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Skin Resurfacing for the Burned Patient

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Skin Resurfacing for the Burned Patient 00. ם NEW DIRECTIONS IN PLASTIC SURGERY, PART II 0094–1298/02 $15.00 SKIN RESURFACING FOR THE BURNED PATIENT Ryan A. Stanton, MD, and David A. Billmire, MD The ultimate goal and eventual reward in factory quality of life and adapt a functional treating severely burned patients is the estab- postburn lifestyle. A rough indicator of indi- lishment of a protective barrier from the out- vidual psychologic rehabilitation is reflected side world. Skin resurfacing for the burned by employment status. Patients who return to patient has made large strides since the mid- work after burn injury have less behavioral twentieth century. Improvements in resuscita- avoidance, higher self esteem, and greater at- tion, management of inhalation injuries, and tention to goals. It has been shown that the other advances in critical care are responsible most significant predictors of return to work for survival rates in burned patients nearly are involvement of the hand, grafting, size of doubling since the 1950s, increasing by al- burn, and age. Patients younger than 45 have most 1% each year.49, 57 Several factors have a higher return to work rate.74 The care of a contributed extensively to the evolution of severely burned patient requires the infra- clinical burn care, including a better under- structure of a dedicated burn center with in- standing of the critical need for adequate terdisciplinary involvement of nursing, coun- fluid resuscitation immediately postburn, seling, group therapy, and occupational and prophylaxis against wound sepsis and its physical therapy. Interventions designed to complications, the importance of adequate aid adjustment, work hardening, and other nutritional support, burn pathophysiology rehabilitative services and marital and family and its inflammatory mediators, management therapy are also important. All these services of airway and pulmonary complications, and are crucial in maximizing a patient’s psy- early surgical intervention. As a result, chologic and functional outcome. burned patients commonly are surviving with greater than 90% total body surface area (TBSA) burns. As of the year 2000, with the MANAGEMENT OF THE ACUTE advances in tissue engineering, it was techni- BURN WOUND cally feasible to resurface a nearly 100% total body surface burn. The goal for managing an acute burn is Despite the long-term sequelae of burn in- coverage. The initial wound should be kept juries, many burned patients achieve a satis- moist and surrounding tissues protected from From the Division of Plastic, Reconstructive, and Hand Surgery, University of Cincinnati College of Medicine (RAS); and Department of Plastic Surgery, The Children’s Hospital Medical Center and The Shriners Hospital for Children– Cincinnati Burn Unit (DAB), Cincinnati, Ohio CLINICS IN PLASTIC SURGERY VOLUME 29 • NUMBER 1 • JANUARY 2002 29 30 STANTON & BILLMIRE trauma. From the time the burn wound pre- thin walled, or across a joint. Another reason sents until the time it is resurfaced com- to remove blisters is that they can obscure pletely, it is subjected to a variety of modal- the view of tissue beneath and its ongoing ities, from the initial cleansing techniques to evaluation for healing or infection. application of topical agents and dressings, escharectomy, and grafting with temporary or permanent coverage by allograft, autograft, Topical Agents or various skin substitutes. A review of the steps from start to finish provides the clini- Topical agents were developed in the 1960s cian with an up-to-date, logical management to help prevent burn wound infection or sep- protocol for the burned patient. sis.47 When the eschar is still present, the clini- cian needs to use topical agents that have penetrating properties. All topical agents Cleansing Techniques should have the quality of being nontoxic locally and systemically. Location, depth of Most patients with a burn injury undergo the burn wound, and the type of micro-organ- some form of hydrotherapy.60 For obvious isms present will dictate the choice of topical full-thickness injury with frank eschar, pa- agent. Topical agents currently available in- tients simply are cleansed with a soapy solu- clude silver sulfadiazine, most commonly tion upon arrival to the burn unit. The pre- used as a topical preparation in the form of a ferred antimicrobial soap at the authors’ 1% soluble cream. It is effective against gram- institution is 4% chlorhexidine. The wounds positive and gram-negative bacteria, includ- then are cleansed daily and dressed with a ing some Pseudomonas. There is some eschar topical antimicrobial and gauze. Those pa- penetration, so it will kill some organisms tients whose burns have not yet declared below the surface. Unfortunately, it has been themselves as deep-partial thickness or full- shown to inhibit fibroblast growth and slow thickness injury are treated to some form of epithelial migration and hence may thwart nonsubmersion or immersion hydrotherapy. these processes in superficial partial-thickness In the nonsubmersion group, they usually are burns. Mafenide acetate is available in a treated daily with a shower or bed bath, de- cream or 5% solution. The cream is an ex- pending on their mobility. Showers must be tremely useful topical agent because of its combined with wiping or scrubbing to de- ability to penetrate eschar with relative ease. crease the bacterial load on the surface of the The solution is used for wet dressings. Both wound effectively. Immersion with or with- formulations are effective against essentially out agitation is used additionally in some all bacteria. It is not effective against yeast, facilities. This immersion is usually in the however, and therefore not recommended as form of a whirlpool and should be limited to prophylaxis or therapy for yeast infections. less than 30 minutes with water temperatures Because of its ability to inhibit carbonic anhy- of 90Њ to 100Њ Fahrenheit (32.3Њ to 37.8Њ Cel- drase, it can lead to metabolic acidosis, espe- sius). Slightly cooler temperatures are needed cially in large-percentage TBSA burns in the for the elderly and the young whose thinner pediatric population. Silver nitrate is avail- dermis is less tolerant to the warmer tempera- able as a 0.5% solution or a 95% stick. It can tures. be used to treat yeast colonization but does Although blisters may be thought of as bio- not penetrate eschar. If needed to target yeast logic dressings, there is controversy whether infection in the subeschar region, it is recom- blisters should be left intact or debrided. Re- mended to cross-hatch the eschar to allow its search has shown that the fluid in blisters can penetration into the subeschar plane. Al- inhibit white cell function and increase the though the ability to penetrate the eschar is a inflammatory response.55 For that reason, re- factor, it is of less concern in current therapy, moval of blisters is common in burn wound which is based on rapid excision and cover- management, particularly if they are large, age. Silver nitrate also is harmful to fibro- SKIN RESURFACING FOR THE BURNED PATIENT 31 blasts and should not be used on a clean, Deep Partial-Thickness Burns (Second De- healing partial-thickness wound. Topical anti- gree, Deep) biotic ointments include bacitracin (Poly- 17. Epidermis, papillary dermis, and par- sporin and Neosporin) and are used primar- tial reticular dermis ily for the antimicrobial activity against gram- 18. Mix of red and waxy white coloration positive organisms. They have not yet been 19. Large amounts of exudate shown to slow re-epithelialization, and they 20. Sluggish capillary refill can be used on clean, healing partial-thick- 21. Dull pain ness wounds if a topical agent is desired. It is 22. Massive edema, causing problems with important that they be used sparingly to range of motion over joints avoid maceration of the surrounding tissue. 23. Spontaneously heals within 21 days (re- As the wound begins to heal, antibiotic oint- epithelializes) ments are no longer necessary and should be 24. Hypertrophic scarring and scar con- halted to avoid a yeast infection. tractures evolve Other topical agents available include en- Full-Thickness Burns (Third Degree) zymatic debriding agents, arginine-glycine- 25. Epidermis and entire dermis involved aspartic acid-peptide matrix, and pheny- 26. Mosaic of colors possible including toin.39, 44 All have been shown in one study black, tan, red, and white or another to enhance the healing of partial- 27. No blanching; reddened areas stay red thickness burns and donor sites. The overall when pressure is applied because of use of these agents is probably rather modest. hemoglobin from trapped ruptured red Finally, the evolving understanding of basic blood cells wound healing and its growth factor milieu 28. Superficial veins may be thrombosed is being manipulated in the burn wound to 29. Dry, rigid, leathery tissue consistency accelerate healing of the skin graft donor site 30. Eschar appears depressed with signifi- and interstices of meshed skin grafts.27, 61, 62 cant edema distally BURN WOUND CLASSIFICATION 31. Escharotomy or fasciotomy may be re- quired Superficial Burns (First Degree) 32. Not painful or tender 1. Epidermis only 33. Hair is avulsed easily from burned 2. Red or pink coloration hair follicles 3. Dry and peels 34. No spontaneous healing 4. Occasional tiny blisters Subdermal Burns 5. Delayed pain 35. Involve subcutaneous tissue (fat, bone, 6. Modest edema, most pronounced in muscle, tendon), commonly from elec- eyelids trical burns 7. Spontaneously heals in 3–5 days 36. Slow demarcation (up to 5–7 days) with 8. No scar electrical burns Superficial Partial-Thickness Burns (Second 37. Mummified appearance Degree, Superficial) 38. Thrombosed blood vessels possible, su- 9. Epidermis and papillary dermis in- perficial and deep volved 39. Neuromuscular involvement/paralysis 10. Large, intact blisters possible 11. Weeps exudate 40. Insensate 12. Exquisite pain 41. No spontaneous healing 13. Blanches with brisk capillary refill 14.
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