Regeneration of nerves in skin grafts and skin flaps

REGENERATION OF NERVES IN SKIN GRAFTS AND SKIN FLAPS

JOHNSTAIGEDAVIS,M.D.,P. A.C.S. ANDEDWARD A. KITLOWSKI,M.D.

BALTIMORE, MD.

T HE question is frequentIy asked by both the patients and the physicians as to whether normaI sensations wiII return in transpIanted skin Asps and skin grafts, and when this return may be expected.

The appearance of cutaneous sensations in areas repaired by the use of free skin grafts and skin Aaps has been casuaIIy noted by surgeons from time to time but no effort had been made unti1 recentIy to determine what the early sensations are, when the process begins, and what the reIationship of these sensations is to each other.

Stranskyl in 1899 reported that he found a perception of coId in a whoIe thickness graft upon the cheek ten days after it was grafted and that the whole graft sIoughed away a few days Iater.

WiIIiams2 in 1928 reported that he had examined an OIIier- Thiersch graft which had been appIied thirty years previously upon the bed of an uIcer and that the sensations of pain, temperature, and deep pressure were onIy sIightIy diminished but that there was considerabIe impairment of sensibiIity to Iight touch. CoIt, 3 Foote4 and Schroeder5 have also made some remarks upon the return of sensations in cases of grafts which they had reexamined. Lehmann and Jungermann in 1920 reported the resuIts of tests made upon 2 I transpIants of skin and fat shifted by means of peduncuIated flaps. They concIuded that the speed of recovery depends upon the type of innervating nerves in the site of the graft, the areas of the pure sensory nerves recovering more rapidIy than the areas innervated by mixed nerves. They aIso reported that touch, pain and temperature return in the order named after pressure which may return as earIy as four weeks.

501

502 J. S. DAVIS AND E. A. KITLOWSKI

RecentIy (1933) KredeI and Evans7 reported on the recovery of sensations in I 7 fI aps and a number of free grafts, and they found that pain appeared first, foIIowed by touch and finaIIy by temperature. Our observations do not confirm either of these investigations as to the order in which the sensations return. It is apparent that there has been no uniformity in the findings of these investigators due, no doubt, to the chang- ing views upon the cutaneous sensations and the difference in the methods empIoyed in testing.

There is stiI1 some controversy concerning the recovery of cutaneous sensations after injury or division of periphera1 nerves. Head expIained the dissociation of cutaneous sensations by stating that there were separate fiber systems for epicritic sensations which are the very fineIy graded and definiteIy IocaIized sensations of tactiIe impressions and miId degrees of heat and coId, and for the protopathic sensations which are the sensations of pain and extreme degrees of heat and coId. Cobb,g Boring,lO Trotter and Daviesll have ques- tioned the dissociation of the types of sensations as expIained upon the separate fiber systems and fee1 that the cause is a quantitative matter depending upon the intensity of the stimuIus. Stopford12 and LickIey13 continue to support Heads hypbthesis. Lee14 has exceIIentIy summarized the Iiterature deaIing with this matter. We mereIy desire to report the resuIts of our own observations upon the return of sensations in skin flaps and free skin grafts. We have used the term epicritic touch to denote the sensation eIicited by the use of a wisp of cotton appIied so IightIy to the skin that it is not depressed, and the term protopathic pain to denote the sensation of pain as eIicited by a pin prick carefuIIy appIied to avoid pressure. The observations have been gathered from our cIinica1 mate- ria1, over a period of severa years, and this report is the resuIt of our findings. The data upon the cutaneous sensations in pedunculated flaps before the pedicIes have been cut have been incorporated into another paper which wiI1 soon be pubIished. l7 In this report the tests were made after the

REGENERATION OF NERVES IN SKIN GRAFTS 503

pedicIes were cut and the transpIants were heaIed in their new beds. .

What difference does it make whether the sensations return or not in these transpIants? As a matter of fact, the return of the sensations is, in many instances, of vita1 importance to the patient because function may be seriousIy interfered with, if the norma sensations are Iacking and in addition unti1 the sensations return the part may be injured or flecome infected without the patient being aware of it.

METHODS OF TESTING

Before beginning the tests every effort was made to obtain the cooperation and interest of the patient. The tests were carefuIIy expIained and demonstrated in fuI1 view of the patient so that each one wouId understand what was desired. The patient was then pIaced in the most comfortabIe position possibIe and was asked to report with a simpIe yes or no concerning the sensation. The tests were carried out in a quiet room, and the patient was not permitted to observe the operator, so that the repIies wouId not be influenced by what was seen. If a patient showed a tendency to tire or to permit his attention to wander, the test was stopped and resumed after a short period of rest. The tests were a11 made by one of us (E.A.K.) to eIiminate any difference in personal error. Intensity of pain or touch is a reIative matter which varies with the individua1 so we Iimited our investigations to determining the Iimits of the sensations of touch, pain and temperature without attempting to compIicate the probIem by demarcating the areas of varying intensity or to evaIuatc degrees of pain and touch, as we feIt that this wouId be con- fusing to the patients and wouId cause inaccurate replies since they were untrained psycho-bioIogicaIIy.

Light touch was tested by the use of a bit of cotton wrapped around the end of a toothpick and frayed so that wisps of the cotton aIone touched the skin without depressing the surface. The transpIants were usuaIIy taken from hairIess areas, other-


wise the part was shaved. In this manner we tested for the fine tactiIe sensation caIIed epicritic or Iight touch which is not conveyed by pressure or hair movements. The wisps of cotton were gentIy appIied to the skin unti1 a point was reached where the patient did not fee1 the touch, and this point was then marked on the transpIant with 5 per cent briIIiant green in aIcoho1. The process was repeated unti1 the whoIe ffap had been tested. The points were then joined and the Iine so formed indicated the Iimits of the sensation of touch.

SensibiIity to pain was tested by pricking the skin with a sharp pointed pin or needIe. The patient was first instructed to distinguish between prick and touch. No effort was made to determine the intensity of the pain and we were carefu1 to make sure that the patient couId distinguish between sharpness and soreness. The pressure appIied was so Iight that the pain sensation which is produced by pressure was not eIicited in our tests. The skin was pricked gentIy over the entire area and the points were marked where pain was no Ionger feIt. This was repeated a number of times over the same area to be sure that a pain spot was not missed.

The sensibiIity to heat and coId was tested by means of ordinary test tubes containing cracked ice or hot water. This method is usefu1 in securing onIy the coarsest observations since it is impossibIe to record the exact temperature for the reason that the gIass wiI1 be of a different temperature from the contents when it comes in contact with the skin. The test tubes were pIaced on the skin and moved from spot to spot unti1 the patient did not fee1 either heat or coId. The testing was first done with the coId tube and then with the hot tube. The end of a test tube is rather Iarge so that the findings couId not be very accurate, and we simpIy noted their Iocation in regard to the Iimits of the sensations of Iight touch and pain.

After the sensations had been tested and their Iimits marked out, a piece of perforated ceIIosiIk was pIaced over

REGENERATION OF NERVES IN SKIN GRAFTS SOS

the transplant and the Iines traced upon it with briIIiant green. The tracings were then transferred to sheets of paper and IabeIed.

The Iimits of the entering sensations were aIways found to be in irreguIar wavy Iines. The distances reported in the summaries are the points of farthest entrance of the sensations. In view of the diffIcuIty in securing accurate data on the hot and coId points, we did not outIine the Iimits of temperature but simpIy noted their probabIe Iimits in regard to the Iines demarcating pain and touch. There is such a great eIement of pressure invoIved in testing with test tubes whose bases are bIunt that more accurate determinations wouId be questionabIe with this method.

OBSERVATIONS

Before describing the resuIts of our observations, it may be we11 to understand the difference between a skin graft and a skin flap. A skin graft is a free transpIant which consists of either the whoIe thickness of the skin or a portion of the thickness of the skin, with no subcutaneous tissue, and which depends on the base on which it is pIaced for its bIood suppIy. A skin jlup, on the other hand, is an area of skin and subcutaneous tissue which is attached at some portion of its periphery or base by a pedicIe or pedicIes, through which it receives its bIood suppIy unti1 the new bIood suppIy is assured from the area into which it is shifted. A fIap can be shifted onIy so far as its pedicIe wiI1 aIIow.

AI1 the tests were made on flaps after the pedicIes had been cut and set in. The resuIts obtained have been grouped under two genera1 headings : Flaps and Grafts.

The flaps have been considered under anatomica regions, such as the face, the hands and the feet. The grafts have been separated into the different types: whoIe thickness grafts; spIit or haIf thickness; OIIier-Thiersch grafts; smaI1 deep grafts. l5


FLAPS

Flaps on Eyelids

CASE I. MaIe, aged twenty-five. A flap, 2 X 4 cm., taken from the arm, was transpIanted into a contracted lid in which keloid was present.

Tests made after sixteen months showed the sensations of pain, tempera-

ture and touch present everywhere.

CASE II. MaIe, aged twenty-six. A flap, 4.2 X 2 cm., taken from the

forehead and temple, was transpIanted into a contracted lid in which

keIoid was present. Tests made after six months showed that pain sensa-

tion was present in the IateraI thirds coming in from the three margins

away from the eyeIid margin. Touch sensation was behind the pain Iine

about 0.5 cm. and temperature was feIt between the two Iines.

CASE III. Female, aged sixteen. A Aap, 3.5 X 2.2 cm., was transpIanted

into a contracted upper eyeIid by means of a tubed Asp secured from the

neck. Tests made ten months after the transpIantation showed a11 the

sensations present.

CASE IV. Female, aged sixteen. A flap, 4 X 2.7 cm., was shifted

into a contracted upper eyelid by means of a tubed flap raised from the

neck. Six months after insertion, pain sensation was present in the edges

away from the eyeIid margin for 3.5 cm. Touch sensation was present for

2 cm. from the margins; temperature sensation was present between these

Iines.

CASE V. MaIe, aged sixty. A flap, 4.2 X 2.3 cm., was shifted into

a contracted upper eyeIid from the forehead and temple. Tests made one

month after insertion showed no sensations. After two months, pain sensa-

tion was present in the flap on a11 the margins for a distance of 0.5 cm.

There was no touch or temperature sensation. After four months, pain

sensation was present 2 cm. in from a11 the margins. Touch sensation was

present I cm. from the margins and the Iimit of temperature sensation

was between the Iines limiting pain and touch sensations. AI1 of the sensa-

tions were present over the whole ffap after six months. (Fig. I.)

CASE VI. MaIe, aged fifty-five. A flap, 4 X 2.5 cm., was shifted from

the forehead and ternpIe into a Iower eyelid, after excision of a radium

burn with an uIcer. Tests made after three weeks showed no sensations.

Four months after transpIantation, pain sensation was demonstrated

in the flap I cm. from a11 the margins except on the margin toward the eye.

There was no sensation of touch or of heat or cold.

CASE VII. MaIe, aged forty-nine. A flap, 5 X 2.5 cm., was shifted

from the forehead and ternpIe into a lower eyeIid after the removal of an

epitheIioma which had been treated with radium. Tests made after one


month showed absence of a11 sensations. After three months, pain sensation

was present 1 cm. from a11 the margins. Touch sensation was present just over the border of the flap but heat and coId sensations were ab-

A

e FIG. I. Case v. Tests of returning sensations made on a single pedxled immediate transfer

flap to eyelid. White man, aged sixty. Ectropion with loss of tissue of left upper eyelid. April 20,

1928. A sing1e pedicIe flap was raised from left temple and immediate1y transferred,

May 4, 1928. PedicIe was cut and shank set in. Surface area of transplant was g.87+ sq. cm.

A. One month after pedicle was set in. No sensations present. B. Two months after pedic1e was set in. Dotted area indicates portion where sensa-

tion of pain was present. Central portion had no sensations. There was no sensation of

temperature or touch. c. Four months after pedicle was set in. Pain was feIt over entire Asp except for

sma11 area near center. Touch sensation was present in area indicated by diagonal lines. Temperature sensation was present beyond touch area but not to hmits of pain area.

D. Six months after pedicIe was set in. AI1 sensations were present.

sent. The sensations were present over the entire flap six months after transplantation.

Discussion. The areas into which these flaps were trans- pIanted are innervated by branches of the trigemina1 nerves which are pure sensory nerves. AI1 of the fIaps were sutured into their new beds so that the lines of entering nerves were about at right angIes to the courses of the severed nerves in the flaps.


No sensations entered unti1 after the first month. The type of base and the condition of the surrounding skin appar- entIy affected the time of entrance of the sensations. In Case v where the surrounding skin was norma and the scar in the base was not extensive, pain sensation had begun to enter before the end of the second month and touch before the end of the fourth month. AI1 the sensations were present in six months. In Case IV, a fIap of about the same size as Case v, the sensation of pain had not compIeteIy returned after six months. In this case, the scar was the resuIt of an oId injury and couId not be compIeteIy excised, so that the ffap was sutured to the scar. Case II had extensive keIoid which couId not be excised entireIy around the margins and this apparentIy interfered with the earIy entrance of sensations. In Case VI, the skin of the face was generaIIy changed by radium, and there was an uIcer near the margin of the eyeIid at the outer corner. In this case, the entrance of the sensations was even more deIayed than when keIoid was present. In Case VII, the origina condition was a basaI-ceII epithehoma which had been radiated, and there remained a smaI1 margin of indura- tion which was easiIy excised. In this case sensations came in about as rapidIy as in Case v.

Flaps on Nose

CASE VIII. FemaIe, aged thirty-two. A flap, 5 X 2.4 cm., from the arm was shifted to the end of the nose after excision of a scar. AH sensations were present ten months after the transpIantation of the Aap.

CASE IX. MaIe, aged thirty-four. A flap, 3 X 2.3 cm., was raised from the forehead and shifted to form the tip of the nose after excision of scar foIIowing a gunshot wound. There were no sensations in the ffap after one month. Two months after transpIantation, pain was feIt I cm. from the margins of the ffap. There were no sensations of touch or temperature. AI1 the sensations were present when the ffap was tested ten months after transpIantation.

CASE x. FemaIe, aged forty-eight. A ffap, 5.1 X 3 cm., from the forehead was shifted to the base of the nose after the remova of an epitheIioma which had been treated with radium. The surrounding skin had radium changes. There were no sensations in the flap after one month. After


two months, pain was demonstrated 0.5 cm. from the margins, but there were no sensations of touch or of temperature. Four months after trans- pIantation, pain sensation was present in the flap I cm. from the margins, but touch and temperature sensations were absent. Six months after transpIantation, pain was feIt in the ffap 3 cm. from the margins. Touch sensation was present 0.5 cm. from the margins. Temperature sensation was not present. After tweIve months, pain sensation was present over the entire flap. Touch sensation was present 3 cm. from the margins and temperature sensation was just beyond the touch Iine. After sixteen months,

al1 of the sensations were present. CASE XI. FemaIe, aged thirty. A flap, 4.5 X 3 cm., taken from the

forehead was shifted to reconstruct a nose. There were no sensations after three weeks. After six months, pain sensation was present in the flap 4 cm. from the margins. Touch sensation was present 2 cm. from the margins and the temperature Iine was just beyond the touch margins.

CASE XII. MaIe, aged fifty-five. A flap, 3.5 X 2 cm., from the forehead

was shifted to the tip of the nose after the remova of a scar and uIcer due to a radium burn. After three years, a11 the sensations were as normal in the ffap as in any other part of the face. This patient had an extensive radium burn which invoIved the whole face.

CASE XIII. FemaIe, aged thirty-one. A flap, 2.3 X 2 cm., was shifted

from the abdominal waI1 to the nose, transferred on the hand, to fiI1 a defect made by the excision of a tubercuIous ulcer. No sensations were present after one month. AI1 the sensations were present one year after transpIantation.

CASE XIV. Female, aged twenty-eight. A Aap, 5 X 2.5 cm., was shifted

from the forehead to the nose for a Iuetic deformity. AI1 sensations were

present when tests were made two years after transpIantation. CASE xv. MaIe, aged thirty. A flap, 5 X 2.5 cm., was shifted from

the forehead to reconstruct a nose injured in a mine accident. There were no sensations after one month. After eIeven months, pain sensation was present over the entire flap. Touch sensation was present except for a tiny area near the tip of the nose. Temperature sensation was present over the entire flap.

CASE XVI. Male, aged twenty-two. A flap, 4.5 X 3 cm., was shifted from the forehead to the nose for a Iuetic deformity. There were no sensations one month after transpIantation. In four months, pain sensation was present in the flap 2 cm. from the margins. Touch sensation was present I cm. from the margins and temperature sensation about the same distance as touch. After six months, pain sensation was present over the entire flap. Touch sensation was present 2.5 cm. from the margins and temperature sensation just beyond the touch Iimits.


Discussion. The areas into which the Asps were trans- pIanted are innervated by the branches of the trigemina1 nerve which is sensory. Sensations began to enter after the first month. In Case IX, the flap was shifted to reconstruct the tip of the nose, which had been destroyed by a gunshot wound. The surrounding skin was in normaI condition and the scar was entireIy excised when the flap was put in. Pain sensation had entered from a11 of the margins during the second month. From the rate of entrance the sensations were a11 present before the tenth month when the next test was made. In Case x, there was an uIcer with surrounding atrophic skin, foIIowing treatment of an epitheIioma with radium. The appearance and advance of the sensations was deIayed prob- abIy because of the effect of the radium upon the surrounding skin. In Case XI, there was a partia1 destruction of the nose due to syphiIis. Here the sensations returned rapidIy and pain sensation had appeared in the entire flap in six months. The sensations aIways came in from the margins and did not appear in isoIated spots, so that there was nothing to suggest that the nerves entered from the base. AI1 of these fIaps were sutured into their new beds with their nerves across the course of the nerves suppIying these areas.

Flaps on Cheeks, Lips and Chin

CASE XVII. FemaIe, aged forty-three. A flap, 8 X 5 cm., was shifted from the back to fiII a cheek defect. The nerves of the whole side of the face had been previousIy destroyed during the remova of an extensive tumor. Tests made one year after transpIantation showed that no sensations were present.

CASE XVIII. FemaIe, aged thirty-five. A flap, 3.5 X 4 cm., was shifted from the arm to the upper Iip near the corner of the mouth for the repair of a defect caused by the remova of a burn scar. There were no sensations one month after transpIantation. In two months, pain sensation was present just over the margins of the flap, but there were no sensations of touch or temperature. After four months, pain was feIt in the ffap 2 cm. from the margins away from the corner of the mouth and about I cm. from the margin near the angle of the nose. Touch sensation was present I cm. at the corner of the mouth and at the margin near the angle of the nose.

FIG. 2. Case XVIII. Tests of return of sensations in opened-out tubed flap to fiII defect prepared by excision of burn scar of cheek and lip.

White femaIe, aged thirty-five. Scar from burn near corner of mouth and nose on left side of face. Flap was raised upon inner side of Ieft arm and distal end after being

divided in stages was opened out and sutured into face defect after ten days (Oct. 19, 1929). Shank was set in ten days later (Oct. 29, 1929). Surface area of transplant in cheek was 18.33+ sq. cm.

A. Two months after heaIing was complete. Dotted area indicates area where pain sensation was present. Margin without pain sensation was that along lip.

B. Four months after healing. Dotted area indicates presence of pain sensation. Lined area shows touch sensation area, and temperature sensation was just beyond limits of touch but not so far advanced as pain sensation. CIear area in center had no

sensations.

c. Six months after heaIing. Clear area near center had no sensations. D. Nine months after healing. Pain sensation was present over entire flap. Touch

sensation was absent in smal1 area near center. Temperature sensations appeared to be present over whoIe Aap. At twetve months a11 sensations were present.


Temperature sensation was just beyond the touch Iimits. In six months, pain sensation was present over the entire ffap except for an area near the center about 0.5 centimeter in diameter. Touch sensation was present 2 cm. from the margins. Temperature sensation was present beyond the Iimits of the touch area but not as far as the pain area. After nine months, pain sensation was present over the entire flap. Touch sensation was absent in an area 0.5 cm. in diameter near the center. Temperature sensation was present over the entire flap. TweIve months after transpIantation, a11 the sensations were present over the entire flap. (Fig. 2.)

CASE XIX. FemaIe, aged six. A flap, 6 X 4.5 cm., was shifted from the neck to the cheek to reIax a contracted burn scar. There were no sensations after one month. In six months, pain was feIt in the flap 4 cm. from the margins, touch 2 cm., from the margins, and temperature just beyond the Iimits of touch. One year after transpIantation, a11 the sensations were present over the ffap.

CASE xx. FemaIe, aged nineteen. A flap, IO X 6 cm., raised from the back was used to reconstruct the chin, which was deformed by a contracted burn scar. Tests made after one year showed pain sensation present over the entire flap. Touch sensation was absent in an area in the center about I X 1.5 cm. Temperature sensation was present in about the same area as touch.

CASE XXI. MaIe, aged five. A flap, 4 X 4 cm., was shifted to the cheek from the neck to fiI1 a defect caused by the remova of scar contracture folIowing the expIosion of a dynamite cap in the mouth. The ffap was put into the mouth to Iine the cheek and the shank was Iater opened out and used to form the outer covering. Tests after one year showed a11 of the sensations present in the whoIe ffap.

CASE XXII. FemaIe, aged thirty-two. A flap, 5 X 4 cm., was shifted to line the cheek from the neck. This scar was the resuIt of radium treatment of an angioma. The shank of the flap was Iater opened and turned upon itseIf to give thickness to the cheek and reIieve the contracture. AI1 of the sensations were present when it was tested after one year.

CASE XXIII. MaIe, aged fifty. A ffap, 6 X 5 cm., was shifted to the cheek from the neck to reIieve a contracted scar. In sixteen months, a11 of the sensations were present.

CASE XXIV. FemaIe, aged eight. A fIap, 5 X 3.5 cm., was raised from the neck and shifted to the cheek to reIax a contracted burn scar. After six months, pain sensation was present in the fIap 3.5 cm. from the margins. Touch sensation was present 2.3 cm. from the margins and temperature sensation was just beyond the touch Iimits. In one year, a11 of the sensations were present.


CASE xxv. Male, aged forty-eight. A flap, 3.2 X 4 cm., was shifted from the neck to the corner of the mouth to fill the defect made by the excision of a scar caused by a radium burn. After one month, there were no sensations. In two months, pain was feIt beyond the Aap margins

in a few spots but no other sensations were present. In three months, pain was feIt 0.5 cm. from the corner of the mouth but not on the other three sides. No other sensations were present. After five months, pain sensation was present I cm. from the corner of the mouth and 0.5 cm. from the other margins. Touch was feIt just beyond the margin at the corner of the mouth. In six months, pain sensation was present 1.6 cm. from the corner of the mouth and I cm. on the other margins. Touch sensation was present 0.5 cm. from the corner of the mouth and just beyond the margins on the other sides. After one year, pain was feIt a11 over the flap. Touch sensation was absent in a very smaI1 area near the center. Temperature sensation was present about the touch line. After fourteen months, a11 of the sensations were present over the entire flap.

CASE XXVI. Male, coIored, aged forty-eight. A flap, 4 X 3 cm., was shifted from the back to the cheek to hII a defect made by the excision of an area of Iupus. After nine months, pain sensation was present except for an area I X 0.7 cm. near the center. Touch was felt about I cm. behind the pain Iine. Temperature was felt just beyond the limits of touch.

CASE XXVII. FemaIe, aged twenty-eight. A flap, 5 X 4 cm., was shifted from the back to the cheek to relax a contracted scar in which keIoid was present. AI1 of the sensations were present when the 8ap was tested fifteen months after transpIantation.

CASE XXVIII. FemaIe, aged twenty-nine. A flap, 4 X 3 cm., was shifted from the back to the cheek to reIax a keIoida1 type of contracted scar. In one year, a11 the sensations were present, but the patient reported that they feIt dull as though through a glove.

CASE XXIX. FemaIe, aged thirty-one. A flap, 3.5 X 2.5 cm., was shifted

from the arm to the upper Iip to reIax a contracted scar. After one month, there were no sensations.

CASE xxx. Male, aged thirty-two. A flap, 5.2 X 4 cm., was raised upon the neck and shifted to form the lower Iip. There was an almost compIete destruction of the right side of the Iower Iip due to noma. After one month, there were no sensations. In six months, pain was felt 4 cm. from the three outer margins but not from the lip margin. Touch was feIt about I cm. behind the pain Iine. Temperature sensation was about the same as touch. After one year, a11 of the sensations were present.

Discussion. The areas into which the flaps were trans- pIanted are innervated by branches of the trigemina1 nerves


which are pure sensory nerves. The flaps in Cases XVIII, xx, xxv and xxx were pIaced so that the courses of the entering nerves wouId be about in Iine with the remains of the nerves which were originaIIy present. The other fIaps in this series were pIaced at various angIes to the entering nerves. There was no apparent difference in the time of entrance or the rate of advance of the nerves in these different flaps. Any difference in time or rate of innervation couId be attributed to the type of base and the character of the surrounding skin. In Case XVII, no sensations appeared after one year, which was due to the fact that there had been destruction of the nerves of the right side of the face by an extensive operation for the remova of a Iarge tumor. In Case XVIII, there was a scar containing portions of a whoIe thickness graft near the corner of the nose upon the upper Iip. AI1 of this area was excised when the fIap was sutured in. Pain appeared in the second month and touch before the end of the fourth month. AI1 sensations were norma before the end of one year. The rate of advance is about I cm. per month so that a Iarger flap wouId require more time for the return of sensations. This is shown in Case xx, where a Iarge Asp was sutured into the chin after the remova of a burn scar. The sensations had not compIeteIy returned after one year. In Case xxv, where radium changes had affected the skin, muscIes and bone, the sensations were deIayed and a year eIapsed before a11 the sensations had returned. In Case XXVIII, a flap was pIaced into the cheek to reIax a contracture due to a burn scar compIicated by an extensive keIoid. The patient reported that a11 the sensations feIt as though he were being touched through a gIove.

Flaps on Wrists and Hands

CASE XXXI. MaIe, aged forty-two. A flap, 7 X 4 cm., was shifted to the paIm of the hand from the abdomina1 wall to relax a contracted scar.

After one month, there were no sensations. In three months, pain sensation

was present in the flap I cm. from a11 the margins except on the dista1

side where it was absent. There was no touch or temperature sensation.


After six months, pain was felt 3.4 cm. from the three margins but none on the distaI side toward the fingers. Touch sensation was present 2 cm. from the margins in Iine with pain. No temperature sensation was elicited.

CASE XXXII. MaIe, aged twenty-six. A flap, 8.5 X 5.5 cm., was shifted to the palmar side of the wrist from the abdomina1 waII to relax a contracted scar in which keIoid was present. After fourteen months, a11 of the sensa-

tions were present. CASE XXXIII. FemaIe, aged twenty-six. A flap, IO X 6 cm., was shifted

to the wrist from the abdomina1 waI1 to reIax a contracted scar. After two months, pain sensation was present just over the margins. There was no touch or temperature sensation. In four months, pain was feIt I cm. from the margins but touch and temperature sensations were stiI1 absent.

CASE XXXIV. MaIe, aged sixteen. A flap, 12.5 X 6 cm., was shifted to the forearm from the abdomina1 waI1 to cure a traumatic uIcer. There

were no sensations after two months. In three months, pain was felt I cm. from the margins of the flap. There was no touch or temperature sensation. In seven months, pain was feIt 4 cm. from the margins. Touch was felt 2 cm. from the margins. Hot and coId points were found between these two Iines. After nine months, pain sensation was present over the entire flap except for an area I cm. in diameter near the center of the flap. Temperature sensation was present just beyond the touch Iine which was 4 cm. from the margins of the flap.

CASE xxxv. MaIe, aged thirteen. A flap, 3.5 X 4.5 cm., was shifted to the hand between the thumb and the index finger from the abdomina1 wall to reIax a contracted scar. AI1 of the sensations were present one year after

transpIantation. CASE XXXVI. MaIe, aged fifty-seven. A flap, 9.5 X 7 cm., was shifted

to the pIamar surface of the hand from the abdominal waI1 after the re- mova1 of an x-ray burn. There were no sensations in the flap three months after transplantation. After six months, pain sensation was present 2 cm. from the margins. Touch sensation was just over the margin. There were no sensations of temperature. After one year, a11 of the sensations were present in the entire flap.

CASE XXXVII. MaIe, aged twenty-one. A flap, 4 X 4.8 cm., was shifted to the palmar side of the hand near the IittIe finger from the abdomina1 wall to relieve a contracted scar. In three weeks, there were no sensations. After two months, pain was feIt just over the margins. There was no touch or temperature sensation. After four months, pain sensation was present 1.7 cm. from the margins. Touch was felt 0.5 cm. from the margins but temperature sensation was not found. After eight months, pain sensation was present over the whoIe ffap. Touch was feIt over the entire flap except for a smaI1 area, 0.5 cm. in diameter, near the center of the flap. Tempera-


ture sensation was present over the same area as touch. After tweIve months, all of the sensations were present over the entire flap.

CAKE XXXVIII. Male, aged twenty-one. A flap, 7 X 5 cm., was shifted to the wrist from the abdomina1 waI1 to reIax a scar. There were no sensations present after one month.

CASE XXXIX. MaIe, aged twenty-nine. A hap, 6 X 4 cm., was shifted from the abdomina1 waI1 to the hand after the excision of an uIcerated scar. There were no sensations after one month. In three months, pain was feIt I cm. from the margins. There was no touch or temperature sensation.

CASE XL. MaIe, aged fifty-five. A flap, 5.5 X 3 cm., was shifted from the abdomina1 waI1 to the dorsum of the hand to repair a defect Ieft by the excision of a traumatic uIcer. In three weeks, there were no sensations. In two months, pain sensation was present just over the margins. There was no touch or temperature sensation.

CASE XLI. FemaIe, aged twenty-two. A Aap, 7 X 5 cm., was shifted to the wrist from the abdomina1 waI1 to reIax a contracted burn scar. After one year, pain sensation was present over the entire fIap except for an area 1-5 cm. in diameter near the center. Touch sensation was I cm. behind pain and temperature sensation was about the same as touch.

CASE XLII. MaIe, aged twelve. A flap, 6 X 5.5 cm., was shifted to the wrist from the abdomina1 waI1 to reIax a burn scar. Pain was feIt over the entire ffap in one year. Touch sensation was absent over an area I cm. in diameter near the center. The area of temperature sensation was about the same as touch.

CASE XLIII. MaIe, aged twenty-nine. A ffap, 5.5 X 4 cm., was shifted to the paImar surface of the hand near the thumb from the abdomina1 waI1 to reIax a scar. After three weeks, there were no sensations.

CASE XLIV. MaIe, aged eighteen. A flap, 7 X 5 cm., was shifted over the finger stumps from the abdomina1 waI1 to reIax a painfu1 scar. After one month, there were no sensations. In six months, pain was feIt 3 cm. from the margins. Touch was feIt 2 cm. from the margins. Temperature sensation was in about the same area as touch. After one year, a11 the sensations were present.

CASE XLV. MaIe, aged seventeen. A flap, 5 X 4 cm., was shifted to the wrist from the abdomina1 waI1 to relax a contracted scar. There were no sensations present after one month.

CASE XLVI. MaIe, aged tweIve. A flap, 12 X 7 cm., was shifted to the stump of a forearm from the abdomina1 waI1 after the excision of a painfu1 uIcerated scar. After seventeen months, a11 of the sensations were present.

Discussion. The areas into which the flaps were trans-

pIanted are innervated by the branches of the median, uInar

REGENERATION OF NERVES IN SKIN GRAFTS 51:

and radiaI nerves. The median and uInar nerves are pureIy sensory nerves whiIe the radia1 nerve is a mixed nerve containing both motor and sensory fibers. AI1 of these flaps were pIaced so that the norma nerves at the site were at about right angIes to the courses of the nerves in the flaps. AI1 of these flaps were pIaced over areas which were innervated by more than one of the nerves of the hand or wrist and usuaIly received innervation from both the radia1 and the ulnar nerves. It was d&uIt to determine any difference in the rate of entrance or advance between the branches of the two nerves since the pedicIes were not sutured in at the same time and caused compIications which couId not be evaIuated. In studying the tracings there is a difference in the time of entrance and rate of advance of the branches of the median and uInar nerves as compared with the radia1 nerve. The type of base and the condition of the surrounding skin area are aIso definite factors in influencing return of the innervation. In Case XXXVI, an x-ray burn of the paIm of the hand, pain sensation was present onIy 2 cm. from the margin of the ff ap after six months, whiIe in Case XXXI, where there was dense surrounding scar present, pain sensation had entered 3.4 cm. from the margins. The time of entrance and the rate of advance of the various sensations in a11 of these cases was sIower than upon the face, even though the type of base and the character of the surrounding skin were simiIar.

Flaps on Fingers

CASE XLVII. MaIe, aged fifty-two. A flap, 3 X 3.5 cm., was shifted from the abdomina1 waII to cover the second joint of the index finger after the excision of an x-ray burn. There were no sensations three weeks after transpIantation. Tests made after two months showed sensations stiI1 absent. After six months, pain was feIt I cm. from the margins. Touch and temperature sensations were present just over the margins. After nine months, a11 the sensations were present over the entire ffap.

CASE XLVIII. Male, aged forty-six. A flap, 3 X 2 cm., was shifted from the abdomina1 waI1 to cover the dista1 joint of the index finger after excision of an x-ray burn. There were no sensations after one month. After three

518 J. S. DAVIS AND E!.. A. KITLOWSKI

months, pain was feIt just over the margins on three sides but not on the side toward the nail. There were no touch or temperature sensations. In Iive months, pain was feIt I cm. from the three margins and just over the edge on the nail margin. Touch was feIt just over the margins on the three sides but not on the nai1 side. Temperature sensation was absent. After seven months, a11 of the sensations were present.

CASE XLIX. MaIe, aged forty. A IIap, 2 X 2.5 cm., was shifted from the abdomina1 waI1 to the paImar surface of the terminal phaIanx of the index finger after the excision of a radium burn. There were no sensations six months after transpIantation. After two months, pain was feIt just over the margins of the flap. There was no touch or temperature sensation. In four months, pain sensation was present 0.5 cm. from the margins but there were no sensations of touch or temperature. After six months, pain was feh. over the entire ffap except for an area 0.5 cm. in diameter near the center. Touch was feIt I cm. from the margins. Temperature sensation was present in about the same area as touch. In seven months, pain was feIt over the entire flap. Touch sensation was present over the whoIe fIap except for an area 0.5 cm. in diameter near the center. Temperature sensation was present in about the same area as touch. After nine months, a11 of the sensations were present over the entire ffap.

CASE L. Male, aged thirty-eight. A flap, 3.5 X 3 cm., was shifted from the abdomina1 waI1 to cover a defect on the index finger between the Hurst and second joints after the excision of an x-ray burn. Tests made after one and two months showed no sensations present. After four months, pain sensation was just over the margins in spots, but no sensations of touch or temperature were present.

CASE LI. MaIe, aged twenty-two. A fIap, 3.5 X 3 cm., was shifted from the abdomina1 waI1 to cover a defect on the index finger near the first joint after the excision of an x-ray burn. One year Iater, a11 of the sensations were present.

CASE LII. MaIe, aged thirty-eight. A fIap, 3 X 2.5 cm., was shifted from the abdomina1 waI1 to cover a defect on the third finger between the dista1 and second joints after the excision of an x-ray burn. There were no sensations after two months. In four months, pain was felt over the margins in spots but there was no touch or temperature sensation.

Discussion. This group of cases are a11 x-ray or radium

burns and a11 the flaps but one were pIaced on the dorsa1 surfaces of the fingers. The fIaps were pIaced at about right

angIes to the courses of the normal nerves. The entrance of sensations was deIayed in aI1. In Case XLVII, pain had advanced


only I cm. in six months. In Case XLIX, it had advanced onI?- 0.3 cm. in the same time. The flaps were a11 smaI1 so that the innervation was rapidIy completed. In Case XLVIII, where the ffap had been pIaced just behind the nai1, the sensations came in aIong the IateraI margins and the margin towards the hand but not aIong the margin towards the nai1. In Case XLIX, the flap was pIaced upon the paImar surface of the termina1 phaIanx of the index finger. Pain sensation did not appear unti1 the fourth month and a11 sensations were present in the ninth month.

Flaps on Feet

CASE LIII. MaIe, aged twenty-one. A hap, 5.2 X 8 cm., was shiftecl

from the calf of the Ieft leg to the soIe of the right foot after the excision

of a scar which had been burned by radium. There were no sensations after

one month. In six months, pain was feIt 2 cm. from the inner side of the

foot and at the margins on the outer side. Touch sensation was present I cm.

on the inner side and absent on the outer side. Temperature sensation was

about the same as touch. After one year, a11 of the sensations were present

over the entire flap.

CASE LIV. MaIe, aged twenty-one. A flap, 3.4 X 8.1 cm., was shifted

from the caIf of the right leg to the sole of the Ieft foot after the excision

of a radium burn. There were no sensations in the flap one month after

transplantation. In five months, pain was felt for 2 cm. from the margin

on the inner side of the foot shaping off toward the heel, on the outer side

there was no pain sensation. Touch sensation followed the pain Iine about

I cm. behind. There were no sensations of temperature. In eIeven months,

pain sensation was present over the entire flap except for a smaI1 area about

0.5 X I cm. near the center toward the heel. Touch was felt about I cm. behind the pain Iine and the temperature sensation area was about the same

as that of touch. After seventeen months, ail of the sensations were present.

CASE LV. MaIe, aged twenty-four. A flap, 7.3 X 5.4 cm., was shifted

from the calf of the Ieft Ieg to the heel of the right foot after the excision

of a painfu1 scar. Tests made after the first and second months showed no

sensations present. In three months, pain sensation was present I cm.

from the margin on the back of the hee1 but not along the other margins.

There was no touch or temperature sensation. After four months, pain

sensation was present 2 cm. from the hee1 margin posteriorly and I cm.

aIong the other margins. Touch sensation was present just over the posterior

margin. There were no temperature sensations present. In five months,

J. S. DAVIS AND E. A. KITLOWSKI

pain sensation was advanced to aImost 3 cm. from the posterior margin. On the outer side, it had entered I cm. from the margins. On the margin toward the toes, it had made no progress since the Iast test. After nine months, there was an area I cm. from the anterior margin, I X 0.5 cm. which had no pain sensations. An area 2 cm. in diameter had no touch sensation. Temperature sensation was about the same as touch. After one year, al1 of the sensations were present in the whoIe flap.

CASE LVI. FemaIe, aged twenty-eight. A flap, 7 X 5 cm., was shifted from the caIf of the Ieft Ieg to the soIe of the right foot near the hee1 after the excision of an x-ray burn. Tests made after eighteen months showed a smaI1 area toward the hee1 which had no sensations. Touch and pain sensations had the same boundary. Temperature was feIt in about the same area but with no certainty.

CASE LVII. MaIe, aged thirty-two. A Asp, 7 X 4 cm., was shifted from the calf of the right Ieg to the soIe of the foot near the hee1 of the Ieft foot after the excision of a scar. In two years, there was an area of about haIf of the ffap toward the hee1 which did not have any sensations. Pain sensation was present over the remaining haIf but touch and temperature sensations were present over about one-fourth.

CASE LVIII. MaIe, aged twenty-two. A flap, 8 X 4.5 cm., was shifted from the calf of the left Ieg to the soIe of the right foot after the excision of a scar. There were no sensations after one month. In three months, pain was feIt I cm. from the posterior margin and 0.5 cm. aIong the IateraI margins but none from the anterior margin. There was no touch or temperature sensation. In five months, pain sensation had advanced to 2.5 cm. from the posterior margin and I cm. from the IateraI margins. Touch sensation had advanced over the three margins but not over the margin toward the toes. There were no sensations of temperature. In seven months, there was an area 3 X 2 cm. near the anterior margin which did not have pain sensation. Touch sensation had entered 2 cm. from the three margins but was just over the margin toward the toes. Ten months after trans- pIantation, there was an area 0.5 cm. in diameter which had no pain sensation. Touch sensation was present over a11 of the ffap except for an area 2 cm. in diameter near the anterior margin. After fifteen months, pain sensation was present everywhere. Up to this time, it advanced sIowIy. Touch sensation was absent over an area I cm. in diameter. Temperature sensation was present in about the same area as touch. After eighteen months, a11 of the sensations were present.

Discussion. These areas were innervated by the branches of the femora1, peronea1 and tibia1 nerves. The femora1 and peronea1 nerves are mixed nerves whiIe the tibia1 is entireIy

REGENERATION OF NERVES IN SKIN GRAFTS $21

sensory. The flaps were pIaced at about right angIes to the courses of the innervating nerves and in areas supplied by more than one of the branches. WaIking upon the flaps caused the formation of callus aIong the margins and thickening of the skin in some areas, and this was apparentIy a factor in determining the extent of the sensations. Sensations came in more rapidIy from the IateraI edges and most sIowIy from the margin towards the toes. The inner side appeared to become sensitive first. In Case LVIII, the patient was upon crutches most of the time the tests were being made and there was no caIIus formation. In this case the sensations did not return compIeteIy unti1 after fifteen months.

Summary of Transplanted Skin Flaps

We have reported 58 cases seIected from 67 cases studied as being typica of the various areas. Age apparentIy is not a factor in the innervation of flaps. In this series the ages ranged from five to sixty years. The source of the flaps does not influence the time or rate of the appearance of the sensations. FIaps pIaced upon the nose from the forehead did not receive their sensations any faster than those taken from the arm.

There was always a dissociation of the sensations. Pain sensation appeared and advanced first. It began to be felt after one month and advanced at the rate of about I cm. per month. The sensations of heat and coId appeared a few weeks after pain and before touch. Touch sensation appeared Iast, about one month after pain, and advanced at the rate of about I cm. per month. In some cases, temperature sensation was not demonstrated unti1 after touch was feIt but the method of testing wouId account for this, inasmuch as the patient had to consider pressure with the temperat.ure sensation. The type of innervation, whether pure sensory or so-caIIed mixed nerves, was a factor in the time and rate of the appearance of the sensations. The innervation of the flaps upon the face, which is in the trigemina1 area, was faster than upon


the hands or feet. However, in the cases upon the hands and feet where the pure sensory and the mixed nerves were both invoIved in the same Asps, the side of the sensory innervation showed greater advance of the sensations than the side where the mixed nerves were present. Due to comphcating factors this couId not be accurateIy evaIuated. The position of the fIaps in regard to the direction of the innervating fibers had an effect upon the rate of advance of the sensations. We found this to be definiteIy true in the regeneration of sensations in peduncuIated flaps before the pedicIes were cut. It is not so pronounced in these observations on account of the effect the type of base and the condition of the surrounding skin have upon the invasion of the nerve fibers into the flaps. The time of entrance of the nerve fibers was sIower when the surrounding skin was inchrated with keIoida1 scar. Pain sensation did not enter unti1 the third month and touch about the fourth month. Where the skin had been affected by radium or x-ray the time of appearance was stiI1 sIower and the rate of advance deIayed. The extent of the deIay caused by these various factors cannot be stated inasmuch as they cannot be isoIated. New scar wouId form at the margins of the fIaps and the depth of scar and the condition of the base and surrounding skin varies with every case.

The changes in the skin due to the new environment upon the soIes and heeIs caused the resuIts of the tests of the ffaps in these areas to vary from the others. There was caIIus formation and the skin became tough and considerabIy Iess sensitive to the fine tests which were made. We fee1 that these are factors in expIaining the apparent sIow return of sensations in these flaps and that probabIy the sensations actuaIIy come back as rapidIy as in the other areas tested.

GRAFTS

Free Whole Thickness Skin Grafts

CASE LIX. Male, aged thirty. Area, 14 X g cm. The graft was ob-

tained from the abdominal waII and was pIaced on the knee after the exci-

C

FIG. 3. Case LIX. Tests on return of sensations in large whoIe thickness graft. Left knee of a man, aged thirty, was burned by x-rays during treatments for eczema. Burned area was excised, Apr. 13, 1929, and a single whole thickness skin graft from abdomina1

ff 5231

J. S. DAVIS AND E. A. KITLOWSKI

sion of an x-ray burn. In three months, there were no sensations. In six months, pain sensation had appeared just over the margins, but there was no touch or temperature sensation anywhere. In ten months, the pain sensation had advanced 2 cm. from the margins. Temperature sensation was just over the margins. There was no sensation of touch. After one year, pain sensation had advanced to 3.5 cm. Touch sensation was 1.5 cm. from the margins. Temperature sensation was between pain and touch.

(Fig. 3.) CASE LX. FemaIe, aged thirty-three. Area, 3 X 3 cm. The graft from

the thigh was pIaced on the heeI after the excision of an x-ray burn. In four months, no sensations were present. In five months, pain sensation was just over the margins. No temperature or touch sensation was present. In seven months, pain sensation had advanced 1.5 cm. from the margins. Touch sensation was present over the margins in spots. Temperature sensation was about the same as touch.

CASE LXI. MaIe, aged fourteen. Area, 13 X 8 cm. The graft from the abdomina1 waII was pIaced on the thigh after excision of an area of dense scar. In one year, no sensations couId be demonstrated. In two years, a11 sensations were present throughout.

CASE LXII. MaIe, aged seven. Area, 5 X 7 cm. The graft from the abdominal waI1 was pIaced on the ankle after excision of scar tissue. In five weeks, no sensations were present.

CASE LXIII. MaIe, aged forty. Area, IO X 6.5 cm. The graft from the abdomina1 waI1 was pIaced on the paIm of the hand after the excision of an x-ray burn. In two months, there were no sensations.

CASE LXIV. MaIe, aged thirty-four. Area, 4 X 3 cm. The graft from the thigh was pIaced on the forehead to Ii11 a defect made by raising a flap. In two months, there were no sensations. In ten months, a11 the sensations

were present everywhere. CASE LXV. FemaIe, aged ten. Area, 5 X 3.2 cm. The graft from the

abdomina1 waI1 was pIaced on the cheek to hII the defect made by excision

waII was immediately sutured in to Ml defect. Surrounding skin showed some atrophy from radiation but was sufficiently good to contraindicate excision. Surface area of

transpIant was 98.93 + sq. cm. A. Six months after grafting. Pain sensation present at margins in smaI1 areas. B. Ten months after grafting. Dotted area indicates advance of pain sensation. No

touch or temperature sensations were present. c. One year after grafting. Dotted area had pain sensations and lined area sensa-

tions of touch. Temperature line was just beyond touch line. D. Four and one-half years after grafting. There has been comparatively IittIe

advance in sensations during Iast three and one-haIf years. In this graft return of sensations has been very SIOW, and they have advanced very IittIe. We doubt that

sensations wiII ever return compIetely. (Reduced one-half.)


of a hairy mole. In four months, there were no sensations. In six months, pain sensation had advanced I cm. from the margins. There were areas in the graft which had not taken weI1. No temperature or touch sensations were present. In one year, a11 sensations had returned.

CASE LWI. FemaIe, aged sixteen. Area, 6 X 3 cm. The graft from the abdomina1 waI1 was pIaced on the forehead to fill the defect made by excision of a scar. In one month, there were no sensations. In six months, pain sensation had entered I cm. No touch or temperature were feIt. In one year, a11 sensations were present over the whoIe graft.

CASE LXVII. MaIe, aged thirty-three. Area, 4 X 3 cm. The graft from the arm was pIaced on the cheek after excision of an x-ray burn. In one year, pain sensation was present everywhere except for an area 0.5 cm. in diameter near the center of the graft. Temperature and touch sensations were about I cm. behind the pain Iine.

CASE I-XVIII. MaIe, aged forty-eight. Area, 3 X 2 cm. The graft from the abdomina1 waI1 was pIaced on the side of the nose after excision of a scar. In one month, there were no sensations. In one year, a11 sensations were present.

CASE LXIX. Female, aged forty-eight. Area, 4 X 3.5 cm. The graft from the arm was pIaced on the forehead to fill the defect Ieft by raising a flap. In two months, there were no sensations. In six months, pain sensation had advanced I cm. from the margins. No touch or temperature sensation was present. In nine months, pain sensation had advanced to 2.4 cm. from the margins. Touch sensation was present 1.5 cm. from the margins. Temperature sensation was between the pain and touch lines. In one year, a11 sensations were present.

CASE w(x. MaIe, aged fifty. Area, 4 X 2.5 cm. The graft from the thigh was pIaced on the ternpIe after excision of a scar. In two years, al1 sensations were present.

CASE LXXI. MaIe, aged thirty-six. Area, 3 X 1.5 cm. The graft from the thigh was pIaced on the IittIe finger after excision of an x-ray burn. In one month, no sensations were present. In six months, pain sensation had entered 0.5 cm. No touch or temperature sensations were present.

CASE LXXII. FemaIe, aged seven. Area, 6.2 X 3 cm. The graft from the thigh was placed on the forehead after excision of a scar. In one month, no sensations were present. In nine months, pain sensation had advanced 3 cm. Touch sensation was in 0.5 cm. Temperature was felt between the pain and touch Iines. In two and one-haIf years, a11 sensations were present.

CASE LXXIII. MaIe, aged fifty. Area, 5 X 1.5 cm. The graft from the thigh was pIaced on the cheek near the Iower eyelid after the excision of a scar. In two years, a11 sensations were present.


CASE LXXIV. Female, aged thirty-five. Area, 4 X 3 cm. The graft from the thigh was placed near the corner of the mouth to Ii11 a defect made by the remova of a scar. In five months, the sensation of pain was found just over the margins. No touch or temperature sensations were present.

CASE LXXV. Male, aged forty. Area, 3.4 X 2 cm. The graft from the arm was pIaced in a defect on the forehead which followed the raising of a flap. In one month, there were no sensations. In six months, the sensation of pain had advanced 1.3 cm. from the margins. No touch or temperature sensations were present. In one year, a11 sensations were present.

CASE LXXVI. MaIe, aged forty-six. Area, 3 X 1.5 cm. The graft from the thigh was pIaced on the middIe finger after excision of an x-ray burn. In one month, there were no sensations. In six months, pain sensation had entered 0.6 cm. No temperature or touch sensations were present. In eight months, pain sensation had advanced to 1.2 cm. Touch was feIt just over the margins. In one year, pain couId be feIt a11 over the graft; temperature was felt a11 over the graft. An area 0.5 cm. in diameter in the center of the graft did not have the sensation of touch.

CASE LXXVII. MaIe, aged twenty-five. Area, 4 X 1.5 cm. The graft from the arm was pIaced in a defect made by excision of a keIoid on the upper Iip. In one month, there were no sensations. In six months, pain sensation had entered to 0.5 cm. from the margins. No temperature or touch sensations were present. In eIeven months, pain sensation was present except for a smaI1 area near the center of the graft. Temperature was not feIt in an area a IittIe Iarger than where pain was missing. Touch sensation was 2.5 cm. from the margins. The sensations had advanced from a11 margins. In sixteen months, a11 sensations were present throughout the graft.

CASE LXXVIII. FemaIe, aged nine. Area, 3 X 7 cm. The graft from the abdominal waI1 was pIaced on the arm after excision of a scar. In one month, there were no sensations present. In five months, pain was felt just over the margins. No touch or temperature sensations were noted. In two years, a11 sensations were present.

CASE LXXIX. FemaIe, aged nine. Area, 3 X 6 cm. The graft from the abdomina1 waI1 was pIaced on the chin after excision of a scar. In six weeks, no sensations were present. In six months, pain was feIt over the margins 0.4 cm. No touch or temperature sensations were present. In two years, a11 sensations were present.

CASE LXXX. FemaIe, aged ten. Area, 4 X I I cm. The graft from the abdomina1 waI1 was pIaced on the neck after the excision of a scar. In one month, no sensations were present. In nine months, pain sensation had advanced 2 cm. from the margin. No touch or temperature sensations were


present. In seventeen months, pain and temperature sensations had advanced over the whoIe graft. Touch sensation was absent in an area near

the center. CASE LXXXI. Male, aged twenty-eight. Area, 2 X 3 cm. The graft

from the thigh was pIaced on the third finger after the excision of an x-ray burn. In three months, no sensations were present. In seven months, pain sensation was present just over the margins. No temperature or touch

sensations were found. CASE LXXXII. MaIe, aged thirty-five. Area, 3 X 6 cm. The graft

from the thigh was pIaced on the forearm after the excision of a scar.

In two months, no sensations were present. In eight months, pain sensation had advanced 2 cm. from the margins. Touch sensation was found just

over the margins. Temperature sensation was we11 over the margins. CASE LXXXIII. MaIe, aged twenty-one. Area, I X 3 cm. The graft

from the arm was placed on the upper eyeIid for the reIief of ectropion. In one month, no sensations were present. In Iive months, pain was felt over the margins. No touch or temperature sensations were present. In

nine months, a11 sensations were present over the whoIe graft. CASE LXXXIV. FemaIe, aged nineteen. Area, 1.2 X 3 cm. The graft

from the arm was pIaced on the upper eyelid for the reIief of ectropion due to scar. In three months, no sensations were present. In ten months, a11 sensations were present over whoIe graft.

CASE LXXXV. FemaIe, aged fourteen. Area, 1.5 X 2.8 cm. The graft from the arm was pIaced on the upper eyeIid to reIieve an ectropion due to scar contracture. In five months, no sensations were present. In eIeven

months, a11 sensations had returned.

CASE LXXXVI. Female, aged twenty-two. Area, 2 X 3.2 cm. The graft from the arm was pIaced on the upper eyehd for the reIief of an ectropion due to scar contraction. In five months, pain was feIt just over the margins. In seven months, pain was felt 0.5 cm. over the margins. No touch or temperature sensations were present. In nine months, pain sensation was present except for an area 0.3 cm. in diameter in the center. Touch and temperature sensations have each advanced 2 cm. In eIeven months, a11 sensations were present.

Discussion of the Return of Sensations in Free Whole Thick-

ness Skin Grafts. The free whoIe thickness skin grafts were cut from patterns made of the defects for which they were intended. They incIuded the fuI1 thickness of corium from which as much fat as possibIe had been removed. The compIete remova of fat eIiminated the nerve fibers and Ieft onIy those


end organs and ends of nerves which are situated in the corium. This eliminated many end organs which are found in the fat of the hypoderm, which is the Iowest Iayer of the skin.14 The graft was then pIaced upon the bed prepared for it in an area from which a11 of the scar or as much as possibIe had been removed. The margins of the graft were then sutured to the surrounding skin. AI1 of the cases here reported had compIete takes except Case LXVIII, where some smaI1 superficia1 areas were Iost aIthough the coriuti survived.

The time of entrance of the sensations into these grafts was much sIower than the time of entrance into the skin ffaps. Pain did not appear unti1 the sixth month and touch unti1 the seventh month. Temperature appeared sometime between these two. The rate of advance was sIower, being about 0.3 cm. per month. This is due probabIy to the fibrous tissue which forms beneath the graft as we11 as around the margins. The grafts pIaced upon the forehead to fiI1 the defects made by raising peduncuIated flaps (Cases LXIV, LXIX, IXXV) secured their innervation the soonest. In these cases there was no scar tissue in the base and the surrounding skin was normaI. Cases LXVI and LXXII were Iarger grafts sutured into the forehead to reIease contractures. The time of entrance and the rate of advance of the sensations was sIower in these than in Cases LXIV, LXIX and LXXV.

AI1 of the grafts eventuaIIy became sensitive to pain, touch and temperature. X-ray burns of the skin aIso tended to deIay the innervation. Case LXXXI had no sensations in seven months. In Case LXXVI pain sensation had advanced onIy 1.2 cm. in eight months. Age pIayed no r6Ie in the innervation, and the source of the graft did not influence the return of the sensations m any way.

Half Thickness Free Skin Grafts

CASE LXXXVII. FemaIe, aged sixteen. Area, 2 X 3.4 cm. The graft from the abdomina1 waII was pIaced on the neck after the excision of a scar. In one month, no sensations were found. In one year, pain sensation was


present except for a very smaII area near the center. Touch sensation was in I cm. from the margins.

CASE LXXXVIII. FemaIe, aged seventeen. Area, 2.5 X 4 cm. The graft from the arm was pIaced on the cheek after the excision of a scar. In one month, no sensations were present. In six months, no sensations were noted. The graft had shrunk about one-fourth. In one year, pain sensation was present everywhere except in an area 0.5 cm. in diameter in the center. Touch sensation is in about I cm. from the margins. In two years, a11 sensations were present.

CASE LXXXIX. FemaIe, aged forty-four. Area, z X 4 cm. The graft from the thigh was pIaced on the temple foIIowing excision of a scar. In one month, no sensations were found. In seven months, pain was feIt just over the margins; no touch sensation. In thirteen months, a11 sensations were present.

CASE xc. FemaIe, aged forty-four. Area, I .5 X 5 cm. The graft from the thigh was pIaced on the cheek foIIowing excision of a scar. In one month, no sensations were present. In seven months, pain was feIt just over the margins, no touch sensation. In thirteen months, pain sensation was present everywhere except in an area 0.5 cm. in diameter near the center. Touch sensation had advanced 2 cm. from the margins.

CASE XCI. FemaIe, aged twenty. Area, 2 X 2 cm. The graft from the thigh was pIaced in the commissure between the thumb and forefInger after removal of a scar. In one month, no sensations were found. In six months, there were no sensations. In seven months, pain sensation was present just over the margins, no touch. In nine months, pain sensation had advanced I cm. Touch sensation was present just over the margins. In eIeven months, pain was feIt everywhere except for a smaI1 area near the center. Touch sensation was absent in an area I cm. in diameter. In tweIve months, pain sensation was present everywhere. A smaI1 area near the center did not have touch sensations. In thirteen months, a11 sensations were present.

CASE XCII. Female, aged twenty. Area, 2.5 X 3 cm. The graft from the thigh was pIaced on the palm of the hand after the remova of a scar. In six months, no sensations were found. In seven months, pain was feIt just over the margins, no touch. In nine months, pain sensation had advanced I cm. from the margins, no touch. In eIeven months, pain was feIt everywhere except an area 0.5 cm. in diameter in the center of the graft. Touch sensation had advanced to I cm. from the margins. In one year, pain sensation was present everywhere. Touch sensation was absent in an area near the center. In thirteen months, touch sensation was not entirely present. In fourteen months, a11 sensations were present.

(Fig. 4.1

3 E FIG. 4. Case XCII. Tests of return of sensations in half thickness or spIit graft. White woman, aged twenty. Patient had deveIoped painfu1 keratosis in palm

of hand near wrist from use of crutches. She had a tendency to deveIop this condition wherever skin was traumatized by pressure or frequent irritation. Area was excised and spIit or haIf thickness graft was taken from right thigh and sutured into defect.

Surface area of transpIant was 6.2g+ sq. cm. A. Pain sensation began to appear after seven months. B. It had advanced about I cm. after nine months. There were no touch or tem-

perature sensations. c. Eleven months after grafting. A small area near center did not have sensations

of pain. Lined area shows advance of touch sensation. Temperature sensation was present just beyond touch line.

D. One year after grafting. AH of area was sensitive to pain. A small area near center was not sensitive to touch.

E. Thirteen months after grafting. There stiI1 remained a small area near center which did not have touch sensation. Temperature and pain were feIt over entire graft. When tested one month Iater, sensations were a11 present everywhere.

I[534


CASE XCIII. Male, aged twenty-eight. Area, 2 X 3 cm. The graft from

the thigh was pIaced on the finger after the excision of an x-ray burn.

In six months, no sensations were found. In one year, pain was felt 0.5 cm.

from the margins. No touch sensations were present.

CASE XCIV. Male, aged twenty-three. Area, 2.4 X 3 cm. The graft

from the thigh was pIaced on the nose after excision of a scar. In one year.

all sensations were present.

Discussion. The haIf thickness or spIit skin grafts were secured by spIitting the corium. The size was taken according to a pattern made of the area to be grafted. In studying the shrinkage of grafts, we found that there was an immediate shrinkage of about one-fourth in spIit grafts and that after the grafts had we11 heaIed, there was aIso some further shrinkage. This made it very diffIcuIt to determine the rate of advance of the sensations.

The entrance of the sensations was sIower than in whoIc thickness grafts. Pain did not begin to appear unti1 after the seventh month and the rate was about I cm. in three months. The dissociation of the sensations was again present. We did not attempt to make many tests for heat or coId since the grafts were so smaI1 that it was difhcuIt to determine the points from which the responses came. We did not eIicit any pain points in isoIated spots in the grafts. The sensations a11 came in from the margins. NaturaIIy the thickness of these grafts varied so that there wouId be some eIement of difference in the rate of entrance of the sensations.

In Case XCI a smaI1 graft was pIaced between the thumb and index finger of the Ieft hand in an area from which a pain- ful caIIus, due to the pressure of a crutch, had been removed. In this case pain sensation began to appear in seven months and touch sensation in nine months. AI1 of the sensations were present in one year. In Case XCIII, where an x-ray burn was excised, the sensations were even sIower in entering.

Oilier-Thiersch Grafts

CASE xcv. Female, aged thirty-six. Area, 6 X 14 cm. The graft taken

from the thigh was pIaced on the soIe of the right foot after excision of


an x-ray burn. In three months, no sensation had appeared. In nine months, no sensations were present. In eIeven months, pain was felt just over the margin on the inner side of the soIe. No touch or temperature sensations

Sl MONTH5 L 2 WoNTIts

FIG. 5. Case XCIX. Tests of return of sensation in an Oilier-Thiersch graft. A white woman, aged frfty-two, had her scaIp burned by expIosion of comb and area

was heaIed by an OIIier-Thiersch graft taken from thigh. Surface area of transpIant was 17.go+ sq. cm. Diagrams show very sIow advance of sensation of pain into grafted area. First diagram of test made seventeen months after grafting shows very smaII margin of pain sensation anteriorly. Last diagram made five years and two months after grafting shows verv sIow advance of sensation of pain. There was no sensation

of touch or temperaturein grafted area. There was no sensation of any kind in blank area. IncompIete return of sensations in transpIants on scaIp is not at a11 unusual.

were present. In fifteen months, pain sensation had advanced 2 cm. from the margin on the inner side of the foot and 0.5 cm. on the outer side. Touch was feIt 0.3 cm. behind the pain Iine.


CASE XCVI. Female, aged thirty-six. Area, 6.2 X 14 cm. The graft taken from the thigh was pIaced on the soIe of the left foot after excision of an x-ray burn. In three and nine months no sensations couId be demonstrated. In eIeven months, pain was feIt 0.3 cm. over the margin on the inner side of the foot. No touch or temperature sensations were eIicited. In fifteen months, pain sensation had advanced 2.2 cm. from the margins on the inner side of the foot and just over the margins on the other side. Temperature sensation was about I cm. behind the pain line. Touch sensation was 0.5 cm. from the inner margin.

CASE XCVII. FemaIe, aged eighteen. Area, 14 X 28 cm. The graft taken from the thigh was placed on the buttock after the excision of a chronic uIcer in scar tissue. In one month, no sensations were found.

CASE XCVIII. MaIe, aged fifty-five. Area, 4.5 X II cm. The graft taken from the thigh was placed on the forehead after excision of tissue invoIved with marked hypertrophic acne. In one month, no sensations had appeared. In six months, no sensations couId be found.

CASE XCIX. FemaIe, aged fifty-two. Area, 5 X 6 cm. The graft taken from the thigh was pIaced on a burned area in the scaIp. In seventeen months, pain was elicited just over the margin anteriorIy. No temperature or touch sensations were present. In twenty-three months, pain sensation had advanced 0.2 cm.; in thirty-four months had advanced 0.4 cm.; in forty months 0.5 cm.; in fifty-one months, pain sensation had advanced 0.8 centimeter from the anterior margin onIy. No other sensations were present. In sixty-two months, there was very sIow advance in the sensation

of pain. There was no sensation of touch or temperature anywhere in the grafted area. (Fig. 5.)

CASE c. Male, aged fifty-four. Area, 2 X 2.5 cm. The graft taken from the thigh was pIaced on the nose after excision of an x-ray burn. In two years, a11 sensations were present everywhere.

CASE CI. FemaIe, aged seventy-three. Area, 6 X 7 cm. The graft taken from the thigh was pIaced on a burn defect of the shouIder. In nine months, there was no return of sensations.

CASE CII. FemaIe, aged forty. Area, 4 X 5 cm. The graft taken from the thigh was placed on a burn defect of t.he scalp. In one year, there was no return of sensations.

CASE CIII. MaIe, aged twenty-four. Area, 5 X 7 cm. The graft taken from the thigh was pIaced on the caIf after the excision of an uIcer. In ten months, pain was feIt just over the margin. In fifteen months, pain sensation was present everywhere except for a smaI1 area in the center. There had been considerabIe shrinkage of the graft. Touch sensation was present except for an area I cm. in diameter in the center. Temperature sensation was just behind pain. In two years, a11 sensations were present.


CASE CIV. MaIe, aged sixty. Area, 2.3 X 4 cm. The graft taken from the thigh was pIaced on the forehead to fiI1 a defect Ieft by raising a flap. In five months, there was no return of sensation. In one year, pain was feIt 0.5 cm. in from the margins. No touch or temperature sensations were present.

CASE cv. Male, aged twenty-one. Area, 5 X 7 cm. The graft taken from the thigh was placed on the caIf to fiI1 a defect made by raising a flap. In one year, pain sensation was present everywhere. There was an area I cm. in diameter in the center which had no touch sensation. In eighteen months, a11 sensations were present.

CASE CVI. Male, aged sixty. Area, 3.2 X 4 cm. The graft taken from the thigh was pIaced on the dorsum of the hand foIIowing excision of an x-ray burn. In fifteen months, a11 sensations were present.

Discussion. These 12 cases were seIected as typica from a group of 32 cases studied.

The OIIier-Thiersch grafts are Iarge, very thin fiIms of skin cut by means of a Thiersch razor so that onIy the tips of the papiIIae of the corium are incIuded with the epitheIium. Most of the end organs and tips of nerves which report the sensations are not incIuded in such thin grafts since they are found deeper in the corium. There was considerabIe contracture of the heaIed areas so that determinations of the rate of advance of the sensations couId onIy be reIative. The nerves must enter from the surrounding skin into fibrous tissue covered by the thinnest of skin fiIms which wouId make progress very sIow. This is borne out by the findings. Pain sensation began to appear in from eIeven months to one year, and temperature and touch sensation Iater. The rate of advance was about I cm. in three months. The scaIp is of especia1 interest. In Case XCIX a burn resuIted from a comb. The area was just above the forehead in the hair. The graft heaIed per primam and repeated tests were made over a period of four and one-haIf years. Pain did not appear unti1 the seventh month and progressed so sIowIy that onIy I cm. on the side towards the forehead had the sensation of pain after four and one-haIf years. There had been no return of the sensations of touch or temperature. OccasionaIIy during a test a pain spot


was found somewhere in the area away from the margin.

However on the next test this point couId not be eIicited. We

attribute this to accidenta increased pressure on the testing

pin which caused a deep pressure pain. Tests lvere made upon

2 cases in which a11 of the hair upon the head had been Iost

through accidents. In one case a traumatic scaIping had

destroyed most of the scaIp and in the second case a burn

had caused extensive destruction. The scaIping case was

tested for sensations five years after the accident when most

of the scaIp was heaIed and the sensations were a11 found to

be present. The burn case was tested one year after the scaIp

had heaIed and a11 sensations were present. We aIso tested

the scar in a scaIp which was the resuIt of a heaIed burn and

found a11 of the sensations present four years after the accident.

In view of these cases, we fee1 that the reason for the deIay

in the appearance of the sensations in the grafts was due

chiefly to the absence of end organs and partIy to the inter-

ference which the scar caused to the invading nerve fibers.

Small Deep Grafts

CASE CVII. MaIe, aged fifty-four. An area, 6 X 7 cm., on the ankle folIowing the excision of an x-ray burn was grafted. After two years, there was an area 2 cm. in diameter in the center in which there was no sensation. In other portions of the grafted area, al1 sensations were present.

CASE CVIII. MaIe, aged fifty-seven. An area, 7 X 8 cm., on the paIm of the hand, following the excision of an x-ray burn was grafted. In one year, pain sensation had advanced I cm. from the margins. There were no touch or temperature sensations. In two years, pain sensation was present everywhere. Touch sensation was absent in a patch 0.5 cm. in diameter in the center of the grafted area.

CASE CIX. MaIe, aged fifty-one. A defect, I I X 13.2 cm., on hee1 sole, foIIowing the excision of an x-ray burn was grafted. In one year, pain sensation had advanced I cm. from the margins. No temperature or touch sensations were present.

CASE cx. Male, aged sixty. An area, 2.5 X 4 cm., on the temple, folIowing the excision of an x-ray burn was grafted. In three years, pain sensation had advanced 2.5 cm. from the Iower margin. Touch sensation had entered I cm. behind the pain Iine.


CASE CXI. Male, aged twenty-one. An area, 6 X IO cm., on the wrist, folIowing the excision of a burn uIcer, was grafted. In six months, there was no return of sensations.

CASE CXII. MaIe, aged forty-seven. An area, 5 X 6 cm., on the paIm folIowing the excision of a burn uIcer, was grafted. In four years, a11 sensations had returned.

CASE CXIII. MaIe, aged nineteen. An area, 4 X 8 cm., on the caIf folIowing the excision of a scar was grafted. In two years, pain sensation had entered about haIf of the grafted area. Touch sensation had advanced 2 cm. from the margins.

CASE CXIV. FemaIe, aged twefve. An area, 28 X 30 cm., on the chest waI1 was grafted. In one year, no sensations were noted. In sixteen months, pain had advanced I cm. from the margins. No touch sensation was eIicited. In two years, pain sensation had advanced 7.2 cm. from the margins. Touch sensation was in 2 cm. from the margins.

CASE cxv. MaIe, aged twenty-one. An area on the dorsum of the foot, 4 X 7 cm., foIIowing the excision of an x-ray burn was grafted. The skin of the entire foot was badIy changed. In seven months, no sensation had returned.

CASE CXVI. MaIe, aged twenty-eight. An area on the buttocks, 3 X 8 cm., foIIowing the raising of a peduncuIated flap was grafted. In one year, a11 sensations had returned.

CASE CXVII. MaIe, aged nineteen. An area on the caIf, 4 X 7 cm., foIIowing the excision of a scar was grafted. In two years, pain sensation had returned except in a centra1 area I X 5 cm. There was no touch sensation.

CASE CXVIII. MaIe, aged forty-five. An area on the caIf, 6 X 6 cm., foIIowing the excision of an ulcer was grafted. In three years, no sensation had returned. There was marked scarring around the grafted area.

CASE CXIX. FemaIe, aged seven. An area on the chest waI1, 18 X 20 cm., foIIowing a burn was grafted. In one year, there was no return of sensations. In fifteen months, pain sensation had entered I cm. from the margins. No touch or temperature sensations were eIicited. In two years, pain sensation had entered 2 cm. from the margins. Touch sensation was just at the matgins.

CASE cxx. FemaIe, aged thirty-two. An area on the scalp, 8 X 8 cm., foIIowing a burn was grafted. In one year, there was no return of sensations. In two and one-haIf years, there was no return of sensations.

CASE CXXI. MaIe, aged sixty-one. An area on the temple, 3.5 X 5 cm., foIIowing the excision of an x-ray burn was grafted. In twenty years, pain sensation had entered 3.2 cm. from the Iower margins, but none from the margins toward the hairIine. Touch sensation had entered 2.8 cm. from


the lower margin, but none from the upper. Temperature sensation was about on the line with touch. (Fig. 6.)

Discussion. We seIected these 13 cases as typica of 30

FIG. 6. Case CXXI. Tests of return of sensations in area grafted with smal1 deep grafts.

A white man, aged sixty-one, had burn resuking from x-ray treatment of epitheIi-

oma. After some preliminary treatment ulcerated area was excised and grafted with smaIt deep grafts in November, 1913. Surface area of transplant was 14.73f sq. cm.

Sensations have not completeIy entered graft after twenty years. Tests were made in November; 1933. It is diEicuIt to explain why aI1 sensations have not returned.

cases studied. The smaI1 deep grafts are secured by raising the skin on the point of a needIe and cutting through the base of the cone, which wiII in&de the whoIe thickness of the skin in its center.15 The diameter of each graft was about 0.5 cm., and the grafts were usuaIIy pIaced about 0.5 cm. apart. The epithehum of these grafts spreads resuIting in a scar with isIands of whoIe thickness skin separated by scar covered with thin epithehum. This type of graft was caIIed a Reverdin graft in KredeI and Evans articIe aIthough the smaI1 deep graft was iIIustrated.

There were many compIicating factors which influenced the time and progress of the appearance of the sensations. Most of the grafts were pIaced on granuIating surfaces, and therefore were surrounded by scar tissue when hearing was compIete. In Cases CXI, CXH, CXIV and CXIX, the margins of the grafted areas had been burned more or Iess deepIy and


the base had formed scar before the granuIations were ready for grafting. After heaIing had taken pIace this scar tissue contracted and thickened, thus interfering with the entrance of the nerve fibers. In the cases where x-ray burns were present, the tissues were usuaIIy so badIy affected that a compIete excision of the invoIved areas couId not be done because it wouId have been necessary to remove tendons or some other important structure. SmaII deep grafts were used immediateIy in some of these cases where the base was reasonabIy good because it was feIt that other types wouId not take, but fre- quentIy granuIations were aIIowed to form before grafting was done.

The entrance of the sensations and the rate of advance is reported to make this paper compIete but the variations are so great that no definite concIusions can be drawn. Sensations apparentIy wiI1 appear in these areas after Iong periods of time have eIapsed. In Case CVIII, a whoIe thickness graft had faiIed to take due to a hematoma and smaI1 deep grafts were transpIanted in order to secure rapid heaIing. Why the sensations came into this area so rapidly, whiIe in Case cx, a much smaIIer area upon the ternpIe, the sensations had not returned in three years, is diffIcuIt to expIain.

Case CXXI was tested twenty years after successfu1 grafting with smaI1 deep grafts in the tempora1 region. The grafts had been pIaced on heaIthy granuIations which had formed on a defect made by the compIete excision of an area changed by the treatment of an epitheIioma with x-rays. The grafted area, 5 X 3.5 cm., was fiat and smooth, soft and freeIy mov- abIe, and the individua1 grafts were stiI1 perfectIy defmite. The surrounding skin seemed to be normaI. Pain sensation was present over two-thirds of the area, and touch and temperature sensations over a IittIe more than one-haIf. The upper third was without sensation. We are unabIe to expIain why sensations had not compIeteIy returned in this case.

The genera1 impression that we get from the study of this group of cases as a whoIe is that the sensations, when they


do appear, come in a IittIe faster than in OIIier-Thiersch grafts, but that the variations in time are Iarge.

COMMENTS

The skin f-laps and skin grafts which had healed in their new beds gave the opportunity to observe the manner and time of entrance and advance of the sensations into this skin which had been compIeteIy separated from its own nerve suppIy and which had been pIaced in an area suppIied by entireIy different nerves.

The tests had to be Iimited to the most simple ones since the subjects were a11 ordinary patients, aIthough a considerabIe number of these were of high grade inteIIigence. The tests were not as compIete as couId be desired because a11 of the patients were not avaiIabIe at given intervaIs. However, numerous tests of simiIar types of transpIants on many other patients gave us a composite picture su&ientIy compIete to warrant deductions.

It is apparent that sensations wiI1 appear in transpIants of skin after varying periods of time. The time and rate of appearance of the sensations depends upon the foIIowing factors: thickness of the transpIant; the type of the base upon which the transpIant is pIaced; character of the surrounding skin; to some extent upon the position of the transpIant in reIation to the course of the innervating nerves; whether these nerves are pure sensory or mixed.

The number of nerve fibers and the number of nerve end- ings and end organs transpIanted depends upon the thickness of the transplant. In a flap, the skin with varying amounts of subcutaneous tissue is transpIanted. This type of transpIant incIudes a11 of the nerve ends and organs with varying Iengths of nerve fibe

Documents

Regeneration of nerves in skin grafts and skin flaps