Early Tangential Excision Research Articles

Application of Split-Thickness Dermal Grafts in Deep Partial- and Full-Thickness Burns

Early tangential excision of nonviable burn tissue, followed by immediate skin grafting with autograft or allograft, has resulted in the improvement of burn patient survival. The aim of this study was to add split-thickness dermal grafts (STDGs) as a new source of auto-skin grafting tool to our reconstructive armamentarium in deep partial- and full-thickness burns and soft tissue defects. The authors successfully applied STDGs along with split-thickness skin grafts as a new source of auto-skin grafting in 11 deep partial- and full-thickness burns over a period of 1 year without any significant donor site morbidity. Dermal graft take was complete in all but one patient. There was no donor site healing problem, and donor site epithelization was completed generally 1 week later than split-thickness skin graft by semi-open technique. Autologous split-thickness skin grafting still remains the standard therapy for burn wound closure but may be in limited availability in severe burns. The authors conclude that STDGs may be a new source of auto-skin grafting tool in extensive deep partial- and full-thickness burns.

The use of Suprathel® in deep dermal burns: First results of a prospective study

IntroductionWhile autologous skin grafting has been the standard for coverage of full-thickness areas, several options for deep-partial-thickness defects exist. With regard to economising donor sites, we compared a copolymer based on dl-lactid acid (Suprathel®) as temporary wound dressing with autologous skin, and analysed time to healing and scar quality in matched areas of deep-partial-thickness burn. MethodsWe recruited 18 patients with a median age of 45 years (range: 25–83 years), for this prospective, non-blinded controlled non-inferiority study, suffering from deep-partial-thickness burns from November 2009 to July 2010. After early tangential excision, matched deep-partial-thickness areas were covered with 1:1.5 meshed autologous skin grafts and the copolymer for direct intra-individual comparison. Scars were evaluated by means of the Vancouver Scar Scale (VSS), the Patient and Observer Scar Assessment Scale (POSAS) and suction cutometry (MPA 580, Courage and Khazaka Electronic GmbH, Cologne, Germany) on days 30 and 90, postoperatively. ResultsFifteen days after surgery, complete wound closure was present in 44.4% (8/18) of all areas covered with copolymer and 88.9% (16/18) in the split-thickness skin graft (STSG) area (p=0.008). Evaluation of the total VSS, POSAS and cutometry satisfied the criterion of non-inferiority for Suprathel® on day 30. Ninety days after surgery, only the Observer Scar Scale showed that Suprathel is non-inferior to STSG, albeit the mean total VSS and Patient Scar Scale were better in Suprathel® areas. ConclusionSuprathel® represents a solid, reliable epidermal skin substitute with longer healing times in comparison to skin grafts but comparable results concerning early scar formation. Suprathel® can serve as a tool in treatment portfolio for adult patients suffering from deep dermal burns. Especially in patients with extensive burns, Suprathel® can be used to cover the deep dermal burn wounds to save STSGs and its donor sites for the coverage of full-thickness burned areas.

Validation of the Zürich burn-biofilm model

Background Despite advances in the use of topical and parenteral antimicrobial therapy and the practice of early tangential burn-wound excision, bacterial infection remains a major problem in the management of burn victims today. The purpose of this study was to design and evaluate a polyspecies biofilm model with bacteria known to cause severe infections in burn patients. The model is simple to prepare, maintain and analyse, and allows for short-term exposure to antimicrobials. Results Initial experiments showed that it was impossible to establish balanced polyspecies biofilms with an inoculum of Gram-positive and -negative bacteria. After 64.5 h of incubation, the Gram-negative bacteria ( Escherichia coli and Pseudomonas aeruginosa) had suppressed the Gram-positives ( Enterococcus faecalis, Staphylococcus aureus and Streptococcus intermedius). However, adding the Gram-negative bacteria after 41.5 h to an established biofilm of Gram-positives resulted in a balanced microbial consortium. After 64.5 h, all species were present in high numbers (10 7 to 10 8 colony forming units (CFU) per biofilm). Multiple repetitions showed high reproducibility of biofilm formation without significant differences between and within experiments. Combined fluorescence in situ hybridisation/confocal laser scanning microscopy (FISH/CLSM) analyses, for which biofilms had to be grown on a different non-flexible substrate (hydroxy apatite), revealed that, by 41.5 h, the biofilm consisted of an almost confluent layer of bacteria firmly adherent to the substratum. After 64.5 h (22 h after the addition of the Gram negatives), the biofilm consisted of a confluent mixture of single cells, an abundance of galaxies of bacteria with small lacunae and large amounts of extracellular matrix polysaccharides. Conclusions The polyspecies biofilm model contains the most prevalent burn-associated Gram-positive and Gram-negative bacterial pathogens and mimics the Gram-negative shift observed in vivo. It shows excellent reproducibility. It should allow adaptation to the bacterial spectrum prevalent in different burn centres and lead to a much more reliable investigation of the efficiency of topical antimicrobial agents than models operating with planktonic bacteria. The experiments further open up the perspective to create an in vivo model using these biofilms as infectious agents.

Thermal injury within the first 4 months of life

Aim To determine the incidence, magnitude of injury, fluid management, role of surgery and outcome in newborns and infants under 4 months of age admitted to a Burns Unit. Method Retrospective analysis of patient records. Results 86 patients under the age of 4 months were admitted over a 37 year period (0.34% of admissions). Their injuries were caused by hot water in 45 and fire in 38, primitive heating devices in 2 and non-accidental paraffin burn in 1. Twenty-eight sustained superficial partial thickness burns, 12 deep partial thickness and 46 full thickness injuries. The total body surface area ranged from 1 to 55% with an average of 11.5%. Bacterial contamination of the burn wounds was present on admission in 52.3% and consisted of both gram positive and gram negative organisms. The resuscitation formula of 3.5 ml/kg/% burn on the first day and 1.5 ml/kg/% burn on the second day plus maintenance fluid at 30–120 ml/kg/day was not always adequate in maintaining haemodynamic stability. Three surgical methods were employed in 59 patients (69%). These included early tangential excision in 25, excision with or without allograft and delayed grafting in 27, and conventional therapy with eventual grafting in 7 patients. Releasing escharotomies were required in 9 children. Nineteen children required amputations. Three craniectomies, 2 tracheostomies and 1 colostomy were additional procedures. The mortality was 9.3%. Three causes of death were identified: magnitude of injury, sepsis and inhalation injury. Conclusion Neonates and infants are very vulnerable and preventable environmental factors are often implicated. Fire and hot water are the most common causes resulting in significant physical trauma. Resuscitation especially during the first few days of life can be problematic. Wound infection and sepsis are common and surgery should be individualised. Long-term outcome is very satisfactory for those with small burns however those with larger burns may remain permanently disfigured.

Burn and Mandible Fracture Due to Pressure Cooker Explosion

A burn case of 42-year-old female patient due to pressure cooker explosion associated with mandibular fracture is presented. After early tangential excision of the deep second- and third-degree-burn areas, a split-thickness skin grafting was applied. Open reduction and internal fixation therapy with miniplate system were done for linear symphysis fracture. As much as we know, there was no report in the literature about pressure-cooking burn accompanying mandibular fracture.

Cultured Epithelial Autografts for Coverage of Large Burn Wounds in Eighty-Eight Patients: The Indiana University Experience

Since 1990, the authors have used a new technique for coverage of large burns, which begins with early tangential excision and coverage with cadaver allograft (A), followed by placement of cultured epithelial autograft (CEA) onto an allodermis base (CEA/A). They present their 18-year experience (1990-present) using CEA in 88 patients (20 children and 68 adults) with age range of 6 months to 73 years. A review of prospectively collected data was conducted on adult and pediatric patients grafted with CEA at the Indiana University Medical Center for definitive wound coverage (TBSA 28-98%). These patients were followed up for 3 to 90 months. Complications, take rates, and outpatient follow-ups were noted. The mean final take rate of CEA/A was 72.7%, and the overall patient survival rate was 91% (80 of 88 patients). Complications were classified as early and late, they included: (early) blistering and shearing (31%), pruritus and itching (4.7%), (late) CEA loss (2 patients, 2.3%), and wound contractures (66%). Contracture releases were performed on 32 patients (36%); of which, 18 were children (56%). Cultured keratinocytes provide an excellent alternative or adjunct to conventional split-thickness skin grafting in treating large burn wounds. A dedicated team of physicians, nurses, and therapists well rehearsed in CEA care are vital for success in keratinocyte grafting. The final graft take of 72.7% with a 91% overall survival rate gives much optimism for continuing to use CEA in critically burned patients.

A Wide Spreading Method in Commits Suicide

In the recent 5 years, there is an emerging local trend of burning charcoal as a form of suicide attempt. Patients who committed suicide usually suffered from carbon monoxide inhalation lung injury and severe deep contact thermal burns if direct fall down on the burning charcoal. Patients are usually admitted to the burn unit and received burn wound management. Early wound closure and better functional results are the goals. We reported a female patient who committing suicide by burning charcoal. Her anterior and lateral knee joint suffered from the 5% body surface third degree burn injury. Very early tangential excision was performed and free anterolateral thigh cutaneous flap (28x21 cm) was transferred immediately after wound debridement to cover the joint capsule and quadriceps tendon. The patient recovered both emotionally and physically and was discharged 18 days after the admission.

Dermabrasion with steel wool in the extensive partial burns during shock stage: A case report and review

As we all know, the burn wound induces a series of responses, which is typified by profound systemic alterations of endothelial immunological, vasoactive, and barrier function [1]. The presence of necrotic tissue not only inhibits of wound healing, but also may deepen the wound through an excessive inflammatory response [2]. Thus it is most important to remove the necrotic tissue as soon as possible. Methods to treat burn wounds have changed in recent decades. In full-thickness burns, excision of eschar is the only method. In partial thickness burns, however, there are several methods to be chosen: tangential excision, YAG laser [3], Enzymatic debridement [4] dermabrasion and so on. Increasingly, aggressive surgical approaches with early tangential excision and wound closure is being applied [5]. Customarily tangential excision of deep burn wound is performed with a roller axle graft knife followed by a skin graft. Although healthy tissue is preserved as much as possible in tangential excision, it is a technique-dependent procedure with difficult depth evaluation and plane level control. Despite the numerous and varied means of depth cover that are available, they are not yet widely in practice. So it still depends on the physician’s own experience. However, in a third of all cases the evaluation is not accurate [6].

The history of early tangential excision

The history of early tangential excision

Wound management in burn centres in the United Kingdom.

Despite advances in the use of topical and parenteral antimicrobial therapy, and the practice of early tangential excision, infection of the burn wound remains a leading cause of morbidity and mortality. The aim of this study was to survey and compare wound management and antibiotic usage in burn surgery in all UK burn centres. A postal questionnaire was used, followed up by telephone. Answers were obtained from all 39 units treating burns in the UK. A written policy on antibiotic usage was used by 13 centres. Excisions were covered routinely by prophylactic antibiotic therapy in 18 units, and three of these used antibiotic cover during all procedures in which the wound was manipulated. No routine antibiotic cover was given in 21 units. All units obtained surface swab cultures, but only two performed punch biopsy of the wounds. Quantitative bacteriology (counting colony forming units) was employed by three centres. Most units cleaned the burn with saline (17 of 39) or chlorhexidine (eight of 39) but combinations of these and other agents were also used. Nearly half (17 of 37) of those who replied had not seen any cases of proven or suspected toxic shock syndrome in the past 2 years. Four units gave prophylaxis against Staphylococcus aureus, and four gave antibiotics against Streptococcus pyogenes, despite recommendations in the literature. Twenty-nine units gave no prophylaxis. This study has revealed that there is no consensus on antibiotic usage amongst centres treating burns in the UK and that most units rely on surface swab cultures to monitor infection.

A hypothesis of the healing of deep dermal burns and the significance for treatment.

Deep dermal burns heal by a combination of new connective tissue formation (granulation) and epithelialization. In deep dermal wounds, which are unhealed after 14 days of conservative treatment, epithelialization can be enhanced by abrasion either alone or combined with provision of a skin graft. Some 42 burn wounds in 25 patients treated by this method have healed quickly and with good results. This method represents a move away from the current trend of early tangential excision and grafting of burn wounds and raises the possibility of developing a regime with the advantages but not the disadvantages of early tangential excision and grafting.

Factors Affecting Success of Split-Thickness Skin Grafts in the Modern Burn Unit

The use of early tangential excision or excision to fascia of burn wounds has led to the application of split-thickness skin grafts (STSGs) to a variety of graft beds, including dermis, granulation tissue, fat, and fascia. Because insufficient objective data are available on the effect of the graft bed on survival of an STSG, a 2-year review of success rates of STSGs on a variety of graft beds was completed. The success rates of all 599 STSGs applied to dermis, granulation tissue, fat, and fascia in 233 consecutive burn patients (mean total body surface area [TBSA] burned, 14.5%) by one surgeon at a regional burn center over a 2-year period were reviewed. Data were analyzed to compare outcomes of STSGs on the graft beds listed and in low-risk versus high-risk groups of patients (TBSA burned < or = 35% and > 35%; age < or = 18 years and > 18 years; age < or = 55 years and > 55 years; and diabetes mellitus). One-way analysis of variance was used to compare results of STSGs on different graft beds, and tests were used to analyze differences in results of STSGs in low-risk versus high-risk groups (p < 0.05, significant). The mean success rate at 14 days for all 599 STSGs applied in the 233 patients was 90 +/- 22%. The success rate of STSG on the various surfaces ranged from 85% (fascia) to 93% (dermis; granulation), but the differences among the four graft beds were not significant. Total body surface area burned (> 35%), older age (> 55 years), and the presence of diabetes mellitus each had a significant impact on the percentage take of STSGs at 14 days after application. In the hands of an experienced burn surgeon, the recipient bed has no significant impact on the success rate of STSGs at 14 days postgrafting, except in those patients 18 years or younger, in which the mean STSG success rate was significantly greater on granulation tissue compared with fat. TBSA burned > 35%, age > 55 years, and the presence of diabetes mellitus continue to have an adverse impact on the success rate of STSGs at 14 days.

Enzymatic debridement of burn wound with collagenase in children with partial-thickness burns

Seventy-eight pediatric burn patients treated by enzymatic debridement with collagenase clostridiopeptidase A (CCA), were compared to 41 patients those burn wounds were excised surgically. Patients whose burn wounds were initially assessed as partial-thickness at admission were enrolled in the study. Total removal of eschar was achieved in 49 of 78 (62.8%) patients by CCA only (group D). In 29 patients (37.2%), therapy with CCA was ceased because of the development of burn wound infection or a manifest need for grafting of the wound, therefore, these patients underwent tangential wound excision (group DS). The records of 41 patients, treated by early tangential excision, having similar burn wounds by extent and depth with groups D and DS were used as controls (group S). There was no significant difference between the time to achieve a clean wound bed in groups D, DS and S (mean 7.8, 8, and 7 days, respectively, P>0.05). In group D, none of the patients required blood transfusion, except one. Patients in group DS were found to have fewer excisions (mean 1.1) when compared to those in group S (mean 1.5, P<0.05). The shortest hospital stay was found in group D (12.5 days, P<0.01). In conclusion, the use of CCA, provided a short hospital stay, reduced the overall need for surgery and blood transfusions in patients with partial-thickness burns. Thus, CCA should be considered as an initial treatment of choice for removal of eschar in children, having a partial-thickness burn wound without infection.

Prolonged intermittent hydrotherapy and early tangential excision in the treatment of an extensive strong alkali burn

It is well known that the first step in the treatment of cutaneous strong alkali burn is very early and persistent washing of the site of injury with large volumes of water. However, ideal duration and the technique of hydrotherapy has not yet been established. Besides hydrotherapy, tangential excision of the injured skin might prevent further tissue damage if it is performed early enough. We report the treatment of a 36-year-old male who sustained 53% body surface area (BSA) cutaneous burn due to caustic soda (NaOH). Prolonged intermittent hydrotherapy, early tangential excision and autografting of the injured skin are the keys for the proper management of extensive strong alkali burn.

Minimizing blood loss in burn surgery.

Significant blood loss continues to plague early tangential excision of the burn wound. Although various techniques to reduce intraoperative blood loss have been described, there is an absence of uniformity and consistency in their application. Furthermore, it is unclear whether these techniques compromise intraoperative tissue assessment and wound outcome. The purpose of this study was to evaluate the effects of a comprehensive intraoperative blood conservation strategy on blood loss, transfusion requirements, and wound outcome in burn surgery. An intraoperative blood conservation strategy (CONSV) that included donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and limb tourniquets was prospectively evaluated and compared with a historical control group (HIST) where only topical adrenaline and thrombin were applied to donor sites and excised wounds. Estimated blood loss was reduced from 211 +/- 166 mL per percentage body surface area excised and grafted in the HIST group to 123 +/- 106 mL in the CONSV group (p = 0.02). Similarly, the intraoperative transfusion requirement in the HIST group was reduced from 3.3 +/- 3.1 units per case to 0.1 +/- 0.3 units per case in the CONSV group (p < 0.001). There was no compromise in wound outcome in the CONSV group, which had a mean skin graft take rate of 96 +/- 4.2%. The application of a strict and comprehensive intraoperative blood conservation strategy during burn excision and grafting resulted in a profound reduction in blood loss and transfusion requirements, without compromising wound outcome.

Early tangential excision and skin grafting of moderate burns is superior to honey dressing: a prospective randomised trial

Methods: In this prospective trial, 50 burn patients were randomised to be treated either with early tangential excision and skin grafting or by the application of honey dressings, with delayed skin grafting as necessary. The 25 patients in the tangential excision (TE) group had burns of 23±4%, 12% of which was full thickness. The honey treated patients (HT), (N=25), had burns of 24±4%, 13% of which was full thickness. Seventeen of the TE patients were operated upon on day 3, the remainder before day 6 post burn. Eleven of the HT patients eventually required skin grafting. Cosmetic and functional results were assessed at 3 months post discharge. Results: In the TE group, the skin grafting take rate was 99±3%. In the HT group, the graft take rate was 74±18% ( P<0.01). The mean percentage of blood volume replaced was 35±12% in TE patients vs. 21±15% in HT patients ( P<0.01). Only one TE patient died due to status asthmaticus, while there were 3 deaths, all from sepsis, in the HT patients. At 3 month follow-up, 92% of the TE patients had good to excellent functional and cosmetic results vs. 55% in HT patients, 3 of whom had significant contractures. Conclusion: Early tangential excision and skin grafting was clearly superior to expectant treatment using topical honey in patients with moderate burns in this randomised, prospective study performed at a General Hospital in the Indian subcontinent. The availability of suitable allogenic blood is a potential problem when TE is employed.

Cirrhosis with steatohepatitis after adjuvant tamoxifen

healing, hyaluronic acid promotes epithelial migration and differentiation, improves angiogenesis, and enhances collagen production. 4 Methods of chemically modifying natural polymers for clinical use have been applied to hyaluronic acid, to produce materials that have different physico-chemical properties but similar biological properties to the native compound. 5 Hyaff-NW (Fidia Advance Biopolymers, Padua, Italy) is a 100% benzyl-esterified derivative of hyaluronic acid processed into fibres and prepared as a flat, non-woven pad dressing, which can be seeded with fibroblasts before application. Laserskin (Fidia Advanced Biopolymers) is a 100% benzyl-esterified hyaluronic acid-membrane for the culture and delivery of autologous keratinocytes. Laser-drilled microperformations allow keratinocytes to migrate through the membrane onto the wound bed. A 45-year-old man sustained 50% full-thickness flame burns to both arms, right chest, and lower abdomen, with a further 30% partial-thickness burns to his legs. On admission, a 4 cm 3 4 cm piece of split-skin was harvested to initiate keratinocyte and fibroblast cultures. Early tangential excision and grafting of the burns with cadaveric allograft or Hyaff-NW containing autologous fibroblasts was then done. 14 days later, allografted areas were demabraded to remove the cadaveric epidermis and produce a dermal bed. 30 Laserskin membranes (3000 cm 2 ), seeded with autologous keratinocytes, were then applied on two separate occasions. 24 days after the first application, 80% of the cadaveric dermis/Laserskin areas and all of the Hyaff-NW/Laserskin areas were covered with epithelium. Histology of both areas revealed an acanthotic, continuous epidermis with interdigitations at the dermo-epidermal junction that resembled the rete ridge pattern seen in normal skin. The underlying wound bed of Hyaff-NW/Laserskin treated areas showed evidence of new collagen synthesis and organisation into a dermis-like structure. The wounds were completely healed 7 weeks after burn excision with no unusual scarring so far. Long-term studies of these biomaterials are required to establish if they improve the survival of patients and reduce morbidity compared with conventional split-skin or keratinocyte grafting. A new era in the management of extensive burns may have begun.

Cryopreserved cadaveric allografts for treatment of unexcised partial thickness flame burns: clinical experience with 12 patients

Partial thickness burns (PTB) usually heal within 3 weeks. Prevention of infection and desiccation of the wounds are crucial for optimal healing. Early tangential excision of the burn eschar and allografting prevent deepening of the burns, and are therefore advocated for treatment with the best functional and aesthetic results. For superficial partial thickness burns (SPTB) conservative use of topical antimicrobial agents with frequent dressing changes are implemented. We compared the conservarive treatment for PTBs and SPTBs to grafting cryopreserved cadaveric allografts with no prior excision.Twelve patients with flame PTB areas were allografted after mechanical debridement without excision of the burn wounds. The allografts were cadaveric skin cryopreserved by programmed freezing and stored at −180°C for 30–48 months. Matching burns for depth and area were treated with silver sulfadiazine (SSD) one to two times daily until healing or debridement and grafting were required.It was found that 80 per cent of the cryopreserved allografts adhered well and 76 per cent of the treated areas healed within 21 days, whereas only 40 per cent of the SSD-treated burns healed within 21 days.Partial thickness burns can be treated successfully with viable human allografts (cryopreserved cadaveric skin) with no prior surgical excision. The burn wounds heal well within 3 weeks. For deep partial thickness burns (DPTB) treatment with allografts has no advantage if they have not been previously excised.

Early tangential excision and skin grafting as a routine method of burn wound management: an experience from a developing country

This study assessed the feasibility of performing early tangential excision and skin grafting for burn wounds ‘routinely’ in a developing country. An analysis of mortality, morbidity and hospital stay was carried out for 90 burns patients with deep partial skin loss burns out of 202 admissions, who underwent ‘early’ tangential excision and skin grafting. Overall survival rate was 86.5 per cent. Children below 14 years of age with burns ⩽ 40 per cent TBSA (total body surface area) had no mortality, 93.5 per cent of adult patients with burns ⩽ 60 per cent TBSA survived in contrast to those with burns of > 60 TBSA per cent who all died. Morbidity for contractures and hypertrophic scars was nil to minimal. The mean hospital stay for adult patients with major burns was 30 days, with minor burns it was 18.7 days. We conclude that in developing countries, early tangential excision and skin grafting can and should be done routinely for all minor burns and for the major burns who are admitted to a well-equipped burns centre, but not for very ‘extensive burns’, until biological skin substitutes are more readily available.

Analysis of 155 patients with chemical injury: a 5-year experience

From July 1986 to June 1991, 155 patients were treated in our department for various chemical burn injuries. The experience over the 5-year period is reviewed. Among these patients, 109 patients were between 20 and 40 years of age and accounted for 70.3 per cent of all chemical burn patients. It is suggested that chemical burns are very common in people of working age. Chemical burn manifestations were unlike those of thermal injury. The scene of injury, type of chemical agent, age of patients, clinical manifestation and management of the burn surface are discussed. Although the patients were given the same physical therapy, early tangential or full thickness excision and immediate autografting yielded better results than conservative treatment and shortened hospital stay.