A geriatric patient with major burns:case report.

As is predictable, mortality and morbidity among geriatric patients are higher in patients with major burns. Decreased radiopulmonary reserves and malnutrition characterized by protein/energy deficiency and ageing of skin are predisposing factors which increase mortality and morbidity. In this study, we present a 90-yr-old patient with 46% total body surface area of 2nd-3rd degree burns. We had to overcome difficulties which can be seen in elderly patients and which succeeded in our treatment.

Treatment with cerium nitrate bathing modulate systemic leukocyte activation following burn injury: an experimental study in rat cremaster muscle flap.

It is suggested that burn toxin known as lipid protein complex (LPC) stimulates phagocytic cells that cause the release of a variety of inflammatory mediators which induce the activation of leukocytes. It is reported that cerium nitrate (CN) might fix LPC in eschar tissue and prevent LPC from entering the circulation. In this study, we tested the hypothesis that prevention or modulation of LPC initiated cell activation by fixing LPC in eschar tissue with CN treatment, would reduce the number of activated leukocytes, which is an important indicator of inflammation, in rat cremaster muscle flap model. Twenty-eight animals were studied in four groups--group I (control), only cremaster muscle flap was dissected; group II (burn injury), burn injury was performed and flap was dissected; group III (saline); and group IV (CN), following burn injury rats treated with saline and CN, respectively, and than flaps were dissected. Blood vessels were observed in vivo under an intravital microscopy system and the number of rolling, sticking, and transmigrating leukocytes were measured in each group. Burn injury significantly increased the number of activated leukocytes (P<0.001). We observed that CN treatment significantly reduced the number of activated leukocytes following burn injury (P<0.001). In conclusion, we demonstrated that CN treatment significantly decreased the activation of leukocytes, which plays an important role in systemic inflammation. Decreased leukocyte activation is interpreted as prevention or modulation of systemic inflammatory response following burn injury.

Cross-foot island instep flap: a new use of instep skin flap for management of persistent wounds after complex plantar foot reconstruction.

When presented with an extensive soft-tissue defect involving the sole of the foot, reconstruction with free muscle flaps covered by a split-thickness skin graft is the proposed method of treatment. However, persistent graft breakdown and a chronic wound of the weight-bearing flap is a challenging problem during the late postoperative period, as experienced by the authors in their patients with high-energy-induced lower extremity injuries. The authors used the instep flap as an island cross-foot flap to manage persistent graft breakdown that involved skin-grafted muscle flaps transferred previously to the heel in 3 patients and to treat a chronic wound involving an amputation stump in 1 patient. The vascular pathology of the injured extremities indicated a cross-leg procedure instead of a free flap transfer. Pedicles were wrapped with split-thickness skin grafts and flaps were harvested superficial to the plantar fascia. Pedicles were divided during postoperative week 3, and no complications related to the operation or to immobilization have been encountered during the postoperative follow-up. During the 1-year follow-up, durable coverage, free from development of open wounds, has been achieved, and patients have expressed their satisfaction. In the case of complicated, high-velocity foot injuries, the authors suggest that this procedure be kept in mind as an alternative treatment option because it has some advantages over conventional cross-leg procedures.

Recontruction of facial defects and burn scars using large size freehand full-thickness skin graft from lateral thoracic region.

Reconstruction of facial defects due to trauma, burn scar and congenital deformities is very challenging for reconstructive surgeons. Although many alternative techniques have been suggested, the ideal technique has not been described yet. Full-thickness skin grafting procedures are one of the options, but when larger grafts are needed, donor site morbidity is problematic. Full-thickness skin graft harvested from lateral thoracic region has some advantages for face reconstruction with its larger size, similar colour, thickness, skin quality and texture.

Lower extremity salvage using a free flap associated with the Ilizarov method in patients with massive combat injuries.

Nine patients with massive combat injuries of the lower extremities were treated with Ilizarov bone transport in conjunction with free muscle flap coverage. In 4 patients soft-tissue coverage was applied first, and distraction osteogenesis was initiated 4 to 6 weeks later. In 3 patients both methods were applied simultaneously, and in 2 patients soft-tissue coverage occurred after distraction. The bones healed well, and all flaps survived. The segmental defects ranged from 8 to 16.5 cm in greatest dimension. The total disability time from initial injury ranged from 16 to 25.5 months. In all patients, full union of the tibia was achieved, and no osteomyelitis occurred. However, in 2 patients the applied flap became depressed, necessitating another flap operation. Despite late treatment in all 9 patients, successful results were obtained. Maintaining the original length of the tibia and providing timely, definitive treatment offer the best outcome for repair of massive injuries of the lower extremities. The Ilizarov transport method, used in combination with muscle flap coverage, represents an effective therapy for repair of massive injury of the lower extremities.

Repair of high-energy-induced tissue defects of the dorsal foot by free muscle transfer and skin graft.

Various alternative methods have been used for repair of extensive dorsal foot defects due to high-energy-induced injuries. The authors reconstructed such defects with free muscle transfers and skin grafts in 9 male patients (average age, 21.7 years) between the years 1995 and 1998. Patients (right foot, 5; left foot, 4) presented with injuries due to military rifle gunshot (N = 4), mine explosion (N = 2), high-voltage electricity (N = 2), and traffic accident (N = 1). The patient injured in a traffic accident was treated with skin grafting only, and experienced osteomyelitis and skin breakdown. The other 8 patients were injured acutely and were hospitalized within 3 weeks of injury. After serial debridement of necrotic tissues, surgery was performed at an average of 6 weeks postinjury. Metatarsal bone defects of 5 cm in 3 patients were repaired by iliac (N = 2) and fibular (N = 1) bone grafts. Free muscle latissimus dorsi (N = 4) and rectus abdominis (N = 5) flaps were transferred microsurgically. The transferred muscle flaps were covered with split-thickness skin grafts. Mean operation duration was 5 hours 12 minutes. All flaps survived. The average area of soft-tissue defect repaired was 93 cm2 (range, 36-231 cm2). Average follow-up was 25 months. No symptoms of osteomyelitis and skin breakdown were encountered in the 8 acutely injured patients. Monofilament sensory tests revealed diminished protective sensation in 5 patients and absence of protective sensation in 4 patients. Partial resorption of bone grafts occurred in 2 patients. Thinning of the flaps was performed by tangential excision in 2 patients whose muscle flaps did not diminish in thickness. All patients were able to wear normal shoes. The authors suggest the use of free muscle transfer in reconstructing extensive soft-tissue defects of the dorsal foot.

Augmentation of facial soft-tissue defects with Alloderm dermal graft.

Numerous materials, both autologous and nonautologous, have been used for augmentation of soft-tissue defects in the facial region. Each has its limitations. There is no ideal material for soft-tissue augmentation. Alloderm dermal graft (LifeCell Corporation, Woodlands, TX) combines the benefits of autografts and allografts. The authors report its use in 11 patients who have soft-tissue defects or scarring on the face. No serious complications such as rejection, mobilization, absorption, dislocation, or extrusion were encountered. The use of Alloderm in these patients minimized two problems: donor site morbidity and lack of adequate tissue for reconstruction. Alloderm is shown to be an excellent augmentation material for soft-tissue defects. The absence of a donor site defect, and adequate tissue for reconstruction are particularly helpful in the pediatric population.

Hot-press hand burn treatment.

Hand injuries are common in the workplace. Modern industrial machines cause complex occupational hand injuries. Hot-press contact hand burns generally are encountered by workers in the dry-cleaning industry. Seventeen patients with hot-press hand burns were treated at the University of California-Irvine Medical Center Burn Center. Eight patients (47%) required skin grafting, seven (41%) were treated with hydrotherapy only, and two (12%) needed flaps. These results were not what we expected.

Intralesional bare fiber laser treatment of hemangioma of infancy.

The purpose of this study is to examine the effects of intralesional fiber with the KTP laser on treatment of hemangiomas in infancy. A series of 12 patients (1 month to 3 1/2 years) were treated for hemangioma of the head and neck regions. Results were as follows: 92 percent, > 50 percent reduction at 3 months; 8 percent, > 50 percent reduction at 6 months. To achieve these results, 50 percent required two treatments (six cases), and 8 percent required three treatments (one case). Improvement of function was clearly in the proliferative phase. Lesions on three patients (25 percent) ulcerated following laser therapy. No other side effects or complications were noted. Intralesional fiber therapy is determined to be effective and safely used to induce involution of voluminous hemangiomas of the face and neck regions.

An extraordinary cause of scalding injury in childhood.

In an attempt to statistically evaluate burn injuries in childhood in terms of incidence, aetiology, mortality and morbidity, a surprising aetiological cause was noticed, not only as having a high mortality rate, but also as being preventable in most cases if simple precautions are taken. Fifteen preschool children had been severely scalded in kitchens by hot milk which was heated in a cauldron to produce cheese, a traditional custom. The clinical data relating to this aetiology and the probable underlying factors pertaining to the social characteristics are given and discussed.

Reconstruction of the orbital floor with lyophilized tensor fascia lata.

PURPOSE: This article describes the results of using lyophilized tensor fascia lata for the repair of orbital floor defects. PATIENTS AND METHODS: During a 2-year period, orbital floor reconstruction was performed in 12 patients using lyophilized tensor fascia lata. A Foley catheter was placed into maxillary sinus and left in place for 10 days to provide temporary support for the fascia. RESULTS: Patients were followed for 12 months to 2 years. No cases of infection, exposure, extrusion, or graft removal were encountered, and enophthalmus, symmetry changes, or restricted movement were not observed during the follow-up period. CONCLUSION: Lyophilized fascia lata is easy to shape and place in the defect. It provides an excellent material for repair of small to moderate-sized orbital floor defects.

A shorter lag period of mesenchymal malignancy on Marjolin's ulcer.

Marjolin's ulcers generally appear on a burn scar a long time after initial burn injury. A 21-year-old man sustained a thermal burn injury to his right elbow. The ulcer appeared 3 years after and the tumour enlarged and reached a size of 11 cm in diameter in a short period of time. The tumour mass was excised and the donor site was grafted. Right axillary lymph node dissection was carried out. Immunohistochemical studies showed that the nature of the tumour was mesenchymal. Both mesenchymal malignancy and shorter lag period are rarely seen in Marjolin's ulcer.

Four limb amputations due to electrical burn caused by TV antenna contact with overhead electric cables.

A 22-year-old man who sustained four limb amputations due to an electrical burn caused by contact of a TV receiver antenna with overhead electric cables is presented. The indications for limb amputation and the necessary preventive measures for such injuries are discussed.

The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases.

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the first, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0-10 years old (40 per cent) and moderate to major burns in the age group 21-30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.

An unusual case of lightning strike: full-thickness burns of the cranial bones.

An unusual full-thickness burn of the scalp and cranial bones due to a lightning strike is reported. A thick nylon cover protected the head from the direct effects of the lightning injury, but heated water over the thick nylon cover caused full-thickness burn of the scalp and cranial bones. The relevant literature has been reviewed.

Reconstruction of anterior neck contractures with sensate expanded radial forearm free flap.

The surgical management of anterior neck contractures, related to burn injuries, is a challenging problem for reconstructive surgeons. The use of sensate expanded radial forearm fasciocutaneous free flaps in two patients suffering from anterior burn contractures of the neck is presented as an alternative method of surgical management. The advantages of employing sensate expanded radial forearm free flaps to reconstruct anterior neck contractures are also discussed in this paper.