Techniques in Plastic Surgery (Series)

Date: 1949
Still from 'Techniques in Plastic Surgery: No.1'

Total Duration: 108:17

In Kodachrome.
Director: Alastair Scobie
Production Company: G.B. Instructional ('The J. Arthur Rank Organisation Ltd.')
Producer: -
Cinematographer: Frank North, & William Oxley
Composer: N/A
Narration: Alvar Lidell
Editor: -
Sound Recording: -
Technical Director: Stephen Ackroyd

Following description from the British Medical Bulletin (produced by the British Council), 1950, Vol. 7, No.1-2, p127-8. Film Review by A.J. Evans.

Techniques in Plastic Surgery - made at plastic surgery units of Ministry of Health and Ministry of Pensions, 1949 ; owned by the British Council ; technical adviser, Stephen Ackroyd ; directed by AUstair Scoble ; produced by Ganmont British Instructional Ltd. ; available in 16 mm. only ; Kodachrome sound versions in English, French, Spanish.

Part 1: Primary repair and secondary suture ; 560 feet [171 m.]; 15 minutes [14:23]
Part 2 : Free grafts ; 1,242 feet [379 m.]; 35 minutes [31:51]
Part 3 : Local flaps ; 625 feet [191 m.]; 18 minutes [16:01]
Part 4 : Direct flaps ; 498 feet [152 m.]: 14 minutes [12:44]
Part 5 : Tubed pedicle flaps ; 758 feet [231 m.]; 21 minutes [19:49]
Part 6 : Chip bone grafting ; 526 feet [160 m.]; 14 minutes [13:29]

This series of six films provides a comprehensive survey of the basic operative techniques employed at various plastic surgery centres in this country. The technical details of many of these reconstructive procedures are not easily dealt with in written descriptions, and so this branch of surgery lends itself particularly to the medium of the film, a point which is well borne out in the series under review, in which the various operations are clearly demonstrated and should be easily understood by those with little special knowledge of the subject.

Primary Repair and Secondary Suture
The first film deals with the principles of wound repair, illustrating the technique of accurate suturing and the avoidance of excessive trauma to the tissues. After direct suture of part of the defect
' (a gun-shot wound of the face), the remainder is closed by a rotation flap, complete wound cover without tension thus being obtained. A case of secondary repair is shown in which, four months after
the original injury, multiple facial scars are excised and tension on the eyelids relieved.

Free Grafts
The longest film is concerned with the methods of cutting free skin grafts and provides several examples of their application. The Blair knife and the dermatome are demonstrated, the value of the latter instrument in obtaining uniform grafts of any desired thickness being particularly stressed. Split skin grafts are shown providing epithelial cover in a case of burns, and in a case of extensive skin avulsion of the buttocks and sacral region where primary skin replacement had been delayed owing to the poor general condition of the patient. The point is made that thin skin grafts are better able to withstand infection, and their application to a granulating surface in the form of " postage stamps " is shown. It was noticed that thrombin was used for graft fixation in some of these cases, a refinement of technique which is perhaps not employed as frequently in most centres nowadays as in recent years. A further example of the use of the Thiersch graft is in the operation of buccal inlay, the details of which are well presented. The good cosmetic appearance of a successful full thickness graft is apparent in its use in the repair of a forehead defect. Its functional value is illustrated by the replacement of scar tissue on the flexor aspect of thumb and fifth finger in a case of burns of the hand. The skin of the flank is regarded as a good donor site for Wolfe grafts to the hand as it is thick and elastic and the secondary defect is easily closed. An example of how both cosmetic and functional requirements can be met is provided by the post-auricular Wolfe graft to the lower eyelid in a case of ectropion following burns.

Local Flaps
In the film dealing with local flaps we are shown a typical Z-plastic operation for the relief of tension due to a vertical scar in the neck. Other examples under this heading include a small forehead flap to replace a defect below the lower eyelid, a double pedicle bridge flap from the forehead to the chin, and a forehead flap rhinoplasty. A scalp flap is shown being rotated to cover a forehead defect, and the extra rotation produced by a judicious back-cut is well demonstrated. A short sequence dealing with the art of undermining would have been appreciated as it is such an essential feature of the plastic surgeon's technique.

Direct Flaps
Direct flaps are used in the transfer of tissue from a distance when donor and recipient sites can be approximated. A good example is the cross-leg flap which is here employed in a leg injury with some bony loss of the tibia. It is emphasized that bone grafting should not be carried out in such a case until good skin cover has first been provided. The statement that all cross-leg flaps should be delayed may not meet with the universal approval of surgeons experienced in this field. An interesting variation in technique is the grafting of the donor site at the first stage, the graft then being buried under the delayed flap. It is pointed out, however, that infection is prone to occur and that the method is not commonly employed. Plaster of Paris fixation is used unless the legs are parallel, when elastic strapping may be preferred. The other example of this type of flap is the replacement of scar tissue in the elbow region by an abdominal flap which is so planned that the joining scar lies on the lateral aspect of the joint where least movement occurs. Raw surfaces are avoided in this as in other similar operations by the raising of a return flap of scar tissue which is sutured to the base of the pedicle.

Tubed Pedicle Flaps
The fifth film is devoted to the use of the tubed pedicle flap, and its value is stressed as a means of transferring skin from any part of the body without running the risk of infection of exposed surfaces. The first case shown is a gun-shot wound of the mandible with loss of soft tissue and bone. An acromiothoracic tubed pedicle is raised and the technique is shown in detail. The four-point stitch closing the triangular defect at each end is demonstrated very clearly, and the correct application of dressings so as to avoid pressure on the pedicle is also included. After an interval of three weeks the lower end is detached, opened out, and let into the recipient site, a small return flap being raised to avoid any raw surface. Elastic strapping is used to prevent undue tension on the new attachment. The final stage shows the division of the lower end, untubing of the flap, and its suture into position. The other example is a case of compound fracture of the tibia in which an abdominal tubed pedicle is transferred in several stages, the wrist being used as an intermediate carrier. Owing to the limited flexion of the affected limb the pedicle has first to be transferred to the opposite leg, so that five stages are required before the procedure is completed. The point is made that, as the scar must be left behind at each stage, it is necessary to plan the original flap a little larger than will ultimately be required.

Chip Bone Grafting
The final film presents the technique of chip bone grafting. The readiness with which cancellous chips acquire a blood supply and become rapidly consolidated, and their value in building up contour, is illustrated in two cases. The first is a mandibular reconstruction in which a gap of two inches between the fragments is filled with bone chips. The iliac crest is exposed, a portion of cancellous bone removed and cut up into suitably sized chips. The mandibular fragments are exposed in a subperiosteal plane and the bone ends freshened. Fixation is obtained by a pin in the posterior fragment which is connected by a rod (insulated so as to prevent ionization) to cap splints on the teeth. A larger portion of cancellous bone is first placed across the gap and the chips are then packed in on top of it. Fixation is removed after four weeks and normal jaw function is allowed, somewhat unexpectedly, after that time. The other example is the restoration of bony contour following the loss of a large part of the frontal bone. The margins of the defect are exposed by careful dissection, the local injection of saline and adrenaline solution being used to assist in finding the correct plane of cleavage. A single bony strip is used to define the supraorbital ridge and the rest of the gap filled with chips which are carefully placed to avoid irregularity. An external mould and pressure dressings are applied at the end of the operation.

These well-produced films, in a total running-time of approximately two hours, succeed in covering many aspects of the field of plastic surgery. The techniques employed and the method of approach to the surgical problems presented can be said to be representative of the current procedures in the major British centres of plastic surgery. Such an authoritative presentation of the subject and the clarity with which the various operations are depicted ensures that this series is of great value for teaching purposes. On the technical side little fault can be found, and the direction and editing arc of a very high order. The sequences are well chosen and always to the point, and we are spared, for example, the irritating by-play with artery forceps which ruins the tempo of so many surgical films. Colour is used throughout and uniform lighting and exposure are maintained with very few lapses. The well-written commentary is admirably delivered and succeeds in being unobtrusive while yet adding greatly to the value of the presentation.

A. J. Evans

National Archive File of this is TNA BW 4-34.