TRANSPLANTATION OF SKIN IN PLASTIC 
OPERATIONS OF THE EYELID. 
By Walter B. Johnson^ M.D. 
Reprint from The American Journal of Ophthalmology, July, 1895. TRANSPLANTATION OF SKIN IN PLASTIC OPERA- 
TIONS ON THE EYELID.1 
WALTER B. JOHNSON, M.D., PATERSON, N. J. 
The transplantation of skin flaps in plastic operations 
upon the eye-lid, by the method in vogue at present, is the 
result of a gradual development in the size of the portions of 
new tissue to be transplanted. The method of supplying new 
dermal tissues where loss of skin had resulted from accidents, 
burns or other causes, was originally introduced by Professor 
J. L Reverdin, of Geneva, Switzerland, in the year 1869. It 
was called "skin grafting" and consisted in the application to 
granulating surfaces of very small portions of epidermis snipped 
from the skin of a living subject, care being taken that the 
dermis should not be included in the graft. The grafts were 
applied to the diseased surfaces and resulted in the formation 
of new cicatricial tissue, which was undoubtedly the product 
of the proliferation of the transplanted elements. Thiersch, 
Pollock, Bryant and others adopted the method, increasing the 
size of the grafts and including the cutis as well as the cuticle, 
believing that the proliferation occurred from the dermis as 
well as the epidermis. Fiddes reported cases in the Lancet of 
new tissue formation resulting from the proliferation of epi- 
dermal scales scraped from the skin by a long bistoury. The 
method rapidly came into general use; it is, however, only skin 
grafting, the implantation of a nucleus for the formation of 
cicatricial tissue and not transplantation of true skin. 
The implantation upon granulating or fresh cut surfaces 
'Read at the Forty-Sixth Annual Meeting of the American Medical Associa- 
tion, May, 1895. Section on Ophthalmology. 4 
of large skin flaps from adjoining parts was introduced by 
Tagliacozzi many years before the possibility of skin grafting 
was thought of. He carefully dissected a portion of skin from 
a point near the surface to be covered, retaining at its base a 
pedicle through which the flap was to receive its nutrition. 
Modifications applicable to various locations were suggested 
by different operators. The procedures recommended for the 
plastic surgery about the eye-lids were not wholly satisfactory 
in consequence of the unsightly cicatrices at the point of re- 
moval of the flap, the thickening about the pedicle and the 
frequency of ulcerative processes intervening which resulted 
in still more serious deformity than existed prior to the opera- 
tion. 
In 1878, Mr. J. R. Wolfe, of Edinburgh, reported in the 
London Medical Times and Gazette, of June 3, 1 new method 
of "the transplantation of skin flaps from distant parts without 
pedicle." Following this, operations were successfully per- 
formed and reported by Wadsworth, Noyes, Aub, Mathewson, 
and others. The many advantages of the procedure led to its 
immediate adoption by ophthalmic surgeons. The object of 
the operation is the transplantation of healthy skin flaps to the 
required situation, the agglutination and healing by first inten- 
tion, the permanent adhesion of the healthy new tissue at the 
point of implantation, and the relief of the existing deformity. 
The skin selected for transplantation must, as nearly as 
may be, approximate the conditions and quality of the skin at 
the location to which it is to be transplanted; an allowance of 
fully one-third must be made for shrinkage of the flap, all 
areolar tissue must be carefully removed, the flap must be 
dipped in tepid water and then thoroughly dried, the site of 
operation must be carefully prepared, and if the transplanta- 
tion is to be made on the day of operation, all small blood 
clots and other detritus must be removed. In some cases it is 
desirable, especially if arteries have been tied, to allow an in- 
terval of two or three days to elapse between the time of the 
preparation of the wound and the application of the flap as 
sepsis may affect the flap if sloughing of any of the tissues 5 
occur. Before transplantation the granulating surface must be 
very carefully washed and dried; the prepared flap is then ap- 
plied and gently pressed into position where it will adhere like 
sticking plaster. The wound is then dressed; no sutures are 
recommended although in many of the cases reported, catgut 
or other sutures have been used; sheet lint compress and band- 
age is applied and allowed to remain in situ for four days. 
Great care should be used in removing the dressing lest the 
flap be torn from its new adhesion by dragging. Goldbeater 
skin plaster is often used next to the flap. 
The following case was operated successfully by the 
Wolfe method: 
H. T., aged 3; colored. Applied at the Paterson Eye and 
Ear Infirmary for treatment, stating that six months ago he 
had received an injury of the right eye-brow from falling upon 
a stone step. The injury was followed by excessive swelling 
and subsequent inflammation. The family physician made an 
incision and a Urge quantity of pus was evacuated. The wound 
closed on two occasions and re-incision was necessary. Ex- 
tensive destruction of the skin of the upper eye-lid resulted 
from ulceration which occurred during the stages of acute in- 
flammation and was never at any time entirely healed. The 
contraction of the cicatricial tissue thus formed produced com- 
plete eversion of the upper eye-lid as shown in Plate No. 1. 
August 2. Upon admission the child was in apparently 
good physical condition. There was eczema about the face 
resulting from the excoriation of the ichorous discharges from 
the eye. The ectropion of the right upper eye-lid was so ex- 
tensive that only about 3 lines separated the ciliary margin 
of the lid and the eye-brow. The everted palpebral conjunc- 
tiva was swollen, thickened and rough, bleeding upon the 
slightest touch. Almost all of the retrotarsal fold was ex- 
posed and it nearly concealed the eye-ball; there was a deep 
central ulcer of the cornea and a constant discharge of thick 
muco pus. 
The patient was aetherized and an incision made exposing 
the frontal bone which was diseased. The carious bone was 6 
removed and the wound dressed. After the opening closed 
the ulceration healed, the swelling of the lid decreased under 
proper diet and palliative medication. The cicatricial contrac- 
tion resulted in an increased eversion of the lid. 
Plate No. i. 
September 25. The patient was again aetherized, and in- 
cision was made midway between the brow and the edge of 
the lid i&/s" in length; the lid was carefully dissected, the at- 
tachment of the cicatricial bands divided and the edge of the 
upper lid stitched to the lower. The result of this procedure 
was a large gaping wound l5/8" in length and 7/8" in width in 
the median line. An elliptical incision was made on the inner 
side of the left thigh 25/8" in length and I*)*" in width at the 
largest diameter of the ellipse. The skin within the lines of 
the incision was carefully dissected from the leg and all areolar 
tissue removed. After preparation the flap measured nearly 
two inches in length and about one inch in width in its widest 
part. The flap and the wound were rendered aseptic; four 
fine catgut sutures were used to unite it to the edges of the 7 
wound, gold beater skin plaster was then placed over the new 
lid and the eye dressed with a compress bandage. 
September 29. The dressings were removed, care being 
taken to prevent dragging upon the flap, the stitch uniting the 
eye-lids and the stitches from the end and center of the flap 
were carefully cut and drawn out. The transplanted skin flap 
seemed to have united in its new location although it presented 
a grayish appearance externally which looked like semi-trans- 
parent glass. The pigment deposit in the deeper layers was 
so dark that it appeared as if sloughing of the entire flap was 
imminent. There was no purulent discharge. The eye was 
dressed with plaster and bandaged as before. 
Plate No. 2. 
October 2. The dressings were again removed and a 
thin gray membrane nearly the size of the flap came away with 
the plaster. This was at first believed to be the flap itself. On 
closer inspection, however, the entire surface of the new lid 
presented a peculiar appearance of semi-granulation points of 
reddish color. The excessive pigment deposit having mate- 
rially lessened, a glazing which seemed to be the result of a 8 
deposit of thick viscid mucus indicated the formation of a new 
layer of epidermis. The dressings were re-applied. 
October 4. The eye-lid when exposed disclosed the 
presence of a grayish membrane with commencing pigment 
spots which covered the entire field of the operation. 
October 6. The membrane has assumed the appearance 
of newly-formed skin, the lid maintains its natural position; 
there has been very little purulent discharge during the recov- 
ery. After this date the skin became more natural in appear- 
ance, softness and pliability. No unfavorable symptoms oc- 
curred. There was complete relief of the deformity. The 
eye-lid could, not, however, be elevated to the extent of that 
of the fellow eye. The accompanying plate No. 2 illustrates 
the condition six weeks after the treatment was discontinued.