[Repair of scars in submaxillary region using expanded forehead axial flaps with fascia pedicles carrying bilateral frontal branches of superficial temporal artery and vein].

OBJECTIVE: To study the feasibility of applying expanded forehead axial flaps with fascia pedicles carrying bilateral frontal branches of superficial temporal artery and vein (expanded forehead axial flap with double pedicles in brief, EFAF-DP) in repairing scars in submaxillary region. METHODS: Sixteen patients with mandibular scars hospitalized in Department of Burns and Plastic Surgery of the First Hospital Affiliated to Fuzhou General Hospital in Nanjing Military Area Command from July 2005 to December 2009 were repaired with EFAF-DP. The operation consisted of 3 stages. Before operation, the location and course of superficial temporal arteries and veins (STAV) and their frontal and parietal branches were identified with Ultrasonic Doppler blood flow detector. In stage I, STAV were dissected from the frontalis muscle as a pedicle to form a skin soft tissue space to hold the dilator of a proper size. In stage II, after gradual dilation by repeated filling with saline, the dilator was removed. EFAF-DP was dissected to repair mandibular scar. Donor site was closed with sutures. In stage III, flap pedicles were divided and pruned. RESULTS: Flap sizes ranged from 25 cm × 6 cm to 33 cm × 16 cm. The duration of dilation was 3-5 months, with 3.6 months in average. Ten patients underwent the operation of EFAF-DP transplantation and cervical skin dilatation. All flaps survived with healing of wounds. Disorder of venous return at the distal end of one flap was seen after second stage surgery, and it was corrected after comprehensive treatment including relieving spasm and improving venous return. Donor site wounds healed with normally grown hair without cicatricial alopecia along the hairline. Few hairs grew around mandible in one female patient out of the three (no hair grew on flaps of other two patients). This female patient and two male patients requesting for beard plasty received laser depilation treatment 1 to 3 months after discharge, with good result. Other male patients received no special treatment for their beard, and they shaped their beard with shaver. Sixteen patients were followed up for 6 to 24 months, and the shape of the flaps and beard (excluding female patients) were satisfactory with good appearance, satisfactory skin color and texture. The mobility of neck was obviously improved. CONCLUSIONS: EFAF-DP provides bigger areas of a thin flap besides promoting vascularization of new vessels of flap. Extra expanded skin can be directly sutured at the fringe of hairline, which makes skin grafting unnecessary, and decreases the incidence of secondary deformity in donor sites. Some hair carried by the flaps can be directly used for beard reconstruction after rotation to help the male patients have a better appearance.

[Change in plasma brain natriuretic peptide and its clinical significance in burn patients after delayed fluid resuscitation of shock].

OBJECTIVE: To observe the early change in plasma brain natriuretic peptide (BNP) level in burn patients with long delayed fluid resuscitation of burn shock and its clinical significance. METHODS: Thirty-six burn patients with second and third degree of burn covering 32%-92% total body surface area were enrolled for the study, among them 10 patients were complicated with serious heart failure (heart failure group), and 26 patients rallied from shock after delayed fluid resuscitation without heart failure (stable group). The level of plasma BNP, lactate dehydrogenase (LDH), MB isoenzyme of creatine kinase (CK-MB), and left ventricle ejection fraction (LVEF) were determined at admission and 3 hours after hospitalization, and 24, 48, 72, 168 hours after the injury in both groups with electrochemiluminescence (ECL). RESULTS: Compared with stable group, the plasma BNP level (ng/L) of heart failure group at 3 hours after hospitalization, and 24, 48, 72 hours after the burn injury increased significantly (3 hours after hospitalization: 1 521.38+/-121.11 vs. 391.36+/-63.27, 24 hours after burn: 2 516.86+/-193.25 vs. 360.79+/-146.56, 48 hours after burn: 1 587.76+/-169.23 vs. 398.92+/-77.46, 72 hours after burn: 974.45+/-166.33 vs. 283.43+/-68.15, all P<0.01), the level of LVEF lowered significantly (3 hours after hospitalization : 0.33+/-0.03 vs. 0.58+/-0.09, 24 hours after burn: 0.36+/-0.09 vs. 0.60+/-0.10, 48 hours after burn: 0.35+/-0.08 vs. 0.62+/-0.11, 72 hours after burn: 0.39+/-0.10 vs. 0.64+/-0.10, all P<0.05). The levels of LDH (micromolxs(-1) xL(-1)) in stable group were 2.87+/-0.50 at admission, 3.02+/-0.43 3 hours after hospitalization, 4.02+/-0.87 24 hours after burn, 6.90+/-0.87 48 hours after burn, 3.64+/-0.75 72 hours after burn, 2.67+/-0.45 168 hours after burn while in heart failure group, they were 2.97+/-1.40, 3.84+/-0.37, 4.29+/-0.45, 8.50+/-0.38, 3.84+/-0.62, 2.30+/-0.38, respectively; and CK-MB (U/L) in stable group were 59.12+/-13.75 at admission, 70.39+/-10.72 3 hours after hospitalization, 79.29+/-17.27 24 hours after burn, 67.44+/-12.77 48 hours after burn, 30.28+/-7.13 72 hours after burn, 21.44+/-3.15 168 hours after burn while in heart failure group, they were 65.76+/-16.38, 81.46+/-7.92, 86.43+/-14.19, 72.53+/-11.27, 36.39+/-6.18, 22.85+/-7.26, respectively. No statistically significant difference was found in changes in both LDH and CK-MB between two groups (all P>0.05). CONCLUSION: Determination of the plasma BNP is a simple and useful method in detecting heart failure during resuscitation of shock after a serious burn injury.

[Effect of reduced glutathione on impairment of hepatic function after delayed resuscitation of severe burn shock].

OBJECTIVE: To investigate the protective effects of the reduced glutathione (GSH) on hepatic injury after delayed resuscitation in patients with severe burn. METHODS: Forty severely burned patients with hepatic injury after delayed resuscitation were randomly divided into two groups: treatment group (T, 20 cases) and control group (C, 20 cases). In the T group, the patients were treated with GSH for 7-14 days, while the patients in the C group were treated with same quantity of "energy mixture" as control. The venous blood sample of each patient of the two groups was collected and examined for the content of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyltranspeptidase (gamma-GT), alkaline phosphatase (ALP), total bilirubin (TBIL), and direct bilirubin (DBIL) before the treatment and 7 days and 14 days after the treatment. RESULTS: The contents of the enzymes in the T group were significantly decreasing gradually in all patients after 7 days and 14 days of treatment (P<0.05 or P<0.01). In the C group, the enzymes showed a decrease in quantity 7 days after the management but without statistical significance. However, they still showed significant decrease on 14th day with the "energy mixture" treatment (all P<0.05). After 14 days of the treatment, ALT, AST, gamma-GT, TBIL and DBIL showed obvious decrease in the T group compared to the C group (all P<0.05), but there was no significant difference in ALP between the two groups. CONCLUSION: The results of this study indicates that early use of GSH may be beneficial in the management of protecting hepatic injury after delayed resuscitation for severe burn.

[Changes of myocardial dynamics in early stage of burn and effect of rapid fluid replacement in delayed resuscitation].

OBJECTIVE: To investigate the changes in myocardial dynamics in early phases of burn shock of dogs and the effects of rapid fluid infusion in delayed resuscitation. METHODS: Twelve mongrel dogs were randomly divided into control (n=6) and burn (n=6) groups. The dogs in burn group were subjected to 35% total body surface area (TBSA) III degree burn and were resuscitated with lactate Ringer's solution 6 hours postburn. The volumes and rates of fluid infusion were controlled basically on the urinary output of 1.0 mlxkg(-1)xh(-1) and cardiac output (CO) of 70%-80% of pre-burn values. The mean arterial pressure (MAP), left ventricular systolic pressure (LVSP), maximum rate of intraventricular pressure rise/down (+/-dp/dt max) and cardiac index (CI) were determined at 0.5, 1,2, 6, 7, 8, 10 and 24 hours postburn. RESULTS: The MAP, LVSP, +/-dp/dt max and CI were significantly lowered from their baseline and those of control group at 0.5 hour postburn, and they kept declining until 6 hours postburn. They showed a tendency of elevation and reached or approached the levels of that in control group within 2 hours of resuscitation, and the differences were not significant between the two groups 4 hours after burn (all P>0.05). The amount of infusion fluid within the first 4 hours of resuscitation was (3.63+/-0.99) ml/kg per 1% TBSA. CONCLUSION: The myocardial dynamics is depressed in the early stage of burn, the effective way to improve it is to infuse a large amount of fluid rapidly when resuscitation is delayed.

[An early comprehensive prevention and treatment of sepsis in severely burned patients with delayed fluid resuscitation].

OBJECTIVE: To study an early comprehensive prevention and treatment of sepsis in severely burned patients with delayed fluid resuscitation. METHODS: From January 1990 to December 2001, 72 cases of patients with delayed fluid resuscitation were admitted to our burn department. Two different periods were divided and analyzed retrospectively. The first period was from January 1990 to December 2001 and the span of the second period was from January 1995 to December 2001. RESULTS: (1)The mortality rate and incidence of sepsis in the second period (6.5 percent and 17.4 percent) were significantly lower than those of the first period (23.0 percent and 57.7 percent, P<0.05 and P<0.01). (2)The time of wound healing in the second period was (1.9+/-0.9) hours, it was lower than that of the first period (6.6+/-2.5) hours. (3)The serum contents of tumor necrosis factor (TNF) and blood lactic acid (BLA) were increased at all times in two periods and were markedly increased in the first period (all P<0.01). CONCLUSION: Our data demonstrated that measures adopted in the second period for patients with delayed fluid resuscitation, including early excision, early rapid adequate resuscitation, early enteral feeding, increased immunity function, early applying antibactials, xenotransfusion of ultraviolet-irradiated blood, application of recombinant human-growth factor (rh-GH), epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), are beneficial to the prevention and treatment of sepsis in severely burned patients with delayed fluid resuscitation.