War Surgery and Medicine
LONG-RANGE PLASTIC SURGERY
LONG-RANGE PLASTIC SURGERY
(See page 371)
For the long-range work it was recognised that the resources of a complete plastic surgery unit were required, including a surgical team, a dental team, physiotherapy department, and occupational therapy department; these were provided at the Plastic Surgery Unit, Burwood Hospital, Christchurch. The complete range of plastic surgery was done here and included
Facial reconstructions and
Repair of soft-tissue defects associated with limb injuries
Fig 10 Facial reconstruction following severe compound fractures of the cranium and facial skeleton, and extensive soft-tissue damage. This patient was at the periscope of a tank which was struck by an anti-tank missile and the periscope was thrust into his face. His early treatment had consisted of removal of the comminuted fragments of the frontal bone. On his admission to Burwood his general health was excellent, but he had (a) a pulsating skull defect, frontal bone; (b) lateral fracture of the nose with marked displacement to the left; (c) an opening into the nasal fossae from the right side of the face
He was treated by
Bone grafting to restore the skull over the pulsating skull defect.
Nasal refracture to restore the nose as nearly as possible to the mid-line. 3. Tubed pedicle flap repair to make good the soft-tissue loss at the root of the nose. 4. Scar excision and plastic repair to restore the soft-tissue displacement
Fig 11 Facial reconstruction. Extensive facial injury with loss of left eye and lower eyelid due to missile entering below right eye, crossing the nasal fossae and emerging in the region of the left eye. Patient was treated by means of
1. Forehead flap repair to restore left lower lid together with local plastic operation on the conjuctiva, scar excision and plastic repair right cheek. 2. Bone grafting to restore nasal bridge line. 3. Manu
Fig 12 Extensive facial injury with compound fracture lower jaw obliteration of left lower buccal sulcus, loss of left nasal ala and extensive soft-tissue damage submental region. Reconstruction by means of
1. Local soft-tissue plastic repair, chin region. 2. Forehead flap repair left nasal ala. 3. Free skin grafting left lower buccal sulcus. 4. Construction of suitable partial lower denture
Fig 13 Repair eye socket. Extensive damage right side of face with loss of right eye and extensive damage to the eye socket. This patient had his eye socket lined with an excellent skin graft, but still suffered from an almost complete absence of the upper lid and marked displacement of the right eyebrow. This was treated by
1. Z plastic operation right eyebrow. 2. Local plastic remaining right upper lid. 3. The construction of an artificial eye together with the adjacent missing parts of the eyelids. 4. Camouflaged by means of convex spectacles
Fig 17 Similar injury right upper lid. Treatment same as for Fig 16
Treated by free skin graft applied on stent mould, kept in position by cast metal cap splint on upper teeth, with extra-oral bar. Loss of levator function upper lid and marginal defect lower lid corrected by means of specially fashioned prosthesis. This had a clear acrylic support for the upper lid with the missing portion of lower lid simulated in tinted acrylic. Camouflaged by means of spectacles
Note: This type of case requires maintenance by a skilled prosthetist as the prosthesis tends to get loose. Because no such service was readily available for maintenance, the state of this repair as shown is unsatisfactory
Fig 20 Soft-tissue repair wrist. Sever injury right wrist with loss of lower end of radius, large soft-tissue defect, lack of stability at wrist. Required bone graft, but needed adequate soft-tissue repair as a preliminary. Treated by means of direct abdominal flap as illustrated, followed by orthopaedic treatment
Fig 22 Repair of sever soft-tissue injury right ankle and heel with adherent scar over os calcis. This foot was extremely painful for weight bearing. It was treated by means of an abdominal tubed pedicle flap transferred by means of the wrist. The diagram shows technique of formation of abdominal flap, including skin grafting of raw area
Fig 24 Repair of unstable scar right calf. Treated in same way as Fig 23
Fig 25 Repair of extensive injury left knee-joint region with complete bony ankylosis and a large bone cavity containing sequestra. Treatment: tubed pedicle flap repair from right flank via right wrist and right or healthy leg (this was necessary owing to the ankylosis of the left knee); preliminary attachment to cavity after removal of lining and dead bone; then the other end of the pedicle flap was attached below the cavity on the left leg; later the skin was removed from over the cavity leaving only the fat filling it, and a fresh skin covering made over this again; then final repair
Several other methods of fixation were employed for fractured mandibles where one or both fragments did not carry teeth. These included circumferential wiring, Darcissac's method, and direct bone wiring. The last of these, direct bone wiring, was a valuable last resort in certain cases where early treatment had been a failure and a non-union had resulted, with gross displacement due to muscle traction. (Figure 4.)
It is worth pointing out that problems of fixation are nearly all concerned with the mandible. If there has been any degree of displacement at all, the mandible can be an extremely difficult bone to maintain in its reduced position, in a state free from mobility between the bone ends. On the other hand the maxilla, by comparison, seldom presents any difficulty, once it has been reduced.
In cases which ultimately require bone grafts and reconstructive plastic surgery, there must necessarily be a long delay till sepsis is cleared and healing completed. In the later stages of the war attempts were made at early bone grafts.
In plastic surgery, the commonest procedure involving the dental surgeon was that of making an intra-oral skin graft, the so-called ‘epithelial inlay’, to enlarge the depth of the buccal sulcus of the oral cavity. This was often necessary where bone loss following the original injury had left no alveolar ridge, thus eliminating the sulcus and making the wearing of an artificial denture impossible. The problem for the dental surgeon was to provide mechanical support for a mould which was used to hold a Thiersch graft in position till it had taken.
Sometimes an epithelial inlay was made for a more extreme purpose, in order to provide a large ‘socket’ into which an intraoral prosthesis (obturator) could be fitted to restore lost facial contour resulting from bone loss, particularly in the region of the premaxilla or the chin. An obturator such as this was usually constructed as part of an artificial denture. Similarly, an obturator constructed as part of a denture might be used to close an oral-nasal or oral-antral gap, or to provide an artificial soft palate.
Treatment and Policy during Second World War
Considerable improvements in methods of treatment were made during this war. At an early stage specialised centres were established in England for the treatment of jaw injuries, together with all other cases requiring plastic surgery. From the work at these centres two outstanding developments in the treatment of mandibular fractures soon made their appearance.
The first was the perfection of a new type of cap splint known as the ‘sectional’ cap splint. The old type, known as the ‘continuous’ cap splint, which had been used during the First page 376 World War, had very serious limitations. Although the sectional cap splint required much more care and work in its construction, it had very many advantages; to mention only one of these, the process of reduction and fixation was transformed from a hit-and-miss struggle to a smooth operation of comparative precision and certainty. (Figure 5.)
The second development was the introduction of the pin fixation method, already described. Although the principle involved in this method was not new, its adaptation for use in fractures of the mandible required a great deal of trial and error before the technical difficulties were mastered sufficiently to make it a really effective procedure. But this was achieved, and the method proved to be the answer to a long-standing problem. In the First World War many very bad results, from the point of view of both appearance and function, had been inevitable owing to the unsolved problem of controlling a badly-fractured mandible when there were insufficient teeth present to carry a cap splint, or when the fracture was in the posterior region of the mandible.
Another idea that seemed to develop during the Second World War was the use of plaster ‘skull’ caps. In the immobilisation of fractured mandibles and maxillae, the principle of encasing the actual part in plaster is quite useless; but during the war carefully placed plaster skull caps were found to be very useful in some cases as a means of anchorage for a floating maxilla, or for a mandible which required immobilisation as a whole. It was necessary for there to be enough teeth present, in maxilla or mandible respectively, to carry a cap splint. (Figure 7.)
Besides these improvements in methods of treatment there was also a considerable change in the policy governing treatment. These methods of fixation are only able to be effectively employed by a specially trained and equipped team, including plastic surgeon, dental surgeon, dental mechanic and dental laboratory. (This does not apply so completely in the case of pin fixation.) In the 2 NZEF such a team was operating with the most advanced general hospital, and casualties which would benefit from immediate treatment on these lines were given priority of evacuation as far as possible. There were, of course, many occasions when such a team would have been more effectively placed with a CCS, and in as much as equipment and trained personnel would permit, this policy was followed in the later stages of the war.
The dental officers attached to the Field Ambulances were equipped to perform first-aid treatment in the nature of temporary immobilisation by wiring or the application of jaw-supporting bandages, and were instructed in the principles of conservation of intra-oral tissue so that they could co-operate with the surgeons of page 377 the Field Ambulances in any emergency treatment. However, the policy was laid down that this first-aid treatment was to be reduced to a minimum or avoided altogether—in the previous war the tendency had been to greatly overdo it, with very bad results—and every effort was to be made to get a casualty with a major jaw injury evacuated as quickly as possible to the advanced general hospital (or to the CCS if it carried a team). In many instances of course, particularly in the North African campaign, such rapid evacuation was impossible and improvised methods of fixation—not mere first-aid treatment—had to be employed by dental officers of the Field Ambulance or CCS. An account of how such treatment was carried out by New Zealand dental officers for casualties in Greece and in phases of the North African campaign is given in the Official War History of the New Zealand Dental Corps.
It is well to emphasize the importance of pursuing a policy of ‘immediate specialised treatment’ for major jaw injuries, even though this was not always possible, as exemplified above. The fundamental importance is that, in many cases, subsequent bone grafts and prolonged plastic reconstruction may thus be avoided by taking full advantage of the great possibilities of tissue conservation; it is only by relatively immediate application of specialised treatment that this can be achieved. Of subsidiary importance is the fact that such treatment usually produces a dramatic change in the comfort of the patient, in his ability to take food, and consequently in his general resistance.
It is interesting to note that the advent of penicillin did strengthen the effectiveness of this immediate treatment by making it possible to be still more conservative with mutilated tissue in the presence of sepsis. Also it made it possible to retain, temporarily, teeth which were valuable as a means of fixation but which would otherwise have quickly become abscessed; however, retention of such teeth could only be continued for as long as the penicillin was being administered; thus the advantage was a limited one.
Of cases requiring ‘delayed’ treatment, all but comparatively minor cases were evacuated to New Zealand and admitted to the plastic surgical unit at Burwood, Christchurch, which was established early in 1943. The nature of the dental aspect of the treatment for such cases has already been summarised. As far as the Second World War is concerned the significant fact is that there was comparatively little work for the dental surgeon in this field, whereas in the First World War there had been a great deal. The reason for this was, in the first place, the lower incidence of major jaw injuries in this war due to the absence of trench warfare; but also, to some extent, it was the result of the improved methods of early treatment and the policy of making that treatment really page 378 ‘immediate’ wherever possible. The surgical technique of bone grafts to the mandible was varied considerably during this war, but we are here concerned only with the dental aspect of this problem; improvements in methods of fixation, already described, were a great asset in this difficult field, and some very elaborate cap splint designs, often in conjunction with pin fixation or plaster skull-cap anchorage, were used.
Prostheses are often a very valuable last resort, but it is again notable that there was far less need for them in this last war than in the previous one, not only for the reasons given already but also as a result of improved methods of plastic surgery. But whenever prostheses were necessary they were constructed in acrylic, which was vastly superior to vulcanite, the material used during the First World War; acrylic is much more hygienic and can be built to varying shapes and contours much more easily.
In conclusion, it must be emphasized that the foregoing record of treatment (both early and delayed), and of policy, is nothing more than a summary of the salient features. There were always so many varying circumstances that the best procedure, particularly in the matter of temporary field treatment, was often a completely individual problem. Details and examples of such problems will be found in the references listed.