Plastic surgery; its principles and practice . I feel that we have added to our arma-mentarium a method of procedure which has hitherto been used onlyon patients resident in the hospital. In other words, the successfuluse of grafts in the out-patient department will not only make for hos-pital economy, but will also hasten the return of many patients to fullwage-earning capacity (Figs. 132, 133 and 134). Ulcers in Old Scars Not infrequently, especially after extensive burns, we find chroniculcers situated in the midst of scars which resist all the usual methods INTRACTABLE ULCERS AND VARICOSE
Plastic surgery; its principles and practice . I feel that we have added to our arma-mentarium a method of procedure which has hitherto been used onlyon patients resident in the hospital. In other words, the successfuluse of grafts in the out-patient department will not only make for hos-pital economy, but will also hasten the return of many patients to fullwage-earning capacity (Figs. 132, 133 and 134). Ulcers in Old Scars Not infrequently, especially after extensive burns, we find chroniculcers situated in the midst of scars which resist all the usual methods INTRACTABLE ULCERS AND VARICOSE VEINS 193 of wound treatment. The cause of this resistance to heaUng is to belooked for in poor circulation, due to dense surrounding and underlyingscar tissue. It is in just such ulcers that malignant degenerationoccasionally occurs. In these obstinate cases we have to resort to ex-cision down to normal tissue—no matter how extensive the excisionmay be—followed by grafting of the defect, or shifting in pedunculatedflaps (Figs. 135-138).. Fig. 135.—Chronic ulcer in the midst of a dense thickened scar, following a fourteen months.—i. The condition of the ulcer. 2. Three weeks after graftingwith small deep grafts. There has been no recurrence during the ten years since this case the ulcer might have been down to normal tissue and the area grafted,but complete excision of the entire thickened scar was impossible on account of its extent. Chronic Ulcers in the Groin Another type of chronic ulcer which has given me much trouble isthat which follows a (probably) chancroidal infection. Such ulcers arevery difficult to heal and in spite of all our efforts are liable to spread. Excision with the cautery is the safest, and in the long run the mostrapid method of procedure, although it seems so radical that one sel-dom has the courage to resort to it until every other method has beentried. In some cases I have used the cautery repeatedly to check
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