Meek Technique Research Articles

Place des substituts cutanés dans le traitement chirurgical des grands brûlés sur plus de 60 % de la Surface corporelle. Revue de patients sur 11 ans dans le centre des brûlés adultes du CHRU de Tours

Progress in intensive care and surgery has made it possible to significantly improve the survival of victims with burns over 60% of total body surface area (TBSA). Coverage of the excised areas of these patients can be difficult when there is a shortage of skin donor sites; then the role of skin substitutes can be important. This retrospective study included patients with burns covering more than 60% TBSA and treated at the Tours University Hospital over a period of 10 years. Patients who died during the first week or who presented superficial burns were excluded. The various substitutions means to temporarily or permanently replace the cutaneous barrier are presented. The biological dressings associated with grafts expanded by six according to the sandwich technique, allografts and xenografts, widely expanded postage stamp skin grafts using a modified Meek technique (Humeca(®)), temporary cutaneous substitutes such as Biobrane(®) and skin substitutes colonized by autologous cells (Integra(®)) are presented. Forty-four patients were admitted. Self-immolations represented 52% of the cases. Twenty-one patients were treated with Integra(®), 5 with Biobrane(®), 17 with sandwich grafts and 4 with postage stamp skin grafts. Integra(®) was widely used when donor sites were insufficient. The mean number of surgical procedures per patient was 8.4. The mean duration of hospitalization was 155 days. Twenty-four patients survived until the end of treatment. Eighteen patients died during the first week before any surgery could be performed. Two patients died at the end of treatment. The overall survival rate was 55%. It was 92% for patients who survived the first week. The principal sequel were functional (hand, cervical, thoracic and axillary contractures) and aesthetic (face and hands). Associated treatments were pressotherapy, physical therapy, ergotherapy and thermal water therapy. By temporarily replacing the cutaneous barrier in the absence of sufficient donor sites, skin substitutes make it possible to increase the survival of patients with very extensive burns and to optimize their treatment.

The use of the Meek technique in conjunction with cultured epithelial autograft in the management of major paediatric burns

BackgroundThe management of major paediatric burns remains challenging, in part due to limited donor sites. Skin graft expansion facilitates rapid closure of the burn wound, reducing the risk of sepsis. We reviewed our unit's experience with a combined modified Meek technique and cultured epithelial autograft (CEA). MethodsA retrospective chart review over a seven year period from April 2004 to April 2011 was conducted of patients whose burns were treated with Meek and CEA. ResultsThe Meek technique was combined with meshed split skin grafts and CEA to either donor, graft site or both in 7 cases. One case had Meek skin grafts alone with cultured cells applied to both donor and graft sites. There were two scald burns and five flame burns, with total body surface area ranging from 30% to 70%. Mean length of stay was 51 days (range 41–74 days). The average number of surgical procedures undergone to obtain good coverage was 3.3. There were small (1–3%) areas of breakdown in six cases which received regrafting. Two of these patients had confirmed wound infections. All patients had varying degrees of hypertrophic scarring (HTS) but remained well at follow up. ConclusionsThe Meek technique facilitates high expansion ratios, allowing for a greater area of skin coverage. Epithelialisation in the burn wound appeared to be enhanced by the application of CEA. The Meek technique in combination with CEA would appear a useful additional option in achieving wound closure in the severely burned paediatric patient.

The modified Meek technique as a novel method for skin grafting in horses: evaluation of acceptance, wound contraction and closure in chronic wounds

The acceptance of skin grafts in horses is unpredictable and the final cosmetic result can be disappointing. Besides movement and infection, graft failure is often caused by chronic inflammation, inherently present during second intention healing of limb wounds in horses. In human burns affected by infection and inflammation, the acceptance of the island skin grafts of the modified Meek technique appeared to be better than meshed sheet skin grafts. The percentage take of Meek micrografts is higher than of other techniques; and rates of both wound contraction and epithelialisation are increased. Large traumatic limb wounds of 13 horses healing by second intention were grafted using the modified Meek technique. Photographs of the wounds were taken at set intervals. Wound areas, and areas of acceptance and rejection were determined using a digital image post processor (Scion Image). The percentages of take, wound contraction and epithelialisation were calculated. The initial mean wound area was 7500 mm2. Graft acceptance was mean +/- s.d. 93.7 +/- 5.9%. Wound closure was due to contraction (55.2 +/- 11.1%) and epithelialisation (44.8 +/- 11.1%) and resulted in a 96.7 +/- 3.6% reduction of the initial wound area 29.1 +/- 6 days after grafting. All wounds showed functional and cosmetic healing. The method for skin grafting in horses achieved higher percentages of take than reported previously and consistent cosmetic and functional results. The grafts increased not only the rate of epithelialisation but also had a strong positive effect on wound contraction, resulting in rapid closure and smaller scars. The modified Meek technique proved to be a novel technique for skin grafting equine wounds in clinical practice, which can be performed easily. The molecular background of the increase of wound contraction by the grafts may provide a clue in the search for medicinal stimulation of wound contraction during second intention healing.

Five years' experience of the modified Meek technique in the management of extensive burns

Five years' experience of the modified Meek technique in the management of extensive burns

Adult Burn Patients With More Than 60% TBSA Involved–Meek and Other Techniques to Overcome Restricted Skin Harvest Availability–The Viennese Concept

Despite the fact that early excision and grafting has significantly improved outcome over the last decades, the management of severely burned adult patients with >/=60% total body surface area (% TBSA) burned still represents a challenging task for burn care specialists all over the world. In this article, we present our current treatment concept for this entity of severely burned patients and analyze its effect in a comparative cohort study. Surgical strategy comprised the use of split-thickness skin grafts (Meek, mesh) for permanent coverage, fluidized microsphere bead-beds for wound conditioning, temporary coverage (polyurethane sheets, Epigard; nanocrystalline silver dressings, Acticoat; synthetic copolymer sheets based on lactic acid, Suprathel; acellular bovine derived collagen matrices, Matriderm; allogeneic cultured keratinocyte sheets; and allogeneic split-thickness skin grafts), and negative-pressure wound therapy (vacuum-assisted closure). The autologous split-thickness skin graft expansion using the Meek technique for full-thickness burns and the delayed approach for treating dorsal burn wounds is discussed in detail. To demonstrate differences before and after the introduction of the Meek technique, we have compared patients of 2007 with >/=60% TBSA (n = 10) to those in a matched observation period (n = 7). In the first part of the comparative analysis, all patients of the two samples were analyzed with regard to age, abbreviated burn severity index, Baux, different entities of % TBSA, and survival. In the second step, only the survivors of both years were separated in two groups as follows: patients receiving skin grafts, using the Meek technique (n = 6), were compared with those without Meek grafting (n = 4). When comparing the severely burned patients of 2007 with a cohort of 2006, there were no differences for age (2007: 46.4 +/- 13.4 vs. 2006: 39.1 +/- 14.8 years), abbreviated burn severity index score (2007: 12.2 +/- 1.0 vs. 2006: 12.1 +/- 1.2) or % TBSA (2007: 72.1 +/- 11.7 vs. 2006: 69.3 +/- 8.7% TBSA). In these two rather small groups of severely burned patients with >/=60% TBSA, the overall survival rate of patients was 70.0% (7/10) in 2007 and 42.9% (3/7) in 2006, respectively. Almost all nonsurvivors in both years died within the first 5 days after admission. If assessing the different treatment modalities of the survivors, we found that although the Meek group patients were older (Meek 48.8 +/- 13.3 vs. non-Meek 26.8 +/- 11.5 years, P = .0381) and had consequently higher Baux scores (Meek 124.0 +/- 2.9 vs. non-Meek 93.8 +/- 8.5, P = .0095) than the non-Meek patients, this seemed to have no effect on length-of-stay (80.5 +/- 9.7 vs. non-Meek 79.8 +/- 33.0 days), hospital length-of-stay (85.7 +/- 14.8 vs. non-meek 84.3 +/- 26.1 days) or number of operations (6.5 +/- 1.0 vs. non-Meek 7.0 +/- 4.1 operations). The achieved results represent a combination of various treatment changes and, therefore, cannot be attributed to a single modality. The Meek technique is one of the technical options to choose from, to achieve permanent skin replacement; we think that it has its place if integrated in a whole treatment concept for management of severely burned patients.

Five years’ experience of the modified Meek technique in the management of extensive burns

Background The Meek technique of skin expansion is useful for covering a large open wound with a small piece of skin graft, but requires a carefully followed protocol. Methods Over the past 5 years, a skin graft expansion technique following the Meek principle was used to treat 37 individuals who had sustained third degree burns involving more than 40% of the body surface. A scheme was devised whereby the body was divided into six areas, in order to clarify the optimal order of wound debridements and skin grafting procedures as well as the regimen of aftercare. Results The mean body surface involvement was 72.9% and the mean area of third degree burns was 41%. The average number of operations required was 1.84. There were four deaths among in this group of patients. Conclusions The Meek technique of skin expansion and the suggested protocol are together efficient and effective in covering an open wound, particularly where there is a paucity of skin graft donor sites.

“Shift to right flypaper technique” a refined method for postage stamp autografting preparation

“Lack of donor skin” is a challenge condition for autografting in the treatment of extensive burns. The modified Meek technique seems to be a practical solution for this problem. However, the equipment and consumed materials for the modified Meek technique are expensive which limits routine use. Designing a less expensive, efficient and easy to apply expansion method may improve burn care quality and shorten hospital stay period. Our previous study reported the “flypaper technique” for preparation of postage stamp autografting. The time for confluence of the burned wound depends on the size of the skin islands and expansion ratio. In clinical practice, 5 mm skin squares is the preferred size of the skin islands; however, the positioning procedure can be modified to improve the wound healing process. According to the chessboard diagram, the “shift to right” positioning technique shortens the 10% biggest distance in six times expansion diagrams and 20% biggest distance in nine times expansion diagrams. By using a quick cutting plate, chessboard tray and petrolatum gauze, the skin islands can be uniformly located and correctly oriented on the gauze. This method allows a true expansion ratio up to nine times. In comparison with the modified Meek technique, this method also offers rapid wound reepithilization but with lower cost. However, the burn scar needs further rehabilitation and compression therapy to improve the functional and cosmetic result. This “shift to right flypaper technique” is worthy of consideration in dealing with extensive burns.

The Combination of Cultured Epidermal Autograft (CEA) and Split Thickness Skin Graft Technique (Meek) in Therapy for Severe Burns

In our treatment of severely burned patients cultured epidermal autografts (CEA) are indicated when the burned surface is more than 65% TBSA (total burn surface area). Therefore laboratory cultured sheets of keratinocytes are used. Since the cultured skin is extremely sensitive to pressure and friction, the available autologous skin is transplanted on the bearing surfaces of the patient. Due to the limited amount of available autologous skin a high expansion ratio is necessary. This can be reached with the help of the Meek technique. Therefore the early wound closure of the severely burned patient is favoured by a combination of CEA transplantation and Meek autografting.

“Flypaper technique” a modified expansion method for preparation of postage stamp autografts

The gold standard for management of extensive burn has been early excision, temporary allografting and final autografting. However, “lack of donor skin” is a challenge condition when autografting in the treatment of extensive burns. Designing an efficient and easy to apply expansion method may improve burn care quality and shorten the hospital stay period. From December 1998 to May 2004, we have performed fly paper technique postage stamp skin autografting for eight major burn patients in the Kaohsiung Medical University Hospital. By using a quick cutting plate, chessboard tray and petrolatum gauze, the skin islands can be uniformly located and correctly oriented on gauze. Then, the gauze with skin islands was grafted on to the wound. The wound healing time depends on the size of skin islands and expansion ratio. This method allows true expansion ratio up to nine times. The average wound healing times are 27.2 days for six times expansion and 34 days for nine times expansion. However, the burn scar needs further compression therapy to improve the cosmetic result. In comparison with the mesh technique, the skin islands are independent of each other, any dislodgement of a skin island will not interfere with the surrounding skin squares. When compared with the modified Meek technique, this method also offers rapid wound reepithilization but with lower cost. This flypaper technique is worthy of consideration in dealing with the extensive burns.

A collagen based dermal substitute and the modified Meek technique in extensive burns: Report of three cases

Treating extensive burns is challenging. The lack of unburned skin is a limiting factor to achieve early total wound closure. Artificial skin helps this problem. With Integra® artificial skin one can excise and close even very big burns rapidly. This is essential to lower the inflammatory response, minimise fluid losses and reduce the undesirable effects of toxins. In our unit, Integra® is used on extensive burn patients, where donor sites are limited. Using Integra®, however, always requires a second stage operation, where the silicone layer is removed and the newly formed neodermis is covered with autografts. Normally a widely meshed thin skin graft is used [1].

Expansion technique for skin grafts (Meek technique) in the treatment of severely burned patients

The important limiting factor in the treatment of the severely burned patient is the lack of autograft donor skin. The method of obtaining uniform widely expanded postage stamp autografts described by Meek in 1963 has been evaluated in this study amongst seven severely burned patients. The expansion ratio of 1:4, 1:6, 1:9 was mostly used. After the removal of polyamide gauze on seventh post-operative day the autografts island were covered with overlay allograft, if the expansion ratio of 1:6 and above was used. The mean epithelialization rate was 90% within 4–5 weeks. The preliminary experience suggests, and proves that, it is a method of choice in severely burned patients.

An easy method for preparation of postage stamp autografts

A modified technique of postage stamp autografting is studied. By using quick cutting plates, chessboard tray, skiing technique and petrolatum gauze, skin islands can be uniformly located and correctly oriented on the gauze. Moving the skin squares on the stainless steel tray is relatively easy, and the expansion ratio can be predicted by means of the chessboard diagram. The skin island grafts adhere to the petrolatum gauze when the gauze is applied to the tray. Then, as in the modified Meek technique, the “autografting carrier” can be used to cover the burn wound. In comparison with the modified Meek technique, this method does not require expensive equipment. The quick cutting plates can take over the function of the modified Meek–Wall dermatome. The stainless steel trays and the petrolatum gauze are easily available. The advantages of this method include: (1) the expansion ratio can reach up to 1:9, (2) the preparation procedures are not time consuming, (3) regular distribution of these skin islands shortens the healing time, and (4) the cost of this method is relative low. The results of this technique are comparable to that of the modified Meek technique. This preliminary study reveals that this technique is an easy and economic alternative for the treatment of extensive burn patients.

A review of current coronary heart disease research

The management of major paediatric burns remains challenging, in part due to limited donor sites. Skin graft expansion facilitates rapid closure of the burn wound, reducing the risk of sepsis. We reviewed our unit's experience with a combined modified Meek technique and cultured epithelial autograft (CEA).A retrospective chart review over a seven year period from April 2004 to April 2011 was conducted of patients whose burns were treated with Meek and CEA.The Meek technique was combined with meshed split skin grafts and CEA to either donor, graft site or both in 7 cases. One case had Meek skin grafts alone with cultured cells applied to both donor and graft sites. There were two scald burns and five flame burns, with total body surface area ranging from 30% to 70%. Mean length of stay was 51 days (range 41–74 days). The average number of surgical procedures undergone to obtain good coverage was 3.3. There were small (1–3%) areas of breakdown in six cases which received regrafting. Two of these patients had confirmed wound infections. All patients had varying degrees of hypertrophic scarring (HTS) but remained well at follow up.The Meek technique facilitates high expansion ratios, allowing for a greater area of skin coverage. Epithelialisation in the burn wound appeared to be enhanced by the application of CEA. The Meek technique in combination with CEA would appear a useful additional option in achieving wound closure in the severely burned paediatric patient.

Expansion techniques for skin grafts: comparison between mesh and Meek island (sandwich-) grafts

In skin grafting operations for patients with extensive burn injuries, mesh techniques are often employed to enlarge the effective surface area covered by autografts. However, substantial strips of autograft are required and the distribution of autograft elements on the wound surface is relatively uneconomical. An alternative technique for expanding autografts, first described by Meek in 1958, makes use of a special dermatome and prefolded gauzes to obtain a regular expansion of autograft squares from small pieces of split skin grafts. In a simple in vitro experiment using allograft skin, the expansion ratio obtained with the Meek micrograft technique was measured at almost 1:9. In contrast, the expansion ratio obtained with allograft meshed ‘1:6’ with a Zimmer Dermatome II was measured at 1:4. The maximum distance between the graft elements obtained with the Meek technique was 9 mm, compared to a maximal distance between the strands of the mesh graft of 12 mm. The Meek technique is a useful alternative to mesh grafts when donor sites are limited. Clinical experience suggests that Meek grafts are also particularly suitable for grafting on granulating wounds under poor conditions.

Widely expanded postage stamp skin grafts using a modified Meek technique in combination with an allograft overlay

A method for obtaining widely expanded postage stamp autografts, first described in 1963 by C. P. Meek, has been evaluated in our burns unit. The technique, in which an expansion ratio of 1: 9 is achieved with the aid of special prefolded gauzes, was combined with an overlay of glycerol-preserved allografts applied 1 week after grafting. This delay did not appear to affect graft take. In a series of 16 consecutive skin graft procedures performed on 10 patients with extensive burns, the mean epithelialization rate was 90 per cent (range 70–100 per cent) within 5 weeks. Cosmetic results were comparable to those achieved with widely expanded mesh grafts. The Meek technique utilizes small pieces of autograft, and has proved to be a practical alternative to mesh grafts when donor sites are limited.