The Wounded Face

Two top-notch speakers on surgery at the District of Columbia Medical Society's 15th Scientific Assembly last fortnight charged that many battlefront and home-front surgeons are not making full use of modern surgical knowledge. Said Lieut. Colonel B. Noland Carter of the Army Medical Corps: "In spite of directives and warnings, some surgeons still continue to close battle wounds. . . . Battle wounds should never be closed except in rarely specified instances."

Said Plastic Surgeon Robert H. Ivy of Philadelphia, who was an Army surgeon in World War I: "Many times in the closure of a cut on the face, very coarse, deep sutures [stitches] including the skin and deeper tissues have been placed with a heavy needle. These later leave broad scars." (The proper method is to stitch the lower layer of a wound, then fasten the skin edges together with a fine thread.)

Other points from Dr. Ivy's paper: > In deep wounds of the face, the first consideration is to make sure that there is a good airway for breathing--bandage should press the chin, the tongue should be kept out of the way (if a patient cannot control his tongue, it can be fastened to the clothing by a single stitch through it). Lives may be saved if men wounded in the lower jaw are kept either upright or lying face downward. Recumbent they may choke to death.

> Wounds of the face should not be cut away too enthusiastically when being cleaned up. The clean-up process can be limited to obviously dead tissue because the face's "rich blood supply permits ready healing."

> Large, gaping wounds should be left open. The others can be closed if the bone fragments can be properly set be neath them.

> Burned areas should have new skin as soon as possible, but not pinch grafts (obtained by lifting bits of skin on a pin point and cutting them free with a scalpel), which seldom look well and often allow the surface to contract -- the very faults grafting is supposed to remedy.

Surgeons now depend on 1) thin grafts which can be done in one operation; 2) a skin flap from near by; 3) a tubed pedicle (when some thickness is needed) which requires three operations about three weeks apart.

> For subsurface padding to restore contours of a nose or ear, the best material is cartilage from the breastbone. Living or preserved cartilage can be used, cut to shape or even diced. Best material for filling out bones in the face is the porous bone from the top of the hip. Tantalum or vitallium plates serve for skull injuries.

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