HX64058751 
 RD12lSe5 1898 Restitution of skin 
 
 RECAP 
 
 RESTITUTION OF SKIN BY PLASTIC 
 OPERATION IN CASES OF EXTENSIVE 
 TRAUMATIC SURFACE DEFECTS OF 
 THE SCROTUM AND PENIS''' 
 
 BY N. SENN 
 
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 (;jj [Reprinte-l Irom The Philadelphia Medical Jouknai,, Xovembor 5, ISO?. I 
 
 RESTITUTION OF SKIN BY PLASTIC OPERATION IN 
 CASES OF EXTENSIVE TRAUMATIC SURFACE- 
 DEFECTS OF THE SCROTUM AND PENIS. 
 
 By X. SEXN, M.D., Ph.D., LL.D., 
 
 of Chicago. 
 
 Professor of the Practice of Surgery and Clinical Surgery iu Rush Meiiical Col- 
 lege ; Professor of Surgery in the Chicago Polyclinic ; Attending Sur- 
 geon to the Presbyterian Hospital; Surgeon-in-Chief to 
 St. Joseph's Hospital. 
 
 Surgeons have for a long time been made aware of 
 the fact that extensive skin-defects of the scrotum 
 caused by injury or disease are usuaUy repaired in a 
 comparatively short time by granulation, cicatrization, 
 and epidermization. In cases of gangrene of the scro- 
 tum resulting in denudation of both testicles, the ex- 
 posed organs are, in the course of a few weeks, furnished 
 with a new coating without operative intervention, by 
 the formation of a contracting scar, which, by making 
 traction upon the surrounding skin, approximates the 
 margins of the granulating surface from all sides, so 
 that when the process of healing is completed the new 
 scrotum is largely composed of normal skin obtained 
 from the neighborhood by cicatricial contraction. 
 
 Bruns attributed to the scrotal tissues a maximum 
 recuperative power in explanation of the speedy and 
 satisfactory healing of extensive skin-defects. Kocher, 
 on the other hand, denies any such special properties 
 inherent in the tissues of the scrotum, and asserts that 
 wounds of the scrotum heal in the same manner, and 
 the healing process requires the same length of time, 
 lis the repair of surface-wounds in any other jiart of 
 the body. He explains the apparently more rapid 
 
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 J;'^. '''^msity 
 
 'ih 
 
 'an, 
 
healing of scrotal wounds by the displacement of the 
 adjacent loose skin by the contracting scar, an opinion 
 that has since become satisfactorily substantiated by 
 extensive and careful clinical observations. 
 
 Skin-grafting by Reverdin's or Thiersch's method has 
 been resorted to and has been strongly advised by 
 some surgeons to expedite the healing of large granu- 
 lating wounds of the scrotum, but it is doubtful if the 
 results obtained with the aid of this modern surgi- 
 cal resource are any better than those following spon- 
 taneous healing of such wounds. The skin-grafts are, 
 at best, only an imperfect substitute for normal elastic 
 skin, and their presence must, necessarily, interfere 
 with the desired displacement of the adjacent skin by 
 the contracting scar. 
 
 Nothing has been done in the way of primary'plastic 
 operations in restoring extensive traumatic skin-defects 
 of the scrotum and penis. Surgeons have relied on the 
 healing of such wounds by granulation in all cases in 
 which, owing to the size of the wounds, suturing was 
 out of the question. The location of such wounds ren- 
 ders it almost impossible to secure and maintain an 
 aseptic condition long enough for the completion of 
 the healing process. The denuded and exposed parts 
 are exposed to the dangers incident to infection, and 
 healing seldom takes place without suppuration, and 
 often weeks and months are required before the injured 
 parts are protected by new and displaced skin. 
 
 Considering that the external genital organs are sur- 
 rounded on all sides by an abundance of loose skin, 
 well adapted for plastic operations, it is somewhat 
 strange that surgeons have not taken advantage of this 
 favorable anatomic environment and resorted to plastic 
 procedures in restoring recent extensive traumatic skin- 
 defects of the scrotum and penis. In the case that 
 forms the subject of this paper such an effort was made. 
 
iind the result was so satisfactory that I liave deemed 
 it of sufficient importance to bring it to the attention 
 of the profession. In this instance the entire scrotum, 
 one testicle, and the whole cutaneous sheath of the 
 penis were torn away in a machinery-accident : 
 
 The patient, a German lal)orer, 33 years of age, in good 
 health, was injured October 11, 1897, and was admitted to St. 
 Joseph'.^ Hospital a few liours after tlie accident occurred. 
 
 
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 I, 
 
 
 Vui. I. — Extent of wound and appearance of parts Ijefore operation. 
 
 He was employed in a hicycle-faetory, and when the injury 
 wa.'i sustained he was standing on a ladder, adjusting a Ix^lt 
 -tin a pidley from the headline-sliaft to a.'^tamping-press. His 
 clrdlies Wi.'re cauglit by the revolving shaft, and, with the ex- 
 ception of his shoes and stockings, were? torn fiom his body. 
 He fell from the ladder down to tiic lloor, a rhstancc of ten 
 feet, and at once discovered the extent of injury to the ex- 
 ternal genital organs. He attempted to arrest tli<^ l)leeding. 
 which was fpiite free, l)y washing tlie wound witli cold water 
 obtained from a sink. A pliysician was called, who dicsscd 
 the wotind an<l sent the patii'ut to the hospital. 
 
On examination at the hospital the entire skin covering 
 the external genital organs, as well as the left testicle, was 
 found torn away with the clothing. The parts lost are now 
 in possession of the physician who iirst dressed the woiuid. 
 Fio-ure 1 represents the extent of the injury and the appear- 
 ance of the parts before the operation. The loss of skni ex- 
 tended nearly over the entire region of the mons veneris. 
 The left spermatic cord and vessels were torn oft near th(^ 
 
 Fig. 2.— Appearance of parts after first operation ; clotted liues showing • 
 incisions of second operation. 
 
 external inguinal ring. The left inguinal canal Avas torn 
 open nearly in its entire length. Hemorrhage from the sper- 
 matic artery had been arrfested by applying hemostatic 
 
 forceps. 
 
 The patient was pale, but did not sufl'er from any severe 
 
symptoms of shock. He was at once jjlaced under the full 
 influence of ether, when the wound and surrounding 
 skin wore thoroughly di^^infeeted. The left spermatic vessels 
 were ligated with catgut and the inguinal canal was sutured 
 with the same material. Formalin-iodoform catgut was used 
 both for ligatures and sutures. The right testicle, spermatic 
 cord, and accompanying vessels were found loose and de- 
 tached from the underlying tissues as far as the external in- 
 guinal ring ; the tunica vaginalis was intact ; pulsation of 
 the spermatic artery was distinct. I decided to cover 
 the wound by undermining and mobilizing the adja- 
 cent skin. The testicle was brought in proper position and 
 was covered with skin by undermining the margins of the 
 wound and suturing it in a vertical direction as fa^r as the 
 root of the penis. 
 
 The skin al>ove was undermined in an upward direction 
 sufficiently to secure room for the denuded penis, when a 
 transverse incision was made sufficiently large to bring the 
 glans penis out, and the mucous membrane of the corona 
 glandis \\as sutured to the skin with hue catgut and horse- 
 hair sutures. The remainder of the wound was then closed 
 transversely, as shown in Figure 2. Drainage was secured 
 from the lower angle of the vertical to the left angle of the 
 tran.sverse wound by inserting a strip of iodoform-gavize. 
 With the exception of the drainage-openings the wound was 
 sealed with iodoform-collodion, over which the ordinary anti- 
 septic dressing was ap^jlied and held in place by means of 
 strips of adhesive plaster. 
 
 The operation was not followed by any untoward symptoms. 
 The patient emptied his bladder without any difficulty, being 
 directed to lie on his side during the evacuation. With the 
 exception of a small place al)Out the left angle of the trans- 
 verse incision, the entire wound healedby primary intention. 
 
 On October 2oth, two weeks after the first operation, a 
 second plastic ojtei-ation was performed, for the i)urpose of 
 relea.'^ing the penis from its abnormal position and pi-oviding 
 for it a complete cutaneous slu!ath from the skin of the ab- 
 domen. The operation was carried out under full ether-an- 
 esthesia. The dittted lines in Figure 2 show the number and 
 <lirection of the incisions. The incision above the glans 
 j>enis secured a Hap to cover the dorsum of the organ. The 
 lat(;ral incisions furnished a Hap to cover at least two-thirds 
 of the circumference of tlu; penis. Tin; dorsal llaj) received 
 an ample blood-supply from its n(!W attachments with the 
 bas(! of the glans jicnis. After liberating the penis and 
 bringing it into its natural position the dor.sal Hap was sutured 
 on each side to the lower Haj), which had become attached 
 in the center to the whoU; Ic^ngth of the under surface of the 
 penis. (Figure 3.) The large wound aitove the penis was 
 covered with two triangular Haps, which were sutured 
 together in the median Mne, and when in ])osition wen; 
 
attaclied to the lateral incision and base of the penis by 
 means of tension-sutures of silk and coaptation-sutures of 
 silkworm-gut and horsehair. The dressing was the same as 
 after the first operation, with the exception that the penis 
 was dressed separately and with special care, _ to prevent 
 harmful circular pressure. Primary union failed to take 
 place at the root of the penis on the left side, where the apex 
 of the triangular flap sloughed, leaving a limited granulating 
 
 Fio. 3. — Penis Ijberaled and coverefl rorapletely w th skin from the abdomen. 
 Wound above closed witli two triangular flaps. 
 
 defect, which healed in a most satisfactory Avay in the course 
 of three weeks. In spite of frequent apd severe erections, 
 the wounds on the side of the penis healed almost through- 
 out by primary intention. The patient left the hospital 
 two months after his admission, highly pleased with the 
 immediate and remote results of the two plastic operations. 
 

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 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) 
 
 RD 121 Se5 1898 C.I 
 
 Restitution of skin by plastic operation 
 
 2002158078