History of Skin Grafting

 


Skin transplantation has a long and colorful history. Loss of skin is very often disfiguring, and so it has easily attracted medical attention. The earliest records indeed deal with such cosmetic repair. In the fifth century AD Sushrutha, an Indian surgeon, lived and practiced on the banks of the Ganges. He wrote seminal medical texts, and proposed several radically forward thinking surgical concepts. He is the first to drain infected abscesses and recommended prospective doctors practice on watermelons and animals before they perform surgery on a human. Sushrutha was also the first recorded physician to perform rhinoplasty, and as such he is often heralded as the father of both skin grafting and plastic surgery. He repaired noses that had been removed as punishment for crimes such as theft and adultery. His method, still used today, involves cutting a strip of flesh from the forehead and flapping it down over the damaged nose. The strip will remain attached to the forehead by what is called a pedicle, though which blood can nourish the skin. After the strip has “taken” to the nose site, they would be surgically detached from the forehead. Records are also made of Sushrutha transplanting flesh from the buttock to the nose, another method still used today.

        In the 1442 the Italian scientist Brancas and his son developed the radical technique of reconstructing the nose with a strip of flesh still attached to the forearm. The procedure was in much demand as syphilis ravaged the country, and thousands of Italians were finding themselves noseless. This procedure received little attention until it was published in 1597 by a fellow Italian named Tagliacozzi, who took all the credit for the procedure.

Baronio, an Italian physician, was fascinated by skin transplantation. He describes in his memoirs once seeing an itinerant salesman hawking a homemade miracle ointment. He would cut off a piece of his skin and reattach it with his ointment to demonstrate it’s potency at closing wounds. Unfortunately this miracle ointment has never been identified, though it did inspire Baronio to experiment with autologous skin grafts in sheep with surprising success in 1804.

        In 1823 Carl Bunger, a german surgeon documents the first modern successful skin graft on a human patient. Bunger was repairing a patient with a nose also destroyed by syphilis. He grafted a small chunk of full thickness flesh from the inner thigh to the nose successfully, in a method very reminiscent of Sushrutha’s. After this, tentative skin grafting began to spring up all over the place. The success was minimal in this era, however. Grafts were inefficiently harvested and larger grafts were never successful. In light of this, a Swiss surgeon named Reverdin developed a method known as pinch grafting in 1869. Pinch grafts, or Reverdin grafts as they are still called, are obtained by pinching up a small amount of skin and cutting it out, to obtain a small circular skin disc. This process would be repeated several times producing many small and easily healing injuries from the donor site. The discs would be spread out over the compromised site, as tiny little islands from which healing could commence. This method is effective, however, the grafts were not very thick, and if the burned area was large and the islands were far apart, the transplant was almost useless.

        It was soon realized that such small grafts would never be applicable to anything beyond small wounds. In 1870 George Lawson proposed a deeper thickeness graft including not only epidermis but dermis as well will probably revascularize more easily, while it will be harder to heal from at the donor site. Indeed, two years later in 1872 Ollier transplanted several grafts of 4-8 square centimeters over several ulcerous and burnt patients. The grafts were carefully harvested deep-partial thickness grafts that were more successful than earlier grafts.

        In 1874 Thiersch used the increasing quality of surgical instruments to advocate the removal of razor thin sking flaps instead. These razor grafts or Thiersch grafts allowed for extremely rapid donor site healing, but they were of very limited strength, and were therefore only usefull for covering very small or static wounds, like simple ulcers or small burns.

        It was not until the 1920’s that Blair and Brown began to study skin physiology in a search for answers. They identified that healing proliferation at the donor site is initiated by deep islands of hair follicle and sebaceous gland epithelial cells. This meant that a graft cut very deep, including even the dermal pad of dense and strong connective tissue matrix, could be harvested and would still heal fully and naturally. These grafts were called split grafts because the tools for harvesting them were adapted from similar tools used for splitting leather in a harness shop. The name stuck, though the tools evolved quickly and wildly. In 1939 Padgett invents the first dermatome, a surgical instrument for easily removing large flaps of skin of a prescribed depth. Many other dermatomes were developed and skin grafting became a common practice and not a miraculous one.

        As the century progressed skin transplantation found more and more applications and techniques continued to improve. As the bodies immune system began to be better understood, treatments could be directed at preventing the bodies rejection of transplanted skin. As skin grating became more common and usefull, doctors looked for new sources of skin. Cadaveric skin became very popular, though it needed to be harvested quickly and treated carefully and extensively. In 1944 Webster begins experimenting with refrigerating skin, and manages to successfully store skin for as long as a couple of weeks to be used as a dressing for a burn. This revelation prompted the US Navy to establish “Skin Banks” at strategic locations filled with frozen skin.

        In 1975 Rheinwald and Green go down a different path and attempt to grow skin in vitro from human keratinocytes, and succeed in growing sheets of epithelial cells. Researchers also began looking for effective skin substitutes or artificial skin. Both of these areas of study remain active and lively today, and neither has been made quite practical. Skin transplantation today is a commonplace procedure for many kinds of patients. It can be lifesaving for burn patients or purely cosmetic for others. The field continues to see exciting research, as well, and promises to only continue to expand in the coming decades.