The history of skin grafts

Journal of Drugs in Dermatology, Dec, 2002 by Alysa R. Herman

The history of skin grafts has its beginnings in ancient India, where Sanskrit texts document skin transplants performed by Hindus in 3000-2500 BC (1-3). Potters and tilemakers of the Koomas caste were reconstructing noses which had been mutilated as punishment for crimes such as theft and adultery. Grafts were obtained from buttock skin, which was reportedly slapped with a wooden paddle until red and congested, and then cut with a leaf to the appropriate size (3-5).

Despite early attempts at plastic and reconstructive surgery, hundreds of years passed until further work advanced the practice of skin transplantation. In Italy in 1442 AD, Brancas developed a novel technique of binding the patient's arm to the site of the skin graft (3). Brancas used skin from the arm to transplant a slave's nose to his master's nose. He unfortunately did not receive recognition for his technique of nasal reconstruction, which was instead credited to his fellow countryman, Tagliacozzi, over a hundred years later. Tagliacozzi, who is considered to be the pioneer of modern plastic surgery, publicized Brancas' method of skin grafting. Although he repaired soldiers' facial battle wounds, the most common reason for nose deformities at that time was tissue infection due to syphilis. In 1597, Tagliacozzi published his work in "De curtorum chirurgia per insitionem," and in so doing, transformed plastic surgery from a trade service to a scientific procedure (3).

Prior to the 1800's, reports (if skin grafting were mostly anecdotal. In 1663, the Royal Society of London attempted experimental skin grafts using a dog (6). After a few failed attempts at securing the graft, followed by the escape of their canine subject, research in that area was temporarily abandoned. In 1731, Garengeot was ridiculed when he reported his experience of warming in wine and then reattaching a soldier's partially amputated nose (7,8). Although the Italians had been performing skin transplantation for quite some time, news of India's longstanding method of skin grafting was only first reported in Europe in 1794 (2). The nineteenth century would prove to be the most influential period with regard to the advancement and acceptance of skin grafting.

In 1804 Baronio demonstrated the first successful autograft using the backs of sheep (4). By 1823, Bunger achieved the same success with autografts in human subjects. Attempting to revive the ancient Indian method of rhinoplasty, Bunger repaired nasal defects using full-thickness skin grafts from the patient's thigh (3,4). In 1869, the Swiss surgeon Reverdin performed the first allograft by pinch grafting very thin pieces of epidermis ('epidermic grafts') (3,9). Using this first split-thickness skin graft, Reverdin demonstrated a more rapid healing of granulating wounds. Two years later, Oilier furthered Reverdin's work and demonstrated a better outcome by using skin grafts that were not only composed of epidermis, but also contained a portion of the dermis (3,4,10). These 'dermoepidermic' grafts effected faster wound healing with less scarring. In 1871 Pollock introduced the idea of using skin grafts to treat burn wounds (11,12). He donated small pieces of his own skin which he used in conjunction with a burn victim's skin to cover a large denuded area. The idea was brilliant and paved the way for one of the most important modern functions of skin grafts, the treatment of burn victims. By the end of the century, Wolfe (13) had introduced full-thickness skin grafts into clinical practice to treat ectropion, and Girdner (14) had published the first report of skin grafting with human cadaveric skin.

The use of skin grafts revolutionized the care and ultimately the mortality of burn patients. However, problems arose because donor grafts uniformly died. Research in the twentieth century thus began with attempts to understand the physiology of graft survival (15). It was not until 1943 that Medawar and Gibson discovered that the rejection of transplanted skin was mediated by the body's immune system (16). The 1940s also witnessed the use of refrigerated skin as a temporary dressing (17), the development of the electric dermatome (18), the establishment of the first U.S. Skin Bank (19), and the discovery of a cryopreservative agent which allowed the freezing of tissue in a viable state (20).

In the latter half of the twentieth century, cadaver skin was employed as a biological dressing in burn patients and research revealed additional merits of skin grafting (21). In addition to providing wound coverage, Eade (22) proved that the bacterial count decreased after graft skin was placed over a wound, and O'Donaghue and Zarem (23) discovered that skin allografts stimulated neovascularization of the wound bed. By the early 1970s, cryopreserved skin (24) had been successfully grafted and a method of in vitro cultivation of epithelial sheets (25) had been developed. With the advent of cultured epithelial autografts, the problem of allograft rejections was eliminated, as was the problem of skin donor availability (26,27). However, cultured epithelial autografts could spontaneously blister and also took time to produce, typically a couple of weeks. And so the search for an optimal wound dressing continued.