Contracture of skin graft in human burns: effect of artificial dermis.

BACKGROUND: Skin grafts with an artificial dermis have been widely used as a part of the efforts to minimize contractures and reduce donor-site scars. We conducted a prospective randomized clinical trial to study the effect of a dermal substitute by measuring the size of the graft after surgery for months. METHOD: The artificial dermis (Matriderm, Dr. Suwelack Skin and Health Care AG, Billerbeck, Germany) was applied in combination with a split-thickness autograft in 40 patients with acute burn wounds or scar reconstruction. Demographic and medical data were collected on each patient. We directly measured the graft size by using a transparent two-ply film (Visitrak Grid, Smith & Nephew Wound Management, Inc, Largo, FL, USA) intraoperatively and 1, 2, 3, and 6 months postoperatively. For effective data comparison, the size of the graft at the time of surgery was taken to be "100%." Then, the size in each phase was estimated in percentage (%). RESULT: During the 1st month, the average size was 89%. The figure decreased to 86% and 82% in the 2nd and 3rd months, respectively. In the 6th month, it slightly rebounded to 85% but failed to return to the original state. The size of patients with acute burns was smaller than the size of scar patients as follows: 85-91% in the 2nd month, 81-87% in the 3rd month, and 85-96% in the 6th month. CONCLUSION: This study examined the progress of skin grafts through the measurement of graft size in the human body. The grafted skin underwent contracture and remodeling for 3-6 months. In terms of skin contraction, an acute burn was more serious than scar reconstruction. The use of an artificial dermis that contains elastin is very effective from the functional and esthetic perspective by minimizing contractures and enhancing skin elasticity.

Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience.

BACKGROUND: This paper discusses the treatment protocol for patients with frostbite. METHODS: We performed a retrospective analysis of a series of 17 patients with second- and higher-degree frostbite who had been treated at our medical institution between 2010 and 2012. RESULTS: Our clinical series of patients (n=17) included 13 men and four women, whose mean age was 42.4±11.6 years (range, 22-67 years). The sites of injury include the foot in six patients (35.3%), the hand in six patients (35.3%) and the facial region in five patients (29.4%). Seven patients with second-degree frostbite were completely cured with only conservative treatment during a mean period of 12.7±3.3 days (range, 8-16 days). Of the five patients with third-degree frostbite, two underwent skin grafting following debridement, and the remaining three achieved a complete cure with conservative treatment during a mean period of 35±4.3 days (range, 29-39 days). Five patients with fourth-degree frostbite were treated with surgical procedures including amputation. CONCLUSIONS: With the appropriate conservative management in the early stage of onset, surgeons should decide on surgery after waiting for a sufficient period of time until the demarcation of the wound. Continuous management of patients is also needed to achieve functional recovery after a complete cure has been achieved. This should also be accompanied by patient education for the avoidance of re-exposure to cold environments.

Correction of postburn equinus deformity.

BACKGROUND: Equinus deformity is characterized by an abnormal tiptoe gait and does not allow normal walking, hence needing correction. Congenital causes of equinus deformity include neurological diseases such as cerebral palsy and poliomyelitis. Acquired causes include injuries such as extensive trauma. We have corrected equinus deformity from extensive lower leg burns by a single operation through excisional release of the scar, Achilles lengthening, and radial forearm free flap. METHODS: Fifteen patients with postburn equinus deformity who were treated between January 2000 and March 2012 were retrospectively studied. We investigated their age, sex, cause and severity of burn injury, equinus degree, ankle range of motion and the changes in the activity, extent of Achilles lengthening, flap size, complication, and the recurrence in these patients. RESULTS: The average degree of equinus deformity before the operation was 45 degrees. With an average Achilles lengthening of 4.6 cm, all patients achieved neutral position. The patients who had poor activity due to tiptoe gait before the operation showed good to fair levels of walking ability postoperatively. During an average follow-up period of 3 years and 9 months, no patients had a recurrence. CONCLUSIONS: Equinus deformity causes significant restrictions to walking and the reconstruction is a challenging problem. Although prevention is more important during the initial stages of treatment, we have successfully corrected patients with existing equinus deformity by scar release, Z-tenoplasty of Achilles, and radial forearm free flap.

Improvement of burn pain management through routine pain monitoring and pain management protocol.

INTRODUCTION: Pain management is an important aspect of burn management. We developed a routine pain monitoring system and pain management protocol for burn patients. The purpose of this study is to evaluate the effectiveness of our new pain management system. METHODS: From May 2011 to November 2011, the prospective study was performed with 107 burn patients. We performed control group (n=58) data analysis and then developed the pain management protocol and monitoring system. Next, we applied our protocol to patients and performed protocol group (n=49) data analysis, and compared this to control group data. Data analysis was performed using the Numeric Rating Scale (NRS) of background pain and procedural pain, Clinician-Administered PTSD Scale (CAPS), Hamilton Depression Rating Scale (HDRS), State-Trait Anxiety Inventory Scale (STAIS), and Holmes and Rahe Stress Scale (HRSS). RESULTS: The NRS of background pain for the protocol group was significantly decreased compared to the control group (2.8±2.0 versus 3.9±1.9), and the NRS of procedural pain of the protocol group was significantly decreased compared to the control group (4.8±2.8 versus 3.7±2.5). CAPS and HDRS were decreased in the protocol group, but did not have statistical significance. STAIS and HRSS were decreased in the protocol group, but only the STAIS had statistical significance. CONCLUSION: Our new pain management system was effective in burn pain management. However, adequate pain management can only be accomplished by a continuous and thorough effort. Therefore, pain control protocol and pain monitoring systems need to be under constant revision and improvement using creative ideas and approaches.

Successful composite graft for fingertip amputations using ice-cooling and lipo-prostaglandin E1.

In distal fingertip amputations where microanastomosis may not be possible, composite grafting might offer the possibility of maintaining digital length and function using the patient's own tissue. Many trials such as ice-cooling, pharmacologic enhancement and hyperbaric oxygenation have been reported to improve the survival rate of the composite graft. Twenty-four cases of unreplantable fingertip amputation were classified as types I to III according to the level of injury. We performed the composite grafting followed by immediate ice-cooling for 2 weeks and intravenous lipo-prostaglandin E(1) (lipo-PGE(1)) injection for 8.8 days each on average. Twenty-two fingertips in 24 patients survived completely with acceptable appearance and sensibility over the 8 month follow-up period. Confirming that therapeutic angiogenesis using ice-cooling and lipo-PGE(1) can increase the survival rate of the composite graft in unreplantable fingertip amputation, we describe the procedures and postoperative care in detail.