Nowadays, skin grafting is not something supernatural. Skin transplantation is most often used in the treatment of severe burns (combustiology). Today, operations of this type all over the world are very successful, not least due to the creation of special tools.
One of the main surgical instruments, without which successful skin grafting would not be possible, is the dermatome. It is with its help that the surgeon cuts off a thin flap of skin used as a material for transplantation. Modern dermatomes are ultra-precise electrical devices that do not leave scars on donor sites, but this was not always the case. A century ago, doctors removed the material for transplantation by hand with medical blades.
Some facts about skin grafting
Skin grafting is a modern trend in surgery. Skin transplantation operations were actively carried out only in the last century, although experts find the roots of this very complex procedure as early as 600 BC. e. in the practice of ancient India.
It is believed that even in those distant times, the skin and fat from the buttocks were used for operations on the ears, noses and lips. It is known that ancient Indian healers used a certain mixture for skin adhesion, the recipe of which is not known today. The experiences of the ancient Hindus are considered to be the earliest practice of skin transplantation. Since those times, many centuries have passed before humanity again decided on something similar.
The first scientific experiments on skin grafting were carried out at the beginning of the 1804th century. The Italian physiologist Baronio conducted the first experiment on sheep in XNUMX. He successfully transplanted the skin from the animal’s tail to another part of its body. In the same century, experiments on skin transplantation were carried out by German, French, Swiss and other surgeons. The results of operations were getting better each time, and the tools used in the work of doctors were constantly improved.
During the experiments, it was found that the thickness of the transplant material is a decisive factor in the healing of the donor site. This conclusion led specialists to the need to develop a device that provides for the ability to control the thickness of the graft.
A skin graft is a piece of healthy skin transferred from one part of the body to another in order to close and heal a large wound surface. Skin grafting is most often used for 3rd degree burns. The operation requires skin of the same type as in the damaged area.
As a rule, two types of material are used for the operation. These can be split grafts that contain the top layer of the skin (epidermis) and part of the middle layer (dermis), or layered flaps (graft material is taken to the depth of the entire dermis).
In early transplantation, many small pieces of transplant material were taken for the operation, which ultimately created ugly scars on the donor site. With the advent of new tools, it became possible to use one large graft for transplantation instead of many small ones. Nowadays, the material for the operation is most often taken from the inner part of the thigh, leg, shoulder or forearm, and a dermatome is used to cut the donor skin.
What is a dermatome
The name of this surgical instrument comes from two Greek words: “derma”, that is, skin, and “tomos”, a segment or layer. The name of the dermatome perfectly displays its functions. With its help, the doctor removes the donor skin, cut off at the level of the dermis (middle layer). Modern dermatomes evenly remove even flaps of a given thickness. The quality of engraftment of the graft and the healing of the wound surface of the donor site depend on the correct thickness of the transplant material and its evenness. Today, doctors have the opportunity to remove rather large flaps, in place of which the surface is quickly epithelialized. But it was not always so.
The most primitive dermatome is an ordinary straight razor blade, which was fixed with a special clip or needle holder.
These were the first attempts by researchers to create a device for cutting the graft. At one time, in order to remove the skin flap, doctors used different blades, for example, Trish’s razor (a primitive “dermatome” in the form of a regular blade), Gambi and Shink knives (they already had screws to adjust the thickness of the peeled flap). By the way, the last two models are used in medicine to this day.
But, perhaps, the main revolution in skin transplantation was made in 1939, when Dr. Earl Pagett, together with engineer George Hoodoo, developed a mechanical device for cutting skin flaps. It was a semi-cylindrical calibrated dermatome. This reciprocating device made it possible to remove thinner and larger skin flaps without damaging them. By the way, the Paget device appeared shortly before the Second World War and was actively used in the treatment of the wounded. The active use of the device during the hostilities allowed doctors to accurately determine all the shortcomings of the first dermatome, which gave impetus to further improvement of the tool.
In 1948, a young American surgeon, Harry Brown, created and tested a new generation of instruments – an electric dermatome. Brown’s development quickly spread around the world. Modifications of the device were created in the USA, England and France. This type of instrument is still successfully used today.
The first dermatome in the Soviet Union appeared in 1946. The devices of that time, produced in Leningrad, were based on the principle of reciprocating motion. And the models produced in Kazan worked according to a rotary scheme that was unique for that time.
Varieties of dermatomov
Different principles are used to classify dermatomes. For example, according to the type of drive, devices can be electric, pneumatic or manual. According to the mechanism of work, reciprocating and disk are distinguished. The latter are either mechanical or electrical.
The first dermatomes were hand-held and based on the reciprocating motion of a knife. This is the simplest kind of tool, an example of which is the same Trish knife. The use of such dermatomes required high qualification and precision of movements from the surgeon. At one time, hand instruments in skin transplantation made a real revolution, but still were far from ideal. With their help, the skin layer was removed of uneven thickness, which did not have the best effect on the quality of the transplant material and the healing rate.
Another example of a hand-operated dermatome is adhesive instruments. These are, in fact, Paget’s mechanical devices, used even in modern medicine in different variations. They have a cylindrical shape and moving blades that are manually operated. The principle of their work is to fix the surface of the drum on the skin, previously treated with an adhesive substance. Then the doctor manually moves the knife, removing the graft. The advantage of such a device is the ability to adjust the size and shape of the graft.
Electric dermatomes do not require the use of adhesive material, and the movements of the blade are determined by an electric motor. Nowadays, such instruments are used in medicine much more often than manually operated options. They are compact, easy to use, allow you to quickly cut long skin flaps of exactly the specified thickness, which is the main advantage for engraftment of graft material.
Operating principle
Regardless of the type of dermatome, its principle of action is identical. With the help of a special stop on the tool, a fold is formed from the skin. Then, during the movement of the dermatome, a very thin and sharp blade removes a layer of material necessary for transplantation.
If an adhesive dermatome is used during the operation, then before the procedure, the donor site is cleaned of dirt and microbes.
Then, using a gauze swab or brush, an adhesive solution is applied to clean skin. It can be composed of medical ester, rosin and rubber. After applying the mixture to the skin, wait about 5 minutes, after which the drum is pressed for 1 minute against the treated surface. Then the edge of the drum with the skin glued to it is lifted and the surgeon, slowly moving the dermatome, removes a thin layer of the donor skin with a sawing motion. With this device, you can cut flaps measuring 10×10 cm.
Disc dermatomes have rotating knives (resembling razor blades) fixed around the perimeter of the entire disc. The device provides the ability to adjust the thickness of the cut material from 1 to 0,15 mm. Disc dermatomes can be manually operated or powered by electricity.
Using the device in operation is quite simple. The tool is pressed against the working surface at an angle of 45 degrees, the motor is turned on (or the disk is rotated manually) and slowly moved over the skin. The flap that appeared above the rotating disk is picked up with tweezers and cut off. With the help of disk dermatomes, it is possible to remove a graft 4-6 cm wide and almost any length (depending on the area of the donor site).
Difficulties in obtaining skin grafts of high quality and uniform thickness prompted researchers to create special knives and more sophisticated instruments. In modern medicine, the dermatome is not a novelty and is very actively used in combustiology. In the meantime, work on improving the device continues.