U.S. flag

An official website of the United States government

Skip to main content
Return to topReturn to top

Medical Science Publication No. 4, Volume 1

23 April 1954




In this presentation we wish to discuss definitive management of regionaltraumatic defects in Korean casualties. Patients arriving from zones ofconflict have shown improved wound care. The early wound healing has resultedfrom judicious use of the free skin graft. In most cases, this has seemedto preserve much extremity tissue. In the head and neck region, preservationof soft tissue parts, coupled with early architectural fixation, has allowedthe salvaging of many features. The rapid wound healing has presented thesepatients to the reconstructive program at an early date, and has reducedthe number of definitive plastic operations.

In general, reconstructive surgery has not been begun until scar tissuehas become soft and mobile and all peripheral tissues have returned tonormal. Each surgical step has been devised to add improvement to thatobtained by the previous operation. Ordinarily areas of motion have beentreated first. Surgery of the nose, eyelids, oral orifice and neck hasbeen necessary to improve the airway, protect the eyeglobe from exposureand trauma, to remove the feeding problem, and to prevent neck contracturesthat fix jaw positions, exposing the oral area. Repairs of extremity partshave dealt first with the flexor and circumferential lesions.

The Free Skin Graft

The free skin graft has been frequently used for definitive repairs.As a type of transplant, it can be had in variable thicknesses, up to andincluding all the corium. The requirements of the recipient site determinethe degree of thinness or thickness of the skin graft. Thin grafts areindicated to obtain early wound healing. The thicker graft is more valuablefor definitive repairs. In general, the requirements of the recipient sitedetermine the thinness or thickness of the skin graft. Each thickness ofgraft has individual characteristics. The thinner the graft is cut, themore apt it is to take. Thin grafts con-

*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


tract with passage of time to a greater degree than do thick grafts.Protective coverage to the part is proportionately decreased with the thinnessof the graft.

For definitive procedures, the choice free graft is one that is cutapproximately three-fourths the skin thickness. At this cutting level,sufficient skin elements are left in the donor area to permit spontaneoushealing in 12 days. Epithelization is accomplished by the process of dedifferentiation.from deep glands or hair follicles. The three-quarter-thickness skin graftcan be made to take perfectly only in clean surgical fields. In the past,plastic surgeons have chosen the full-thickness graft for definitive plasticsurgery because it offered the maximum coverage qualities to the recipientsite, contracted the least during the postoperative course, and usuallyoffered a better color match than the thinner graft. A drawback, however,was the fact that the donor site, if the graft was large, had to be skingrafted from elsewhere to get closure. The three-quarter skin graft, however,has now proven definitely equal to the full-thickness cut in regard tofundamental characteristics. It offers an additional factor, that if cutby machine and properly applied, it will take 100 percent. A full-thicknessgraft is always cut by scalpel and carries an overall percentage loss intake up to 20 percent.

Recipient sites for free skin grafts in addition to blood supply alsohave individual characteristics which influence serviceability of transplant.The stability of architecture influences graft contracture. Thin graftsof nonresilient backgrounds contract little, while those on soft mobilestructures contract the most. Examples would be the forehead in the former,and the neck in the latter. When drawing up in the graft site occurs, furthergrafting has to be done to release the contracture. This process continuesuntil surface replacement equals surface loss in volume, area, and character.

A practical point is noted in the attempt to overcorrect a region inanticipation of subsequent contraction. Skin grafts will take, if fundamentalsurgical principles are not violated. There must be proper and completeapposition of the graft to the part. Immobilization must be present for14 days. Grafted clean wounds do not usually require a dressing under 8days. Where the skin is over a granulating area, the first dressing changeis done on the fourth postoperative day. Continuous wet dressings are usedin this latter situation. Fibrous attachment of a skin graft is not completeuntil the fourteenth postoperative day. Up until that time, it may be slippedon its site and lost.

Before the skin graft is applied, the recipient area is completely freedof fibrosis, and hemostasis is accomplished. Infection must be


absent. In the granulating wound, on the other hand, the recipient situationby specific preoperative care is made relatively free from bacteria. Granulatingsites ready for grafting are cherry red in color. They are nonedematousand there is no peripheral cellulitis. The thinnest type of graft is tobe used in this situation.

The free skin graft must cover a denuded area having a good blood supplyin order to survive. The recipient site, therefore, is a determinant inthe choice of soft tissue coverage. The pedicle flap, in contrast, reliesupon its own blood supply through its pedicle. Obviously then the use ofthe free graft would be for coverage upon fresh, clean denuded areas possessinga healthy, vascular supply, and the flap would be best to cover recipientsites possessing poor blood supply. The free skin grafts as a type of transplantcan be had in variable thicknesses.

Several ways of handling the granulating surface prior to graft havebeen followed; each has its own merit. It is felt that, where it is feasible,avulsion of all granulations just before application of skin graft is thepreferable method. Where the granulating area is on an extremity, a tourniquetcan be applied above the lesion; this method is quite satisfactory. Withthe use of antibiotics, a somewhat thicker type of graft can be made totake. Results may be such that no subsequent definitive skin graft willbe necessary. This then would eliminate much hospital time and subsequentoperative procedures for patients. However, in general, it may be statedthat for early healing of wounds, the thinner graft is used.

The homografting procedure, combined with the autograft, offers a methodof application. For example, in one case 7 donors supplied 14 segmentsof skin measuring approximately 4 by 8 inches each. These pieces were unitedto form a large blanket. Four segments of the patient's own skin were appliedto the buttocks area and the blanket added to cover the remaining granulatingarea. The whole application procedure lasted less than an hour.

Unusual accidents from trauma occur now and then. These may presentproblems in surface coverage application. One patient, a motorcycle casualty,sustained the avulsion of the entire leg, genital organs and one-half ofthe bony pelvis. As an emergency procedure, the full-thickness skin andsubcutaneous tissue was removed from the avulsed extremity and used asan immediate coverage. It is obvious that such an addition, without a tubeto supply blood, would die. However, it served as a lifesaving procedureand remained in place until sufficient granulations formed. Débridementwas accomplished in stages. The completed area with preoperative cleansingpresented a recipient site adequate to receive a free skin graft. The


closure resulted in a relatively firm diaphragm. This is in contrastto a recent similar case in which the patient was treated by using a firststage repair, a free skin graft with adherent subcutaneous tissue. Thegraft take was successful, but to date the diaphragm so formed is thinand fluctuant, indicating the possibility that for final repair, a pedicleflap will have to be substituted.

Occasionally long one-piece grafts can be used effectively. This isespecially noted in hands and arms. One method that we use employs thereplacement of the dermatome drum without graft severence. The continuedcutting then gives a double drum length of skin. The method of re-splittingskin grafts, described by Zintel, Marcus, White, and Dupertuis, doublesthe donor material available and may eliminate the necessity of homograftingin some situations.

In the early treatment of large open wounds with granulating surfaces,the avulsed wounds may be healed by coverage with a free skin graft. Subsequently,this entire segment may be excised, the adjacent skin undermined and advancedto produce a single line closure. This type of repair procedure is especiallydesirable when the soft tissue covers mobile parts.

In the definitive or late stage, surface repairs are frequently indicated.The residual scar contracture is excised and the denuded area covered witha three-quarter-thickness dematome cut graft. Vaseline gauze is applieddirectly over the attached gauze, followed by a superimposed moistenedcotton layer cut to pattern shape. These two layers are firmly approximatedto the recipient site stent fashion, using gauze fluffs. The peripherallyplaced long sutures fix the modeled pack in place, pulling the recipientsite and graft together as an immobile unit.

Reference is made at this time to procedures of plastic surgery in childrenfor comparisons of related cases. In children, the institution of freegrafts follows the growth curve. Ordinarily it is best to wait as longas possible for complete scar softening before definitive repairs, butone should always act before serious contractures occur. In one infantwith a severe burn scar contracture involving the axilla, arm, forearmand hand, the first operation eliminated all contractures by excising limitingcicatrix and supplying normal coverage. The free grafts used were obtainedfrom the abdomen. In such cases peripheral long sutures tie over gauzepacks in the axillary space. This eliminates the old method of circularbandages alone for fixation and their concomitant circulatory hazards.

In hands, free graft coverage is always best. This type of skin mightnot be indicated when intrinsic repairs are necessary. In this situation,a pedicle flap would be required.


The Tube Pedicle

Skin tube pedicles as separate units have been frequently employed whencoverage by open flap could not be conveniently designed. The skin tubeoffers a clean, healed, soft tissue transplant having migratory featuresnot otherwise attainable.

The initial construction of the tube pedicle on the abdomen begins byparallel incisions through the skin and subcutaneous tissue to the fascia.This flap of tissue is undermined completely, using care not to buttonholethe fascia. Complete control of blood vessels, not only from the fascialarea, but also flap adipose base, is imperative. Hemostasis, if neglectedor masked by novacain adrenalin anesthesia, may subsequently spell disaster.

The tissue flap properly prepared has its cut edges united forming theskin tube. Closure of the subjacent denuded area can be brought about bya variety of methods depending on the location, size of the tube formed,personal experience and training of the surgeon. When tubes are small,adjacent undermining of soft tissue mobilizes it for closure. This, ifdone, should always be accomplished without tension. If the latter is present,healing usually occurs with scar formation. The width of scar is directlyproportional to the degree of tension. If the tube is to be large, closureis best by added free graft. The periphery of this graft is mattressedto the skin and subcutaneous tissue of the recipient border. The free graftis approximated and fixed by a form-fitting stent-type dressing. Thesetubes, if large, must be prepared before transfer by band constrictionor delay procedure at the end to be moved prior to transfer to recipientsite.

Another method is to use the intermediate carrier but eliminate someof the stage procedures. For example, the arm may be used and the flapapplied as a forehead soft tissue reconstruction. In this case a bone graftto complete skull continuity may be needed also. In some situations showingforehead defects, residual soft tissue is adequate so that only bone isnecessary to complete the reconstruction. Grafts are usually taken fromthe ilium.

Intermediate carrier transfers occasionally may be needed in jaw reconstruction,where massive bone grafts are necessary to rebuild the mandible. The abdomenmay be preferable as a soft tissue substitute for it is the thickest materialat hand. This soft tissue skin surface of the transplant rarely matchesthe adjacent facial skin. To improve the facial appearance after architecturalrepair is complete, the surface pedicle skin can be excised and the adjacentfacial skin mobilized over the summit of the added subcutaneous tissue.


The Open Flap

The open flap differs from the tube in that the flaps are left openin continuity. These flaps are placed directly on the recipient site. Theraw areas, both donor and free flap base, are free grafted in order topresent a completely healed postoperative lesion. In cases where all denudedareas are "skin dressed," the pedicle can be immediately imbedded.The second operation then completes the procedure.

The abdomen is the common site for open flaps. The free skin graftsmay produce early healing, eliminating the fibrotic phase. It may be necessaryto substitute a flap in order to have soft tissue coverage that would insurean adequate soft tissue bed for intrinsic repair.

Flaps in general are constructed so that they completely cover the defect.They are attached without tension and in a manner so that the free areaof the flap, joining the body completing the vascular continuity, doesnot bend or kink. If this allowance is not observed, nutritional supplyis jeopardized. Small sharp bends may, if subjected to subsequent edema,be converted into pressure kinks which will destroy the vascular supplyto the transplant. The periphery of the flap should be carefully approximatedto the wound circumference.

The anterior chest offers a flap of thinner character than the abdomenand may be the choice for certain defects of the hand. Complete avulsionof the integument and tendon fascia in many places involving the indexand long fingers of the hand was treated by immediate insertion of thedigits into a skin pocket. The definitive procedure consisted of removingenough attached thoracic skin and subcutaneous tissue to completely wraparound the fingers. In one case, three delay procedures were felt necessarybefore complete detachment.

The open jump flap popularized in World War II has been used frequentlyand seems to be a somewhat faster procedure for the transportation of largetissue masses than in certain combined flap types. This, however, is avariable thing for much depends on the individual operator.

Good results have been obtained by resurfacing both legs in preparationfor bilateral bone grafts to the tibia. In one case of this type, one extremityhad a rather large defect and required a transference of soft tissues thatwould cover approximately two-thirds of the lower leg. The open jump technicwas employed with the arm as intermediate carrier. The left leg, havinga smaller defect, but requiring good coverage, was repaired by tube pedicletransplant from the abdomen.

In lower extremity resurfacing for deep surface defects, several methodshave been found satisfactory. The immediately rotated flap has been usefulwith a skin graft covering the denuded site. This type


of tissue transfer, properly done, carries added circulation to therecipient area. Parallel double pedicle shifts can sometimes be used wherelesions are susceptible to these reparative procedures. Rapid repair, shortenedconvalescence and facilitated postoperative care are the benefits of boththese methods. The recipient site determines the technic of soft tissuetransfer.

The cross-leg open flap has been utilized and can be a one-stage affair,depending upon its location. In general, for lesions on the lateral legor foot, cross-leg pedicles will have to be located in situations which,because of blood supply, necessitate a delay procedure to augment vascularity.Meticulous surgical care is paramount. An improperly or inadequately delayedflap will subsequently show marginal or continuity losses. Flap destructionsdue to improper design or surgical technic are dreadful things and greatlymultiply hospital time.

By and large, lower leg flaps are easier and more certain to be successfulthan thigh transplants. Thigh flaps are indicated, however, where a largeramount of subcutaneous tissue is required. They may also be indicated wherea cross-leg flap has been previously lost, or there are amputation prohibitions.Inner thigh tubes and reverse suprapatellar flaps in general are successful.

When the open calf flap is used, the split distal end allows the transplantto cover a bilateral defect of the ankle. Tube pedicle defects of the soleof the foot are infrequently used as transplants and are much more timeconsuming in comparison to the open flap cross-leg technic.

Face and Jaw Repairs

For face and jaw wounds, the basic procedure plan has been outlinedpreviously. This worked successfully in World War II. It is thought ofas a basis that may be modified according to terrain and hospital facilitiesavailable. The following plan for early care is outlined:

As soon as an individual sustains a facial wound, three things in hiscare must be of immediate concern: the cessation of hemorrhage, the establishmentof a free airway and the stabilization of the parts. One may attempt tostop bleeding, first, by applying digital pressure on known parts. Thispressure, when applied, should he properly located over a feeder bloodvessel and in such a way that the blood vessel will be compressed againstsome hard structure. Control of hemorrhage may be accomplished by the applicationof pressure through a gauze pack. This gauze pack is helpful for inaccessiblebleeders. If hemostats are at hand, the lacerated vessel can be clampedand tied. It is important to bear in mind that tissue should not be manipulatedmore than necessary, for it is possible to advance infec-


tion into deeper recesses. If the gauze pack is employed to stop bleeding,its pressure must be maintained continuously for a period of time. It isnot necessary to put great pressure through a gauze pack. Such pressure,improperly applied, may strangulate structures. A small amount of pressure,properly placed, will collapse the vessel. The gauze pack should be heldwith moderate pressure.

To insure an airway, an immediate attempt may be made to remove bloodclots and foreign material from both the mouth and the nose. A rubber tubeslipped through the nose or over the dorsum of the tongue may be helpful.When the tongue drops back in the throat as during an unconscious state,or from lack of support because of fracture of the mandible, the attendantmay lift up on the tip of the chin and pull out the tongue. The appliedmethod is similar to that which is used occasionally while giving an anestheticfor a surgical operation.

The preliminary stabilization of bones and soft tissue is the thirdgoal. The movement of injured parts jostling around may cause the recurrenceof hemorrhage or occlude the recently established airway. This movementis painful as well, and therefore may be considered a shock factor. Stabilizationat this stage may be accomplished by some simple means; the Barton bandagehas been the most helpful method for temporary control. Members of theMedical Department in combat zones ordinarily are supplied with first aidpackets. These sometimes are admirably adapted for the treatment of facialwounds. The compress with its lateral tail can be used as a sling to holdand support torn and loose tissues. If gauze packs are not available, thecompress itself can be separated from the bandage part and used as a packor dressing.

In combat zone care, tracheotomy should be considered as a last resort,for at this stage, actually little more can be accomplished than the applicationof the compress and the four-tailed bandage. Where intrinsic fracturesof the bony architecture are present and a dental surgeon is available,some temporary splinting of the teeth by application of wires may be feasible.Intermaxillary rubber band fixation would be the only consideration, andeven this would not be applied if transportation or evacuation is to beaccomplished unattended by Medical Department members. The object in preliminarytreatment will be to prepare the patient rapidly and adequately so thathe may be transported to a station back of the combat zone where he mayreceive more specialized treatment.

Proper positioning of the patient for transportation may reduce themortality rate in the maxillofacially wounded individual. If he is ambulantor semiambulant, it would be well for him to be transported


sitting up. If he is a litter case, position would be face down, ifthere would be any danger of obstruction of the air passages.

Where time is favorable and the setting proper, one may attempt someearly care. If this is possible, the surgeon will attempt to save all thebone and soft tissue possible, remembering always that it is better toleave tissue that may die than to cut away some that may live. A few treatmentcautions would be: Do not remove fragments of bone that are attached toperiosteum or muscle; do not probe around for foreign bodies; débridementis not indicated as part of first aid treatment; parts must not be manipulatedany more than is absolutely necessary for the purpose of stopping bleeding,establishing the airway, or stabilizing the parts.

At the first hospitalization, if conditions are appropriate, the routinewould be, first, to check for breathing and free airway, second, to considerthe patient as a neurological problem, and third, to examine the wound.In this latter care, one looks for fractures of the bony architecture,checks for lacerations or tears into the mouth, into the nose and conjunctiva,examines the eyeball, checks the function of the seventh nerve, examinesfor bony and soft tissue obstructions of the nasal airway and damage totheparotid duct. X-rays will help reveal the presence of fractures and alsonasal sinus involvement. It is important to check the condyles of the mandible,to palpate the orbital border, the frontal bones and the whole zygomaticarea.

Primary repair is best achieved before swelling and infection occur.It is preferable to carry out the surgical procedure in the first 12 to20 hours. Time lapse between accident and wound closure depends upon thekind and type of wound present and surgical judgment. For example, it iswell known that infection sets in early in contused and crushed tissues.A clean-cut laceration can be united as long as 24 hours after injury withgood results. We would delay primary repair in the presence of neurologicaldamage. Jaws would not be fixed until the patient was free from vomiting.The anesthesia preferred would be local, infiltration and nerve block,bearing in mind that the wound edges are sometimes insensitive. Generalanesthesia is avoided if possible. Débridement is carried out onthe wound if it is indicated. This begins with cleansing by using salinesolution, soap and water, with ether as a solvent. Foreign bodies are removed.Surgical excisions are limited. Only obviously dead tissues are excised.Radical surgery sometimes destroys what later might be salvaged as a feature.Attempt is made to conserve bone fragments. Any portion of bone that isattached will be left in place. Those exposed will have the areas coveredby suture of adjacent soft tissue, if possible. Occasionally soft tissuesare disrupted and torn away with much bone


exposure. Direct fixation is sometimes considered; when this is accomplished,drains are left in place.

Types of fractures of the maxillae are many and varied. Sometimes theymay occur singularly or in combination. Recent fractures of the mandible,which show no bony loss and are associated with no fractures of the superiormaxilla, are generally treated best by the simple method of intermaxillaryrubber band fixation. The upper jaw is used as a splint. The displacedfragments are reduced by the utilization of the rubber band traction. Themultiple loop intermaxillary wiring with intermaxillary rubber hand fixationhas been shown by Stout to be the one most applicable for the early careof the war wounded. It carries the least danger in fracture reduction,and in many cases gives the best results. Splinting of the jaw for bonyfractures is instituted as soon as the patient's general physical conditionhas become stabilized.

Through-and-through bone wiring for fragment control ordinarily is contraindicated.The dangers are: rotation distortion, necrosis around the wires and unnecessarycompounding of bone. External pin fixation is contraindicated, except whenattempted by experts, then only when insufficient teeth are present. Externalpins do not always hold securely and cannot be considered practical asfront line procedure. They tend to loosen in the bone, permitting unduefragment mobility, and unless aseptically inserted, cause scar dimplingof the face, which sometimes results in permanent scar tissue deformity.

In the case of the edentulous mandible with fracture, circumferentialwiring about a superimposed form-fitting splint is the most satisfactorymethod for general use. The early care of the fractured mandible showingbone loss near the angle of the mandible needs no special treatment. Simplesplinting of jaw to jaw is sufficient. When lateral losses necessitatingbone graft are present, no attempt is made to control the posterior edentulousfragment, unless a transplant is anticipated within the succeeding 3 months.The anterior superior displacement of the ramus fragment does not interferewith the mechanics of occlusion during the preliminary period, and it canbe more advantageously cared for later. Where the fracture line in theinferior maxilla lies posterior to the last occluding molar, some difficultymay be incurred from the action of the elevator muscle. If healing is permittedwith the resultant displacement, the patient may eventually be unable toopen his mouth normally.

Occasionally a second or third molar is present and situated in sucha way that its position in the fracture line maintains the posterior fragmentin the proper place. In such an instance, the tooth would be allowed toremain in the fracture line for it would act as a wedge splint holdingthe posterior fragment in place. After about 3 weeks


the surrounding soft tissue would be sufficiently firm to hold the fragmentin proper alignment. At that time the tooth could be removed; if allowedto remain, it might continue to act as a foreign body, inhibiting properhealing. If no tooth is present to hold the ramus downward and backward,special intra-oral splints may be made to hold the fragment in position.An alternative method would be transosseous wiring or the modified tantalumplate. Posterior traction by means of silver wire passed through the boneis now only occasionally employed.

In the case of the partially edentulous jaw, where it is necessary todo intermaxillary fixation, the use of the half-round arch bar is satisfactory.Cross-wires are passed over the arch bar to obtain proper fixation. Thesectional splint introduced by Stout is valuable as well. Ordinarily littleor no displacement is seen in fractures of the ramus of the mandible. Thisis largely due to the muscle protection given by the pterygoid and masseter.Simple fixtation of the lower to the upper teeth suffices. This is alsothe usual treatment in fractures of the neck of the condyle. Infrequentlythe occasion is such that open reduction is indicated.

Fractures of the superior maxilla are seen in all degrees, from theseparation of small areas of the alveolar ridge to the complete separationof all the upper facial bones from their attachment to the cranial base.Associated complications vary from simple ecchymosis and swelling of thesoft tissue up to large lacerated wounds with associated fractures intothe nasal fossa and sinuses. Every attempt should be made to replace thebone fragments in their proper anatomical position as soon as possiblefor bony union takes place quite rapidly in this area. Accuracy here isquite important because slight variations from normal make noticeable variationsin contour as well as influencing proper aeration and sinus drainage. Replacementis obtained by mobilization and constant pressure exerted in an upwarddirection.

The reconstruction of occlusion and maintenance of position can be broughtabout in several different ways. A heavy arch bar may be secured to theteeth with wire ligatures. This in turn may be attached to a plaster headcast by metal side arms. This method permits mobility of the lower jaw.If there is some doubt about obtaining proper occlusion, one may do intermaxillarywiring, securing the mandible in addition by an arm bar to the plasterhead cast. In some cases, all that may be needed would be a felt cap chinappliance associated with intermaxillary fixation.

In any injury of the upper facial bones, one should look for possibleinvolvement of the zygomatic arch and malar bone. The side supports ofthe latter are usual sites of fracture. It is not uncommon,


however, to see the malar bone driven backward and downward and impactedin this position. These depressed defects sometimes cause fearful deformities;care must be instituted within the first 10 to 15 days, as replacementcan be impossible after 2 weeks. The depressed malar may sometimes inpingeupon the coronoid process of the mandible, mechanically interfering withjaw movements.

Fractures of the orbital rims and floors also may be associated withdisplacements of the malar zygomatic compound. Fracture displacement ofthe orbital floor and lateral orbital rim is associated with downward andbackward displacement of the eye globe. Upon clinical examination wherethis has occurred, there is a resulting one-sided flatness of the face.There is a definite pupillary descent as measured against the unaffectedside, and the skin fold in the upper lid appears deeper than usual. Thepatient may complain of diplopia; this may be transitory or permanent.The lateral canthus of the eye may also be displaced. By palpation, onemay notice a steplike notched defect of the lower orbital rim.

When the malar bone is impacted into the antrum crushing through theanterior wall, splinters and spicules may be present in the antrum as foreignbodies associated with hematoma. Several surgical technics have been employedto replace these structures. Extra-oral approach has been valuable in somecases. It has seemed that the intra-oral approach has been found to bethe most satisfactory in the majority of situations. In the former, theapproach is through the temporal region. An elevator is passed betweenthe muscle fibers and the temporal fascia, forward and downward, to themedial surface of the bone. The depressed fragment then is elevated intoplace by leverage, aided by the insertion of a gauze roll beneath the elevatoras a fulcrum. This method is indicated for depressed fractures of the zygomaticarch.

Interference caused by the masseter muscle sometimes contraindicatesthe intra-oral approach for this defect. Intra-oral approach to the antrumthrough the canine fossa allows the surgeon access to the depressed orbitalfloor plate. After the anterior wall of the sinus and malar has been elevatedout of the way and loose spicules of bone and hematoma removed, one mayreplace the orbital floor. The gauze pack is left in place to maintainposition. This should not be packed too tightly. It can be removed aftera few days through the canine opening or through the newly formed naso-antralwindow. When it is difficult to maintain the reduced position, interosseouswiring of the frontal process of the zygoma to the lateral orbital rimmay be necessary. A small external incision in the involved area sufficesfor approach. Stainless steel wires are satisfactory. These are passed


through drill holes in both segments, reestablishing the continuityof the frontal zygomatic bones.

Bony fractures are sometimes associated with soft tissue defects. Inattempting this type of repair, it is well to have a basic plan in mind.The assemblage should begin from some known point. This might be the vermilionborder of the lip or nostril border or eyelid margin. If it is impossibleto find a key point to start the soft tissue repair, one attempts closureby placing the first suture in the center of the wound and bisecting theremaining segments. These methods are helpful also in replacing loose flaps.One attempts to unite the parts with normal appearance as the goal, butthere is never any attempt made to improve the patient's natural appearance.The sutures when placed may be deep, but never wide. In some situations,stay sutures can be introduced from the inside. If they must be placedoutside, they are left long and tied up over the broad gauze pack. Suchsutures should be removed in 3 to 4 days.

We would like to say in closing that the quality of results in Koreancasualties has depended not only upon the definitive procedures, but ina large part upon the superior care given these patients in the early treatmentperformed in other theaters. Methods of early care have recently been studiedby Colonel Chipps, who has shown procedure modifications that were successfullyestablished in the Far Eastern Theater. The recent studies of over 1,000cases by Chipps, his personal work, have been helpful in showing the attainmentof better results in all definitive centers.

It is with great pleasure that I say we have Colonel Chipps with ustoday to tell of his experiences in the early care of facial casualties,which have played so great a part in the superior results that have comeout of facial wound care in Korean casualties.