LIVITH THE AUTHO. z~ COMPLIMENTS.] 
A CASE OF ECTROPION, 
TREATED BY TRANSPLANTATION OF A LARGE 
FLAP WITHOUT PEDICLE. 
O. F. WADSWORTH, M. D. 
[Reprinted from The Boston Medical and Surgical Journal, December 28, 1876.] 
CAMBRIDGE : 
Iprintcfci at tljc £xiljcr(oi£jc £)rc££. 
1877. A CASE OF ECTROPION TREATED BY TRANSPLANTATION 
OF A LARGE FLAP WITHOUT PEDICLE. 
O. F. WADSWORTH, M. D. 
The following case is one of deformity in consequence of a burn, 
successfully operated on by a method recently proposed and carried out 
by Mr. Wolfe, of Glasgow ; a method which consists in the transplan- 
tation of a large piece of skin, without pedicle, upon the surface of a 
fresh wound. Mr. Wolfe published, in the London Medical Times and 
GrazeHe, June 3, 1876, a brief account of two cases of ectropion thus 
operated on. This method offers so important an improvement in oui' 
means of dealing with deformities resulting from cicatricial contraction 
following injuries that now, in its infancy, any instance of its successful 
application appears worthy of notice. It must prove particularly valu- 
able in cases of destruction of part or the whole of the skin of the eye- 
lids. At the worst, even if the transplanted skin should not live, the 
condition of the parts still remains as good as before the operation, 
while, on the other hand, if a flap taken from the neighboring skin 
sloughs, the effort of the surgeon has resulted only in rendering the 
deformity greater than ever. The face, on account of the great vascu- 
larity of its tissues, offers, of course, a specially favorable ground for 
the performance of the operation ; whether it can be effectively em- 
ployed in other parts of the body remains to be seen. 
A healthy, well-grown girl of sixteen years, who had been burned 
on the left side of the face while an infant, was brought to me by her 
father in the lattei' part of July, 1876. A cicatrix, not generally very 
dense, involved all the skin in the vicinity of the left orbit. The left 
eyebrow, its hair follicles in part destroyed, was dragged downward so 
as to stand at a considerably lower level than the right; the upper lid 
was much shortened, and the lower so much pulled down that its con- 
junctiva was completely everted. On attempted closure of this eye a 
space remained open between the lids throughout their whole length, 
narrow at the outer part, but some 2/z/ in width between the puncta 
lachrymalia. There was moderate thickening of the conjunctiva of the 
lower lid thus continuously exposed. The cornea had continued nor- 
mal. 
July 30th, the patient having been etherized, an incision was made A Case of Ectropion. 
2 
through the skin of the lower I'd, parallel to, and l|//z below the lashes. 
The inner extremity of the incision was just below the punctum, and 
it extended outward half an inch beyond the outer canthus. The tis- 
sues were dissected till the edges of the lid could be easily raised far 
enough to reach the upper lid and allow replacement of the everted 
conjunctiva. Then the two lids were fastened together' by four sutures 
passed through their free edges. This left a raw 
surface l-|n in a horizontal, and in a vertical di- 
rection at their widest part. Next, a portion of skin 
was removed from the inner side of the fore-arm, 
about by in size. This was dissected off as cleanly as possible, 
to avoid the presence of subcutaneous connective tissue, and after sepa- 
ration was laid with its inner surface upward across the fingers of the 
left hand, while a few shreds of connective tissue still adherent were 
removed with curved scissors. Its inner surface, thus prepared, was 
quite as pale as the outer, very nearly smooth, dotted with minute de- 
pressions filled with fat cells, and recalled in some degree the appear- 
ance of the outer surface of a side of sole leather. It was scarcely 
y in thickness. The shrinkage on removal was very considerable, 
ble, and the detached skin when spread out on the clean, raw surface 
of the lid was barely more than sufficient to cover it easily. At this 
part of the operation a little difficulty was experienced, since the thin 
layer of skin tended to roll in on its under surface, and to obviate this 
tendency, at one point just below the outer canthus, where the surface 
of the wound made a double curve, two fine sutures, -fa" apart, were 
placed. Gold-beater's skin was laid over the lids and covered by thick 
layers of cotton-wool secured by a flannel bandage. The sound eye 
was also bandaged to secure immobility. The edges of the wound in 
the fore-arm were dissected up and brought together. 
The dressing was not disturbed for forty-eight hours. At the end of 
that time the bandage and cotton-wool were removed. Through the 
transparent gold-beater's skin it was seen that the outer two thirds of the 
transplanted piece lay quite smooth, its color, normal, and its edges in 
exact juxtaposition to those of the surrounding skin, while only a thin, 
dark line marked the boundary between them. There appeared to be 
absolutely no swelling. The inner third of the graft was somewhat un- 
even, and the inner two of the sutures intended to hold the lids together 
had broken away and allowed the lower lid to fall down a little. Some 
mucus and tears had run out from the conjunctival sack and smeared 
the innermost portion of the graft and the skin about it. To remove 
the mucus a part of the gold-beater's skin was cut away and the skin 
washed with a weak solution of carbolic acid. A little cotton moistened 
with carbolic-acid solution was laid over the inner canthus, and the 
packing and bandage were renewed. A Case of Ectropion. 
3 
The next day the graft was everywhere in good condition. Even at 
the inner corner, where its edge was a little raised and at first appeared 
unattached, a minute fragment snipped off with scissors seemed alive. 
Cleansing and packing were repeated daily. The gold-beater's skin 
was removed on the fifth day after the operation, the bandage was 
omitted, and the sutures holding the lids together were removed on the 
eighth day. The graft was now everywhere firmly united, although 
furrowed horizontally along its entire length by a shallow fold. 
On the tenth day I found the edges of the graft at some spots a little 
thickened and paler, and feared suppuration might be taking place be- 
neath, but this proved to be only the commencement of a throwing-off 
of the horny layer of the epidermis, the same process as is well known 
to occur in the ordinary minute skin grafts. It was five or six days 
later before the horny layer was thrown off over the whole surface. 
The girl was sent home eighteen days after the operation. Union was 
everywhere perfect, the ectropion completely relieved, and the dragging 
down of the brow considerably lessened, but still the lids could not be 
brought quite together over the inner half of their length. The graft 
then measured by 
Four months from the time of operation the patient was seen again. 
The ectropion was still entirely relieved, and she had been able to attend 
school regularly without inconvenience, though the lids hardly closed as 
much as at the time she went home. . The engrafted skin had become 
a little narrowed at its inner end perhaps, but it yet measured in 
length and in width at the widest part. It showed but little difference 
of level from that of the surrounding skin. The day was cold, and the 
new skin appeared considerably paler than the skin about it; this pale- 
ness, as was to be expected, was stated to be more marked on exposure 
to cold, but to be gradually becoming less noticeable.1 
The shrinkage of the thin layer of skin removed to form the graft 
1 The cuts were made from photographs taken the one immediately before, the other four 
months after the operation. The size of the photographs was not exactly the same, but it 
was thought best to reproduce them as they were. 4 
A Case of Ectropion. 
was decidedly greater than that which occurs in the flap of much greater 
thickness and retaining its connection by a pedicle, which is ordinarily 
employed in plastic operations, and this fact should not be lost sight of 
in estimating the size of the flap to be taken. How large a surface may 
be successfully covered by this method at once can be determined only 
by experiment. The surface covered in the case reported was larger 
than that in either of Wolfe's cases ; in each of those it was about the 
same size and somewhat less in length than the free border of the lids. 
If the attempt were made to cover a much larger surface at one opera- 
tion it would probably be better to apply more than one graft, both on 
account of the greater convenience this would give of obtaining suffi- 
cient skin for the purpose, and because the difficulty of getting the thin 
graft to lie flat must increase with its size. 
Wolfe took the precaution to set the flap so that the edges of the 
surrounding skin overlapped it and answered the purpose of stitches. 
The experience of the above case shows that such a procedure is evi- 
dently unnecessary, and certainly if employed here, union at the edges 
could not have taken place so readily and evenly. Of course the sur- 
face laid bare should be made as smooth and clean as possible, and haem- 
orrhage from it should be checked before the graft is placed in position. 
But is it absolutely necessary that the transplanted material should be 
so thin and so carefully freed from all subcutaneous tissue ? Wolfe was 
led to think so from observing the behavior of flaps in which connection 
was retained by a pedicle, where the operation was only partially suc- 
cessful. The occurrence of serous discharge and suppuration in such 
cases he regarded as the result of an effort to throw off the connective 
tissue previous to adhering. This consideration is not, however, con- 
vincing. A stronger argument is found in the fact that in his first case, 
in which the flap was divided into three pieces, one piece, supposed to 
have been sufficiently freed from connective tissue during removal, was 
placed in position without further preparation and in great part sloughed, 
while the other two pieces, from which the connective tissue was care- 
fully cleared after their removal, lived. Moreover, experience has shown 
the successful application of minute skin grafts to be dependent on their 
freedom from subcutaneous tissue. More evidence is desirable defi- 
nitely to settle the question.