minimizing evapora- tion and this method they have now put into effect using 0.5 per cent silver-nitrate solution as the best available antiseptic. They claim that the whole treat- ment of deep burns as extensive as 50 per cent of the body surface can be regularly and successfully accomplished without transfusions of plasma, p!asma substitutes, or blood, without infection, without slough excision, and without anaemia. In a series of 21 extensive burns in whom the expected mortality was 80 per cent only a third died.

These are impressive claims, but the technique is not without disadvantages. While it is claimed that 0.5 per cent silver nitrate is non-caustic, I per cent is, and therefore drying must be avoided. The dressings must be continuously wet and changed once or twice daily. Silver nitrate blackens on exposure to light, and dressings, bed linen, clothing, and skin are all affected. It is recommended that the floors and walls of the treatment room should be painted black and the attendants must protect their own skin and clothing.

SILICONE-RUBBER IMPLANTS Until the homograft reaction is overcome, recon-

structive surgery will continue to rely on inert im- plants to replace many missing tissues. The body seems tolerant of such foreign bodies if they are not chemically or electrolytically irritant and not subject to undue stress. It is a well-known engineering fact that when a structure composed of two materials, one of which is hard and the other soft, is put under load, the effects of the loading are most severe at the junction between the materials. Rigid implants of metal and plastic are successful replacements for skull defects or when applied to other bones for orthopaedic purposes, but rigid implants in the soft tissues often fail because of the shearing stresses

GIBSON: WHAT’S NEW

which occur at their periphery and which lead to separation, haematomata, and secondary infection. An intensive search has been made in recent years for suitably soft, pliable, plastic materials to replace tissues other than bone. By far the most popular and promising of these are the silicone rubbers.

Silicone rubbers are polymers of dimethyl siloxanes. Certain catalysts such as stannous octoate increase the number of cross-linkages between the long- chained molecules and so increase the strength and consistency of the material; fillers may be added for the same purpose. Most of the development of ‘ medical’ grades of silicone rubbers has been under- taken by the Dow Corning Company of the United States and they are marketed as ‘silastic’. They can be sterilized by boiling or autoclaving and several experimental studies in animals (Marzoni, Upchurch, and Lambert, 1959; Brown, Fryer, and Ohlwiler, 1960; Brown, 1961; Conway and Goulian, 1963; Speirs and Blocksma, 1963) have shown them to be inert and productive of virtually no reaction in the tissues. Indeed, this has proved to be a slight dis- advantage, and Azzato and Kapiloff (1964) empha- size the need to anchor ‘silastic’ implants to avoid migration.

A wide range of ready-for-insertion implants are now on the market. Testicular prostheses, otoplasty prostheses (to supply the supportive skeleton in a reconstructed ear), nasal-bridge prostheses, and even an artificial 0s penis for cases of impotence are avail- able. The material is expensive and at present a pair of breast prostheses for mammary augmentation consisting of a silicone gel enclosed in a ‘silastic’ membrane costs 175 dollars. ‘Silastic’ may be pur- chased as blocks of different grades of rigidity for carving by the surgeon or as sponge implants. Do-it- yourself kits enable the surgeon to cast implants of any desired size or shape or consistency!

Unpolymerized silicone rubber can also be injected directly into the tissues. The catalyst is added just before injection and the material gels in the tissues some minutes later. This is currently an extremely popular technique in Japan and the Far East where the demands of Oriental girls for augmentation of their relatively flat breasts is being satisfied by such techniques, often by unqualified practitioners (which is, to me, potentially dangerous, since often the material lies interstitially and would be almost im- possible to remove if anything went wrong). It is safer to prepare a cavity surgically into which the material is then inserted and where it will remain in one piece.

I N PLASTIC SURGERY 847

REFERENCES AZZATO, N. M., and KAPILOFF, B. (1964)~ Plastic reconstr.

BAKAMJIAN, V. (1963), Zbid., 31, 103. BROWN, J. B. (1961), Zbid., 28, 86. -- FRYER, M. P., and OHLWILER, D. A. (1960), Zbid.,

Surg., 34, 414.

26, 264. CONVERSE, J. M. (1964), in Modern Trends in Plastic

Surgery-Z (ed. GIBSON, T.), p. 173. London: Butter- worths.

CONWAY, H., and GOULIAN, D. (1963)~ Plastic reconstr. surg., 32, 294.

FELLER, I. (1965)~ Proceedings of the Second International Congress for Research in Burns, Edinburgh, 1965. Edinburgh: Livingstone. In the press.

HARRISON. H. N.. MONCRIEF. 1. A., DUCKETT, 1. M.. and MASON,. A. D.-(1964), Surgery, St Louis, 56; 203.-

JACKSON, D. M. (1965), Proceedings of the Second Znter- national Congress for Research in Burns, Edinburgh, 1965. Edinburgh: Livingstone. In the press.

JOHANSON, B., and OHLSSON, A. (1961), Acta chir. scand.,

JONES, R. J., and LOWBURY, F. J. L. (1965)~ Proceedings of the Second International Congress for Research in Burns, Edinburgh, 1965. Edinburgh: Livingstone. In the press.

KIEHN, C. L., and DES PREZ, J. D. (1964), in Modern Trends in Plastic Surgery-Z (ed. GIBSON, T.), p. 189. London: Butterworths.

KING, T. C., and ZIMMERMAN, J. M. (1965), Surgery Gynec. Obstet., 120, 1271.

KOHN, J. (1963),JI R. Army med. Cps, 109, I . -- (1965)~ Proceedings of the Second International

Congress for Research in Burns, Edinburgh, 1965. Edinburgh: Livingstone. In the press.

MCGREGOR, I. A. (1963), Br. J . plast. Surg., 16, 318. MARZONI, F. A., UPCHURCH, S. E., and LAMBERT, C. J.

(I959), Plastic reconstr. surg., 24, 600. MOOSE, S. M. (1964), Br. J . oral Surg., I, 172. MOYER, C. A. (1962), Am. Znst. Biol. Sc., Publi, 9,

113. -- BRENTANO, L., GRAVENS, D. L., MARGRAF, H. W.,

and MONAFO, W. W. (1965)~ Archs Surg., Chicago, 90, 812.

OBWEGESER, H. (1964)~ Br. 3. oral Surg., I , 157. OFEIGSSON, 0. J. (1965), Surgery, St Louis, 57, 391. OSBORNE, R. (1964), Br. J . plast. Surg., 17, 376. REHRMANN, A. (1964), Modern Trends in Plastic Surgery-

Z (ed. GIBSON, T.), p. 50. London: Butterworths. ROE, C. F., KINNEY, J. M., and BLAIR, C. (1964), Surgery,

St Louis, 56, 217. SCHUCHARDT, K. (1966), in Modern Trends in Plastic

Surgery-ZZ (ed. GIBSON, T.). London: Butterworths. SEVITT, S. (1966), in Modern Trends in Plastic Surgery-

ZZ (ed. GIBSON, T.). London: Butterworths. SPEIRS, A. C., and BLOCKSMA, R. (1963), Plastic reconstr.

122, 112.

Surg., 31, 166. WINSTANLEY, R. P. (1965), Br.J. oral Surg., 2, 173.