The temporary use of allograft for complicated wounds in plastic surgery.

A retrospective analysis was performed on the use of glycerol-preserved allografts (GPA) in the preparation of complicated wounds for secondary wound closure. All files from the plastic surgery department in the period 1992-1998 were screened. Thirty-three patients within a total 85 GPA treatments were selected and screened for indication of use of GPA, frequency of GPA changes, duration of treatment and whether or not subsequent autografting was possible. GPA was used as a biological cover for the following indications: problematic wound healing, 13 cases; non-healing burns, 12 cases; carcinoma, 4 cases; unstable scar, 2 cases; shortage of skin, 2 cases. The average frequency of GPA application was 2.6 times, with a mean duration of 5 days per application. In 84 cases (32 patients) the wound was successfully covered with autograft. In conclusion, GPA was used with good results as a temporary cover for complicated wounds. We postulate that angiogenic effects of this biological dressing may have contributed to the improved healing conditions and successful secondary wound closure.

Dermal substitution in acute burns and reconstructive surgery: a subjective and objective long-term follow-up.

Tissue engineering and dermal substitution are currently prominent topics of wound-healing research. However, no extensive clinical trials with objective evaluation criteria have been published so far that support the clinical effectiveness of dermal equivalents in the long term. The dermal substitute that is discussed here is derived from bovine collagen and elastin-hydrolysate and has been shown to improve skin elasticity during a short-term clinical follow-up of scar reconstructions. In this study we will present the long-term outcome by means of objective and subjective scar assessment tools for dermal substitution in acute burn wounds and scar reconstructions. In a clinical trial, an intraindividual comparison was performed between the conventional split-thickness autograft and a combination of the collagen/elastin substitute with an autograft. After 1 year, scars were evaluated by the Cutometer SEM 474 for objective elasticity measurements and by planimetry to establish scar contraction. An independent observer subjected scars to a generally accepted clinical scar assessment tool: the Vancouver Scar Scale. In addition, patients gave their impression of the outcome. Forty-two paired burn wounds and 44 paired scar reconstructions were included and evaluated 1 year after surgery. Although substituted scar reconstructions demonstrated an elasticity improvement of approximately 20 percent compared with control wounds, no statistically significant differences were found for skin elasticity, scar contraction, Vancouver Scar Scale, and patient's impression in both categories after 1 year. An extensive long-term follow-up shows that the dermal substitute, which was proven effective in a clinical trial on a short-term basis, did not yield statistical evidence for a long-term clinical effectiveness of dermal substitution.

Graft survival and effectiveness of dermal substitution in burns and reconstructive surgery in a one-stage grafting model.

Survival of the autograft and objective parameters for scar elasticity were evaluated after dermal substitution for acute burns and reconstructive surgery. The dermal substitute, which was based on bovine type I collagen and elastin-hydrolysate, was evaluated by intraindividual comparison in a clinical trial. The substitute was applied in a one-step procedure in combination with a split-thickness autograft. This treatment was compared with the conventional treatment, the split-thickness antograft. After 1 week, the percentage of autograft survival was assessed. The Cutometer SEM 474 was used to obtain objective measurements of skin elasticity parameters 3 to 4 months postoperatively. Forty-two pairs of wounds (31 patients, age 32.9 +/- 19.3 years; burned surface area, 19.8 +/- 14.5 percent) were treated because of acute burns. Reconstructive surgery was performed on 44 pairs of wounds (31 patients, age 33.9 +/- 17.5 years). Autograft survival was not altered by the substitute for reconstructive wounds, although a slight but significant reduction (p = 0.015) was established in the burn category for substituted compared with nonsubstituted wounds. However, the necessity for regrafting was not increased by substitution. Cutometer measurements of reconstructive wounds with a dermal substitute demonstrated a significant increase of pliability (50 percent, p < 0.001), elasticity (defined as immediate extension, 33 percent, p = 0.04), maximal extension (33 percent, p = 0.002), and immediate retraction (31 percent, p = 0.01), as compared with nonsubstituted wounds. After burn surgery, no improvement was found for the different elasticity parameters. Dermal substitution in a one-stage grafting model seems feasible with respect to graft survival. Skin elasticity was considerably improved by the collagen/elastin dermal substitute after reconstructive surgery.

Correction of the post-burn malpositioned nipple-areola complex by transposition of two subcutaneous pedicled flaps.

Symmetrical anatomy of the chest wall is the aesthetic goal in any technique for nipple-areola complex positioning in post-burn patients. In 15 patients, a new surgical technique was applied by transposition of two subcutaneously pedicled flaps, one of which carries the malpositioned nipple-areola complex. The long-term results of this procedure were found to be satisfactory in all patients.

The use of allografts in the management of exposed calvarial electrical burn wounds of the skull.

Deep burns of the scalp and skull are often caused by high voltage electrical injuries. In an early stage, protection and preservation of the skull is important. Covering the wound with a full-circulatory skin flap or a myocutaneous free flap is a reasonable selection, but is not our first choice. In our experience, preliminary use of glycerol-preserved allograft wound dressing significantly improved the development of granulation tissue to perform an autograft at a later stage. With these allografts, there is a significantly shortened healing time compared with the results found in the literature.

High voltage electrical injury leading to a delayed onset tetraplegia, with recovery.

High voltage electrical injury can cause considerable damage to the central nervous system. Delayed spinal cord injury is uncommon, usually incomplete, and comprises predominantly motor fallout. The injury can be progressive, with only a few patients showing partial improvement. We present a case report of a 20-year-old male who had a delayed onset spinal cord injury after a high voltage electrical injury. The symptoms started several days postburn with an ascending paralysis, leading to tetraplegia. Gradual recovery became evident at 3 months after the accident, starting with his arms and later showing partial recovery of his lower limbs. The mechanisms of injury and pathophysiology to the spinal cord are poorly understood. Possible explanations for the delayed onset of neurologic complications are given. The exact reasons for the delayed, ascending paralysis and the mechanism of recovery still need further investigation.

The prognostic factors regarding long-term functional outcome of full-thickness hand burns.

The treatment of the burned hand has always been a subject of special interest. In order to obtain a better understanding of the parameters involved in the long-term functional outcome of hand burns a retrospective study was performed on 88 consecutive patients with hand burns (143 hands), treated according to a standardised protocol. Patients were followed for at least 12 months postburn. Hand function was assessed by the seven objective test criteria (7-OTC) described by Jebsen. Logistic regression analysis produced five parameters that were found to have a significant predictive value for long-term hand function. In order of predictive value, these were finger amputations, age on admission, impaired autograft take, the full-thickness hand burn surface area and the full-thickness total body burn surface area. By fitting these five variables into an equation, a probability model was obtained, which could be applied to estimate a prognosis concerning the final hand function of an individual patient with a hand burn. No relationship was found between the postburn day of operation and the long-term hand function. This finding is inconsistent with the current consensus that functional outcome is improved by early excision and grafting. In practice, it suggests that hand function is well preserved when burns of uncertain depth are treated expectantly, followed by selective debridement and grafting. Advantages include reduced blood loss, no loss of vital tissue and a reduction of the need for donor sites.

Surgical release for intubation purposes in postburn contractures of the neck.

Postburn contractures of the neck can cause difficult endotracheal intubation when cervical hyperextension and lifting of the mandible are impaired. alternative techniques to direct laryngoscopy may be hampered by the presence of rigid scar tissue which obscures the mandibular and laryngeal anatomy, or by the presence of microstomia following retraction of scar tissue in facial burns. This report describes our experience with a safe and quick surgical neck release to facilitate endotracheal intubation in such cases. Following release, intubation was established at the first attempt in all cases. Patients who have suffered flame burns to the thorax with an ascending involvement of the neck and mandibular region are particularly prone to develop extreme contractures. Problems with intubation should be anticipated in patients with healed burns of the neck, and equipment for aiding intubation should be on hand. Furthermore, the surgeon must be available during the induction of anaesthesia to perform an emergency neck release if necessary.

Some aspects of the burned little finger.

Compared with the other fingers, the little finger is more often and more severely involved by flame and flash burns. The post-burn sequelae found in this finger are described and the resulting impairment of hand function highlighted. It is suggested that more attention should be paid to the post-burn problems of this finger.

Reconstructive surgery of the post-burn boutonnière deformity.

A retrospective study of fifty-four longstanding post-burn boutonnière deformities was carried out to evaluate the problems associated with the surgical procedures. The aim is to describe the pathophysiological changes of the burned fingers, the primary treatment, the reconstructive principles, the patients and materials and the final post-operative results.

Burns of the hand.

Estimating the depth of burns of the hand remains difficult and requires considerable experience. One reason for this is that the depth of the burn can change in the first three days as a result of vascular spasm and thrombotic processes in the microcirculation of the skin. Extensive burns over the rest of the body and edema development also influence skin perfusion. The pathophysiological changes of thermal injury of the hand are discussed together with the interaction between infection reaction, edema development and mobility. The guidelines for primary treatment of burns of the hand are discussed. In essence the therapy consists of closing the skin as soon as possible, to eliminate the edema and to prevent infection. Recently a clear controversy has developed between conservative treatment or surgery of deep second degree burns and deep mixed burns of the hand. The advantages and disadvantages of these two therapies are discussed.

The reversed forearm flap using scarred skin in hand reconstruction.

A reverse forearm flap was used in the reconstruction of the hands of two epileptic patients, who had sustained deep dermal burns of the right hand and forearm. The base of both flaps consisted of scarred, transplanted skin. Furthermore one flap was split. Venous drainage was preserved. A good result was observed in both cases.

Retrospective study of reconstructive surgery of the burned hand.

During the 5 years 1979-1983 915 patients were admitted to the Rode Kruis Ziekenhuis, Beverwijk, for the primary treatment of burns, including 618 cases in which the hands were involved. Subsequently 105 patients required secondary surgery to 180 burned hands. This study assesses the treatment of these burned hands, the aim being to describe the problems of burned hands in relation to post-burn sequelae, in general; and particularly to the reconstructive procedures employed, and to assess the final results.

Cross-finger flaps from scarred skin in burned hands.

An innovation is described in the secondary repair of two types of longstanding post-burn flexion contracture of the little finger. The correction of the PIP joint flexion contractures caused by palmar burns can result in a defect on the palmar side of the finger after incision or excision of the scar. The reconstruction of the post-burn buttonhole flexion deformity of the PIP joint, can result in a defect on the extensor surface of the PIP joint after excision of the dorsal scarred skin. Both acquired defects were covered by two different cross-finger flap techniques, despite extensive scarring of the adjacent finger. It is evident that mature post-burn scarred skin on the dorsum of the finger can be utilised for a cross-finger flap procedure.