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Plastic Surgery Repairs in Korean Casualties

Medical Science Publication No. 4, Volume 1

FRIDAY AFTERNOON SESSION
23 April 1954

MODERATOR
COLONEL BERNARD N. SODERBERG, MC


PLASTIC SURGERY REPAIRS IN KOREAN CASUALTIES*

COLONEL BERNARD N. SODERBERG, MC

In this presentation we wish to discuss definitive management of regional traumatic defects in Korean casualties. Patients arriving from zones of conflict have shown improved wound care. The early wound healing has resulted from judicious use of the free skin graft. In most cases, this has seemed to preserve much extremity tissue. In the head and neck region, preservation of soft tissue parts, coupled with early architectural fixation, has allowed the salvaging of many features. The rapid wound healing has presented these patients to the reconstructive program at an early date, and has reduced the number of definitive plastic operations.

In general, reconstructive surgery has not been begun until scar tissue has become soft and mobile and all peripheral tissues have returned to normal. Each surgical step has been devised to add improvement to that obtained by the previous operation. Ordinarily areas of motion have been treated first. Surgery of the nose, eyelids, oral orifice and neck has been necessary to improve the airway, protect the eyeglobe from exposure and trauma, to remove the feeding problem, and to prevent neck contractures that fix jaw positions, exposing the oral area. Repairs of extremity parts have 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 and including all the corium. The requirements of the recipient site determine the degree of thinness or thickness of the skin graft. Thin grafts are indicated to obtain early wound healing. The thicker graft is more valuable for definitive repairs. In general, the requirements of the recipient site determine the thinness or thickness of the skin graft. Each thickness of graft has individual characteristics. The thinner the graft is cut, the more 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.


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

For definitive procedures, the choice free graft is one that is cut approximately three-fourths the skin thickness. At this cutting level, sufficient skin elements are left in the donor area to permit spontaneous healing in 12 days. Epithelization is accomplished by the process of dedifferentiation. from deep glands or hair follicles. The three-quarter-thickness skin graft can be made to take perfectly only in clean surgical fields. In the past, plastic surgeons have chosen the full-thickness graft for definitive plastic surgery because it offered the maximum coverage qualities to the recipient site, contracted the least during the postoperative course, and usually offered 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 skin grafted from elsewhere to get closure. The three-quarter skin graft, however, has now proven definitely equal to the full-thickness cut in regard to fundamental characteristics. It offers an additional factor, that if cut by machine and properly applied, it will take 100 percent. A full-thickness graft is always cut by scalpel and carries an overall percentage loss in take up to 20 percent.

Recipient sites for free skin grafts in addition to blood supply also have individual characteristics which influence serviceability of transplant. The stability of architecture influences graft contracture. Thin grafts of nonresilient backgrounds contract little, while those on soft mobile structures 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, further grafting has to be done to release the contracture. This process continues until surface replacement equals surface loss in volume, area, and character.

A practical point is noted in the attempt to overcorrect a region in anticipation of subsequent contraction. Skin grafts will take, if fundamental surgical principles are not violated. There must be proper and complete apposition of the graft to the part. Immobilization must be present for 14 days. Grafted clean wounds do not usually require a dressing under 8 days. Where the skin is over a granulating area, the first dressing change is done on the fourth postoperative day. Continuous wet dressings are used in this latter situation. Fibrous attachment of a skin graft is not complete until the fourteenth postoperative day. Up until that time, it may be slipped on its site and lost.

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


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absent. In the granulating wound, on the other hand, the recipient situation by specific preoperative care is made relatively free from bacteria. Granulating sites ready for grafting are cherry red in color. They are nonedematous and there is no peripheral cellulitis. The thinnest type of graft is to be used in this situation.

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

Several ways of handling the granulating surface prior to graft have been 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 the preferable method. Where the granulating area is on an extremity, a tourniquet can be applied above the lesion; this method is quite satisfactory. With the use of antibiotics, a somewhat thicker type of graft can be made to take. Results may be such that no subsequent definitive skin graft will be necessary. This then would eliminate much hospital time and subsequent operative procedures for patients. However, in general, it may be stated that for early healing of wounds, the thinner graft is used.

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

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


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closure resulted in a relatively firm diaphragm. This is in contrast to a recent similar case in which the patient was treated by using a first stage repair, a free skin graft with adherent subcutaneous tissue. The graft take was successful, but to date the diaphragm so formed is thin and fluctuant, indicating the possibility that for final repair, a pedicle flap will have to be substituted.

Occasionally long one-piece grafts can be used effectively. This is especially noted in hands and arms. One method that we use employs the replacement of the dermatome drum without graft severence. The continued cutting then gives a double drum length of skin. The method of re-splitting skin grafts, described by Zintel, Marcus, White, and Dupertuis, doubles the donor material available and may eliminate the necessity of homografting in 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 advanced to produce a single line closure. This type of repair procedure is especially desirable 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 with a three-quarter-thickness dematome cut graft. Vaseline gauze is applied directly over the attached gauze, followed by a superimposed moistened cotton layer cut to pattern shape. These two layers are firmly approximated to the recipient site stent fashion, using gauze fluffs. The peripherally placed long sutures fix the modeled pack in place, pulling the recipient site and graft together as an immobile unit.

Reference is made at this time to procedures of plastic surgery in children for comparisons of related cases. In children, the institution of free grafts follows the growth curve. Ordinarily it is best to wait as long as possible for complete scar softening before definitive repairs, but one should always act before serious contractures occur. In one infant with a severe burn scar contracture involving the axilla, arm, forearm and hand, the first operation eliminated all contractures by excising limiting cicatrix and supplying normal coverage. The free grafts used were obtained from the abdomen. In such cases peripheral long sutures tie over gauze packs in the axillary space. This eliminates the old method of circular bandages alone for fixation and their concomitant circulatory hazards.

In hands, free graft coverage is always best. This type of skin might not be indicated when intrinsic repairs are necessary. In this situation, a pedicle flap would be required.


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The Tube Pedicle

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

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

The tissue flap properly prepared has its cut edges united forming the skin tube. Closure of the subjacent denuded area can be brought about by a 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, if done, should always be accomplished without tension. If the latter is present, healing usually occurs with scar formation. The width of scar is directly proportional to the degree of tension. If the tube is to be large, closure is best by added free graft. The periphery of this graft is mattressed to the skin and subcutaneous tissue of the recipient border. The free graft is approximated and fixed by a form-fitting stent-type dressing. These tubes, if large, must be prepared before transfer by band constriction or delay procedure at the end to be moved prior to transfer to recipient site.

Another method is to use the intermediate carrier but eliminate some of the stage procedures. For example, the arm may be used and the flap applied as a forehead soft tissue reconstruction. In this case a bone graft to complete skull continuity may be needed also. In some situations showing forehead defects, residual soft tissue is adequate so that only bone is necessary to complete the reconstruction. Grafts are usually taken from the ilium.

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


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The Open Flap

The open flap differs from the tube in that the flaps are left open in continuity. These flaps are placed directly on the recipient site. The raw areas, both donor and free flap base, are free grafted in order to present a completely healed postoperative lesion. In cases where all denuded areas 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 grafts may produce early healing, eliminating the fibrotic phase. It may be necessary to substitute a flap in order to have soft tissue coverage that would insure an 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 area of the flap, joining the body completing the vascular continuity, does not bend or kink. If this allowance is not observed, nutritional supply is jeopardized. Small sharp bends may, if subjected to subsequent edema, be converted into pressure kinks which will destroy the vascular supply to the transplant. The periphery of the flap should be carefully approximated to the wound circumference.

The anterior chest offers a flap of thinner character than the abdomen and may be the choice for certain defects of the hand. Complete avulsion of the integument and tendon fascia in many places involving the index and long fingers of the hand was treated by immediate insertion of the digits into a skin pocket. The definitive procedure consisted of removing enough attached thoracic skin and subcutaneous tissue to completely wrap around the fingers. In one case, three delay procedures were felt necessary before complete detachment.

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

Good results have been obtained by resurfacing both legs in preparation for bilateral bone grafts to the tibia. In one case of this type, one extremity had a rather large defect and required a transference of soft tissues that would cover approximately two-thirds of the lower leg. The open jump technic was employed with the arm as intermediate carrier. The left leg, having a smaller defect, but requiring good coverage, was repaired by tube pedicle transplant from the abdomen.

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


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

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 leg or 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 delayed flap will subsequently show marginal or continuity losses. Flap destructions due to improper design or surgical technic are dreadful things and greatly multiply hospital time.

By and large, lower leg flaps are easier and more certain to be successful than thigh transplants. Thigh flaps are indicated, however, where a larger amount of subcutaneous tissue is required. They may also be indicated where a 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 transplant to cover a bilateral defect of the ankle. Tube pedicle defects of the sole of the foot are infrequently used as transplants and are much more time consuming in comparison to the open flap cross-leg technic.

Face and Jaw Repairs

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

As soon as an individual sustains a facial wound, three things in his care must be of immediate concern: the cessation of hemorrhage, the establishment of a free airway and the stabilization of the parts. One may attempt to stop bleeding, first, by applying digital pressure on known parts. This pressure, when applied, should he properly located over a feeder blood vessel and in such a way that the blood vessel will be compressed against some hard structure. Control of hemorrhage may be accomplished by the application of pressure through a gauze pack. This gauze pack is helpful for inaccessible bleeders. If hemostats are at hand, the lacerated vessel can be clamped and tied. It is important to bear in mind that tissue should not be manipulated more than necessary, for it is possible to advance infec-


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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 is not 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 held with moderate pressure.

To insure an airway, an immediate attempt may be made to remove blood clots and foreign material from both the mouth and the nose. A rubber tube slipped 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 attendant may lift up on the tip of the chin and pull out the tongue. The applied method is similar to that which is used occasionally while giving an anesthetic for a surgical operation.

The preliminary stabilization of bones and soft tissue is the third goal. The movement of injured parts jostling around may cause the recurrence of hemorrhage or occlude the recently established airway. This movement is painful as well, and therefore may be considered a shock factor. Stabilization at this stage may be accomplished by some simple means; the Barton bandage has been the most helpful method for temporary control. Members of the Medical Department in combat zones ordinarily are supplied with first aid packets. These sometimes are admirably adapted for the treatment of facial wounds. The compress with its lateral tail can be used as a sling to hold and support torn and loose tissues. If gauze packs are not available, the compress itself can be separated from the bandage part and used as a pack or 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 application of the compress and the four-tailed bandage. Where intrinsic fractures of 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, and even this would not be applied if transportation or evacuation is to be accomplished unattended by Medical Department members. The object in preliminary treatment will be to prepare the patient rapidly and adequately so that he may be transported to a station back of the combat zone where he may receive more specialized treatment.

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


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

Where time is favorable and the setting proper, one may attempt some early care. If this is possible, the surgeon will attempt to save all the bone and soft tissue possible, remembering always that it is better to leave tissue that may die than to cut away some that may live. A few treatment cautions would be: Do not remove fragments of bone that are attached to periosteum or muscle; do not probe around for foreign bodies; débridement is not indicated as part of first aid treatment; parts must not be manipulated any 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 routine would be, first, to check for breathing and free airway, second, to consider the 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, examines for bony and soft tissue obstructions of the nasal airway and damage tothe parotid duct. X-rays will help reveal the presence of fractures and also nasal sinus involvement. It is important to check the condyles of the mandible, to palpate the orbital border, the frontal bones and the whole zygomatic area.

Primary repair is best achieved before swelling and infection occur. It is preferable to carry out the surgical procedure in the first 12 to 20 hours. Time lapse between accident and wound closure depends upon the kind and type of wound present and surgical judgment. For example, it is well 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 with good results. We would delay primary repair in the presence of neurological damage. 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. General anesthesia is avoided if possible. Débridement is carried out on the wound if it is indicated. This begins with cleansing by using saline solution, 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 is attached will be left in place. Those exposed will have the areas covered by suture of adjacent soft tissue, if possible. Occasionally soft tissues are disrupted and torn away with much bone


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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 they may occur singularly or in combination. Recent fractures of the mandible, which show no bony loss and are associated with no fractures of the superior maxilla, are generally treated best by the simple method of intermaxillary rubber band fixation. The upper jaw is used as a splint. The displaced fragments are reduced by the utilization of the rubber band traction. The multiple loop intermaxillary wiring with intermaxillary rubber hand fixation has been shown by Stout to be the one most applicable for the early care of the war wounded. It carries the least danger in fracture reduction, and in many cases gives the best results. Splinting of the jaw for bony fractures is instituted as soon as the patient's general physical condition has become stabilized.

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

In the case of the edentulous mandible with fracture, circumferential wiring about a superimposed form-fitting splint is the most satisfactory method for general use. The early care of the fractured mandible showing bone loss near the angle of the mandible needs no special treatment. Simple splinting of jaw to jaw is sufficient. When lateral losses necessitating bone graft are present, no attempt is made to control the posterior edentulous fragment, unless a transplant is anticipated within the succeeding 3 months. The anterior superior displacement of the ramus fragment does not interfere with the mechanics of occlusion during the preliminary period, and it can be more advantageously cared for later. Where the fracture line in the inferior maxilla lies posterior to the last occluding molar, some difficulty may be incurred from the action of the elevator muscle. If healing is permitted with the resultant displacement, the patient may eventually be unable to open his mouth normally.

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


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the surrounding soft tissue would be sufficiently firm to hold the fragment in proper alignment. At that time the tooth could be removed; if allowed to remain, it might continue to act as a foreign body, inhibiting proper healing. 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 tantalum plate. Posterior traction by means of silver wire passed through the bone is now only occasionally employed.

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

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

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

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


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however, to see the malar bone driven backward and downward and impacted in this position. These depressed defects sometimes cause fearful deformities; care must be instituted within the first 10 to 15 days, as replacement can be impossible after 2 weeks. The depressed malar may sometimes inpinge upon the coronoid process of the mandible, mechanically interfering with jaw movements.

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

When the malar bone is impacted into the antrum crushing through the anterior wall, splinters and spicules may be present in the antrum as foreign bodies associated with hematoma. Several surgical technics have been employed to replace these structures. Extra-oral approach has been valuable in some cases. It has seemed that the intra-oral approach has been found to be the most satisfactory in the majority of situations. In the former, the approach is through the temporal region. An elevator is passed between the muscle fibers and the temporal fascia, forward and downward, to the medial surface of the bone. The depressed fragment then is elevated into place by leverage, aided by the insertion of a gauze roll beneath the elevator as a fulcrum. This method is indicated for depressed fractures of the zygomatic arch.

Interference caused by the masseter muscle sometimes contraindicates the intra-oral approach for this defect. Intra-oral approach to the antrum through the canine fossa allows the surgeon access to the depressed orbital floor plate. After the anterior wall of the sinus and malar has been elevated out of the way and loose spicules of bone and hematoma removed, one may replace the orbital floor. The gauze pack is left in place to maintain position. This should not be packed too tightly. It can be removed after a few days through the canine opening or through the newly formed naso-antral window. When it is difficult to maintain the reduced position, interosseous wiring of the frontal process of the zygoma to the lateral orbital rim may be necessary. A small external incision in the involved area suffices for approach. Stainless steel wires are satisfactory. These are passed


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

Bony fractures are sometimes associated with soft tissue defects. In attempting 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 vermilion border of the lip or nostril border or eyelid margin. If it is impossible to find a key point to start the soft tissue repair, one attempts closure by placing the first suture in the center of the wound and bisecting the remaining segments. These methods are helpful also in replacing loose flaps. One attempts to unite the parts with normal appearance as the goal, but there 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 placed outside, they are left long and tied up over the broad gauze pack. Such sutures should be removed in 3 to 4 days.

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

It is with great pleasure that I say we have Colonel Chipps with us today 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 come out of facial wound care in Korean casualties.