Color Atlas of Burn Reconstructive Surgery Hiko Hyakusoku · Dennis P

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Color Atlas of Burn Reconstructive Surgery Hiko Hyakusoku · Dennis P. Orgill Luc Téot · Julian J. Pribaz Rei Ogawa (Eds.)

Color Atlas of Burn Reconstructive Surgery Hiko Hyakusoku, MD, PhD Julian J. Pribaz, MD Professor Professor of Surgery Nippon Medical School Hospital Program Director, Combined Residency Department of Plastic and in Plastic Surgery Reconstructive Surgery Harvard Medical School 1-1-5 Sendagi Bunkyo-ku Brigham and Women’s Hospital Tokyo 113-8603 Division of Plastic Surgery Japan 75 Francis Street [email protected] Boston, MA 02115 USA Dennis P. Orgill, MD, PhD [email protected] Professor of Surgery Harvard Medical School Rei Ogawa, MD, PhD Brigham and Women’s Hospital Associate Professor Division of Plastic Surgery Nippon Medical School Hospital 75 Francis Street Department of Plastic and Boston, MA 02115 Reconstructive Surgery USA 1-1-5 Sendagi Bunkyo-ku [email protected] Tokyo 113-8603 Japan Luc Téot, MD, PhD [email protected] Professor CHU de Montpellier Service de Chirurgie Plastique et Reconstructrice 34295 Montpellier France [email protected]

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Springer is part of Springer Science+Business Media (www.springer.com) Prefaces

Reconstructive surgery of burns, especially of extensive burns, is a topic that requires the ideas and inspiration of plastic surgeons. Traditionally, it is considered that almost all burn wounds can be reconstructed using simple skin grafting. However, sophisti- cated reconstructive surgery based on knowledge of various surgical methods is needed to accomplish both functionally and cosmetically acceptable long-term results. The contents of this book represent ideal guidelines for burn reconstructive surgery and were provided by authors from 14 different countries. In other words, this book is the grand sum of the newest surgical technologies and strategies proposed by plastic surgeons. I have been involved in reconstruction surgery for extensive burns since I became a plastic surgeon. I have developed many reconstructive procedures and have been able to apply these methods clinically. Burn reconstruction has brought many thoughts to develop flap surgical methods to me. Moreover, I have realized that burn reconstruction should be accomplished via an all-out mobilization of knowledge on flap surgery and that this is an area that requires continual development of surgical methods. However, I have met many plastic surgeons who are performing novel and inno- vative methods. This book is a collection of these worldwide experiences. I hope that this book will provide great benefits for burn patients worldwide.

Tokyo, Japan Hiko Hyakusoku, MD, PhD

v vi Prefaces

Damage to skin from thermal, electrical or chemical injury has devastating effects on aesthetic and functional outcomes of burn victims. The stigmata of burn patients remains one of the most devastating injuries that man can survive. Fortunately, over the last 30 years, there have been simultaneous advances in scar biology, materials science and knowledge of microanatomy, surgical techniques, transplantation and cell culture. As a result there are now many treatment options available that give greater hope to our patients restoring function and improving their societal interactions. In this atlas, Dr. Ogawa has brought together the world’s experts to review the important topics of super-thin flaps, pre-fabricated flaps, dermal and epidermal replacements as well as vacuum-assisted closure technologies. This atlas will be an important resource for practicing plastic surgeons as well as students and residents in training. Examples in the atlas will also be valuable for patient education of these varied techniques.

Boston, MA, USA Julian J. Pribaz, MD Dennis P. Orgill, MD, PhD Prefaces vii

Burns represent a pathology remaining among the hardest to heal wounds. Even if important progresses in rescucitation allowed life-threatening body surfaces to regress during the last 50 years, force is to recognize that restoring the original function after extensive and deep burns requires a long period of fight against contractures, hyper- trophy and tissue shortening. A multi-disciplinarity approach is mandatory to obtain a return to the social and working life, but skin has changed for the rest of the life of the patient. The development of microsurgery in the 80s, followed by an intense activity in anatomical studies could evidence the angiosomes and the skin, muscle, tendon and bone vascular cartographies. From this era, all types of flaps were proposed, including pre-fabricated and perforator flaps, a founding melting pot and a source of intense activity for the new plastic and reconstructive surgery. This atlas details how to use them in burn reconstructive surgery. During the last decade, the surgical possibilities of dermal replacement becomes more and more efficient. The recent development of tissue engineering, leading to added biological similarities with the normal skin, opens a new space for reflexion and trials, based on cell–extracellular matrix interactions via cytokines and growth factors. The need for repairing the cosmetic outcome of facial burns remains a social challenge and will certainly be a long-term contract for the new generation of burns specialists and plastic surgeons.

Montpellier, France Luc Téot, MD, PhD viii Prefaces

Every reconstructive surgeon thinks that evidence-based burn reconstruction is an ideal method; however, it is yet to be established. The reason for this may be that every single wound or scar is unique. Moreover, the color, texture, thickness and hardness of the skin vary according to human race, age, sex and body site. Thus, we are forced to select treatment methods on a case-by-case basis according to the limited experience of each surgeon. Meanwhile, during the finishing stage of reconstruction, large parts of the surgical procedure should include elements of aesthetic surgery. In this stage, it may not be an exaggeration to state that evidence-based surgery is not beneficial. Treatment methods should be selected and performed based on the aesthetic sense and cultivated sensitivity of each surgeon. Evidence-based surgery and artistic reconstruction represent a big dilemma that is posed to every burn reconstructive surgeon. I believe this book, which is entitled Color Atlas of Burn Reconstructive Surgery provides an answer for this particular dilemma. This answer may be the fusion of evidence-based surgery and artistic reconstruction. After reading this book, the surgeon will recognize what part of the reconstruction should be carried out using evidence-based surgery and what part should be performed artistically. We should not give up on the generation of evidence-based standardized protocols for patient safety or on the education of younger-generation surgeons. In addition, we should not neglect artistic reconstruction at any time. In this book, international authors who have wide perspectives in burn reconstructive surgery shared their own valuable experiences and concepts about the character- istics and indications of their methods. The contents include wound management, classification and evaluation of wounds/scars, various artistic and geometric methods and future treatment strategies from a “regenerative medicine” standpoint. I hope that this book will enhance the work of burn reconstructive surgeons and confer tremendous benefits to burn patients. Finally, I thank all authors and coeditors who have taken time from their busy schedules to assemble this book. In addition, I appreciate the tremendous help of Ms. Ellen Blasig at Springer in Germany. Her contribution was essential for the accomp lishment of this project. Moreover, I thank the illustrator Mr. Kazuyuki Sugiu from Studio Sugi’s for preparing the figures.

Tokyo, Japan Rei Ogawa, MD, PhD Contents

Part I Primary Burn Wound Management...... 1

1 Primary Wound Management: Assessment of Acute Burns...... 2 Luc Téot

2 Primary Wound Management: Strategy Concerning Local Treatment...... 6 Luc Téot

3 Debridement of the Burn Wound...... 10 Hans-Oliver Rennekampff and Mayer Tenenhaus

4 Application of VAC Therapy in Burn Injury...... 16 Joseph A. Molnar

5 Use of Vacuum-Assisted Closure (V.A.C.)® and Integra® in Reconstructive Burn Surgery...... 22 Joseph A. Molnar

6 ReCell...... 26 Fiona M. Wood

7 Strategies for Skin Regeneration in Burn Patients...... 38 Victor W. Wong and Geoffrey C. Gurtner

Part II Burn Scar Management...... 43

8 Diagnosis, Assessment, and Classification of Scar Contractures...... 44 Rei Ogawa and Julian J. Pribaz

9 Prevention of Scar Using bFGF...... 62 Sadanori Akita

10 Medical Needling...... 72 Hans-Oliver Rennekampff, Matthias Aust, and Peter M. Vogt

ix x Contents

11 Treatments for Post-Burn Hypertrophic Scars...... 76 Rei Ogawa, Satoshi Akaishi, and Kouji Kinoshita

12 Make-Up Therapy for Burn Scar Patients...... 82 Ritsu Aoki and Reiko Kazki

Part III Dermal substitutes/Skin Graft...... 89

13 Dermal Substitutes...... 90 Luc Téot, Sami Otman, and Pascal Granier

14 Acellular Allogeneic Dermal Matrix...... 100 Yoshihiro Takami, Shimpei Ono, and Rei Ogawa

15 Application of Integra® in Pediatric Burns...... 108 Paul M. Glat, John F. Hsu, Wade Kubat, and Anahita Azharian

16 Pediatric Burn Reconstruction...... 118 Paul M. Glat, Anahita Azharian, and John F. Hsu

17 Skin Grafting...... 132 Matthew Klein

18 Skin Graft for Burned Hand...... 140 Wassim Raffoul and Daniel Vincent Egloff

19 Tips for Skin Grafting...... 146 Masahiro Murakami, Rei Ogawa, and Hiko Hyakusoku

Part IV Local flap method...... 159

20 Z-Plasties and V-Y Flaps...... 160 Shigehiko Suzuki, Katsuya Kawai, and Naoki Morimoto

21 Use of Z-Plasty in Burn Reconstruction...... 172 Rodney K. Chan and Matthias B. Donelan

22 Local Flaps for Burned Face...... 178 Allen Liu and Julian Pribaz

23 The Square Flap Method...... 186 Hiko Hyakusoku and Masataka Akimoto

24 Propeller Flap and Central Axis Flap Methods...... 198 Hiko Hyakusoku and Masahiro Murakami Contents xi

25 Facial Reconstruction...... 208 Pejman Aflaki and Bohdan Pomahac

Part V Expanded flap, Prefabricated flap and Secondary vescularized flap...... 219

26 The Expanded Transposition Flap for Face and Neck Reconstruction...... 220 Robert J. Spence

27 Expanded Thin Flap...... 230 Chunmei Wang, Junyi Zhang, and Qian Luo

28 Tissue Expansion for Burn Reconstruction...... 240 Huseyin Borman and A. Cagri Uysal

29 Scalp Alopecia Reconstruction...... 250 Jincai Fan, Liqiang Liu, and Jia Tian

30 Nasal Reconstruction...... 260 Jincai Fan, Liqiang Liu, and Cheng Gan

31 Ear Reconstruction...... 270 Chul Park

32 Reconstruction in Pediatric Burns...... 276 Jui-Yung Yang and Fu-Chan Wei

33 Secondary Vascularized Flap...... 288 Hiko Hyakusoku and Hiroshi Mizuno

34 Prefabricated and Prelaminated Flaps...... 300 Brian M. Parrett and Julian J. Pribaz

35 Prefabricated Facial Flaps...... 310 Luc Téot

Part VI Regional Flap and Thin Flap...... 319

36 Scarred Flap...... 320 Hiko Hyakusoku

37 Use of Previously Burnt Skin in Local Fasciocutaneous Flaps...... 330 Rodney Chan and Julian Pribaz

38 Supraclavicular Flap...... 338 Vu Quang Vinh and Tran Van Anh xii Contents

39 Superficial Cervical Artery Perforator (SCAP) Flap...... 344 Rei Ogawa, Shimpei Ono, and Hiko Hyakusoku

40 Super-Thin Flap...... 356 Hiko Hyakusoku, Rei Ogawa, and Hiroshi Mizuno

41 Super-Thin Flaps...... 368 Jianhua Gao and Feng Lu

Part VII Free flap and Perforator flap...... 377

42 Anterolateral Thigh Flap for Reconstruction of Soft-Tissue Defects...... 378 Jianhua Gao and Feng Lu

43 Free Muscle Flaps for Lower Extremity Burn Reconstruction...... 388 Huseyin Borman and A. Cagri Uysal

44 Prepatterned, Sculpted Free Flaps for Facial Burns...... 398 Elliott H. Rose

45 The Deltopectoral Free Skin Flap: Refinement in Flap Thinning, Pedicle Lengthening, and Donor Closure...... 408 Kenji Sasaki, Motohiro Nozaki, and Ted T. Huang

46 Shape-Modified Radial Artery Perforator (SM-RAP) Flap for Burned Hand Reconstruction...... 416 Musa A. Mateev and Rei Ogawa

47 The Radial Artery Perforator-Based Adipofascial Flap for Coverage of the Dorsal Hand...... 428 Isao Koshima, Mitsunaga Narushima, and Makoto Mihara

48 Microdissected Thin Flaps in Burn Reconstruction...... 434 Naohiro Kimura

49 Perforator Pedicled Propeller Flaps...... 442 Hiko Hyakusoku, Musa A. Mateev, and T. C. Teo

50 Perforator Supercharged Super-Thin Flap...... 452 Hiko Hyakusoku and Rei Ogawa

51 Perforator Supercharged Super-Thin Flap...... 462 Vu Quang Vinh

52 Extended Scapular Free Flap for Anterior Neck Reconstruction...... 470 Claudio Angrigiani, Joaquin Pefaure, and Marcelo Mackfarlane

References...... 478

Index ...... 495 Part I Primary Burn Wound Management 2 CHAPTER 1 Primary Wound Management: Assessment of Acute Burns

luc tÉot

Introduction Estimation of Burn Depth

The burn is depicted as a traumatic lesion provoked by Burn depth is traditionally defined in three degrees, and several possible agents (thermal, chemical, mechanical, clinical observation remains the main source of infor- or electrical) involving different skin layers to a certain mation for the clinician, even though some complemen- degree. Assessment of the clinical situation is based on tary examinations can be useful to determine the exact (1) evaluation of the total body surface of the burns, and extent of deep burns. In the majority of cases, the surgi- (2) estimation of burn depth. cal indication for excision and grafting depends upon Visual assessment and vascular evaluation of the the visual evaluation of the wound. This part of burn wound are crucial [1, 2]. assessment remains difficult and cannot be done with precision, even with experience, before the third day post injury. In second degree burns, the first assessment Evaluation of the Total Body Surface has been estimated to be accurate in less than 70% of of the Burns cases.

Rule of 9

Anatomical area Head Upper limb Lower limb Ant body Post body Genital area (chest + abdomen) (thorax + back) Estimated % of surface 9 9 9 2 × 9 2 × 9 1

TBSA Following Age

Anatomical area Adult TBSA (% for each side Fifteen year TBSA (% for each Ten year TBSA (% for each of the structure) side of the structure) side of the structure) Head 3.5 4.5 5.5 Neck 1 1 1 Trunk 13 13 13 Arm 2 2 2 Forearm 1.5 1.5 1.5 Hand 1.25 1.25 1.25 Genital area 1 1 1 Buttock 2.5 2.5 2.5 Thigh 4.75 4.5 4.25 Leg 3.5 3.25 3 Foot 1.75 1.75 1.75

L. Téot, MD, PhD Montpellier University, France e-mail: [email protected]

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_1, © Springer-Verlag Berlin Heidelberg 2010 Primary Wound Management: Assessment of Acute Burns CHAPTER 1 3

Clinical Evaluation

First Degree

The first degree corresponds to a shallow wound. The aspect is red, and the area is extremely painful, as the sensory endings remain intact. A typical example of this is sunburn. Only the superficial layer of the epidermis is involved. When the total body surface is important, complications like cerebral edema can be encountered, but the wound remains easy to heal.

Superficial Second Degree

Superficial second degree burns usually present as blisters, appearing some hours after the accident. Once the blister is removed, the wound can be observed. Redness is uniform and pain is extreme, rarely allowing the phy- sician to touch the lesion. Healing time is short, usually within the first 2 weeks, without aesthetic sequellae. The superficial dermis is exposed, without involving the basal membrane, which guarantees a quick healing in the superficial aspect of the skin (Figs. 1.1–1.5). ⊡⊡Fig. 1.2 Palmar aspect of the same hand. Same difficulty, but the fact that both aspects of the hand are involved is worse than when only one is involved

⊡⊡Fig. 1.1 Early assessment of second degree burns over the ⊡⊡Fig. 1.3 Sand burns of the palmar aspect of the feet after dorsum of the hand. Blister has just been removed. Diff icult walking over a long distance on a hot beach. Second degree, to evaluate if deep. Reevaluate the next day and the day after superficial 4 CHAPTER 1 Primary Wound Management: Assessment of Acute Burns

endings. Blanching of the skin under digital pressure cannot be obtained. These burns have a tendency to heal spontaneously, except in critical general conditions or if TBS burnt is extensive. The wound will stay unhealed or deteriorate and transform into a third degree burn. Usually, healing can be observed within 2–3 weeks, but as the deep dermis is exposed, a permanent scar will remain. These wounds can sometimes require an excision and a skin graft (Fig. 1.6).

Third Degree

Third degree burns are deep burns involving the subder- mal structures. Extent in depth can be important, reaching aponeurosis or even bones. Lesions are sometimes cir- ⊡⊡Fig. 1.4 Fresh scald burns (second degree). Blister appear- cular on the limbs, a source of ischemia for the distal ing progressively. Reevaluate after some hours before estab- segments, necessitating emergency surgical procedures lishing a prognosis of discharge incisions to reestablish a normal distal blood flow. Lesions present with a white color and the tissues are hard. A black eschar will be observed after carbonization (Figs. 1.7 and 1.8). Establishing the risk of vital issue is an important step, most of the time to be realized in emergency. Factors like surface, location of deep burns around the orifices and

⊡⊡Fig. 1.5 Fresh burns of the face. Ophtalmologic assessment. Removal of blisters is necessary before a proper assessment of the burns

Deep Second Degree

Deep second degree burns also present blisters, but after removal, the aspect is white or similar to patchwork. Sensibility to touch is not as important as in more super- ⊡⊡Fig. 1.6 Deep grill burns of the plantar aspect of the foot ficial lesions, due to a partial destruction of sensory on a diabetic patient. Excision and grafting Primary Wound Management: Assessment of Acute Burns CHAPTER 1 5

⊡⊡Fig. 1.7 Electric burns of the scalp: third degree with possible cortical bone involvement. Deep excision and preopera- ⊡⊡Fig. 1.8 Deep necrotic burns of the hand after digital tive assessment of the bone. If necrosed, removal of the outer amputation. Exposed tendons can be covered with negative cortex. The use of NPT may then be necessary before skin pressure therapy, with serial excisions of still necrosed struc- grafting tures before skin grafting

Degrees of burns First Second superficial Second deep Third Anatomical structure Epidermis Dermis above basal Dermis below basal membrane Whole skin involved membrane Color Red Red below the blister Red–white below the blister White or black Skin hardness and Supple Humid Medium hard Hard thick dry vascular density Bleeding at contact No bleeding High Moderate No Pain Painful Extremely painful Painful No pain Time for closure No wound Less than 2 weeks Within three to four weeks. Needs skin replacement Sometimes, needs skin graft (graft, VAC, flap) Scar formation No scar No scar Notable scar formation and Notable scar formation contractures and contractures

prevention of infection have to be determined urgently. Conclusion Above a surface of >10% TBSA in adults and >5% TBSA in children, burns are considered serious. In over 30% of Establishing the risk of functional issue is focused on surface in adult and 10% in children, life-threatening dif- reestablishing the limb vascularization and the need for ficulties can be encountered. It is important to check the discharge incisions when third degree burns are circum- face, nostrils, and hair, to assess the risk of tracheal and ferential. Other functional issues are linked to possible pulmonary burns (an endoscopy is often needed for exposure of joints. Immobilization of interphalangeal diagnosis when in doubt). The risk of burns infection is joints on the hands or ankle must be realized as soon as higher when initial management is delayed (septicemia). possible. 6 CHAPTER 2 Primary Wound Management: Strategy Concerning Local Treatment

luc téot

Introduction

Primary wound burn strategy depends on burn wound assessment. Deep second degree and third degree burns are candidates for surgery such as excision and grafting, while superficial burns can be treated using topical antimicrobials. In superficial burns, emergency management is based on cooling using water at a mild temperature. Burns are irrigated with water for a period of 5–10 min. Essentially, the aim of cooling is to remove pain. Antiseptics are applied to the wound, soaked with sterile water and dried using gauzes.

Blister Management ⊡⊡Fig. 2.1 Blister is removed on the fourth finger, and not removed on the third finger. Debridement of blister allows Blisters are encountered both in superficial and deep a right assessment of the burn wound second degree burns. A blister is an obstacle for the assessment of burns and should be removed. The top of the blister is gently cut with a sharp scalpel, allowing the burn will necessitate a surgical decision of immediate liquid to leak out and then the whole non-adherent epi- excision followed by a skin graft (Figs. 2.2–2.3). dermis is excised, while trying to prevent painful contact with the base of the wound (Fig. 2.1). Local Dressings

When to Operate Silversulfadiazine cream is the most commonly used local treatment, worldwide. This drug is a combination Assessment is determinant for strategy, but cannot be of sulfamides and silver, with a low risk of resistance and conclusive during the first examination. Surgical exci- allergy, proposed in various situations. The cream modi- sion and grafting in deep second degree burn wounds fies the local ground and can be applied over a period of will be decided after a period of 2–3 days, as the evolu- 3 weeks. The need for a persistent antimicrobial dressing tion of the burn wound can be positive. Diagnosis of during the whole evolution of superficial burns has to be burn depth is difficult during the first days. Thirty- per revisited (Demling). Most of the authors propose the cent of burn experts cannot determine the exact wound use of non-antimicrobial dressings as soon as the diag- depth when analyzing the burns at the first assessment. nosis of superficiality is complete. Dressings formed by On the contrary, observation of a frank third degree hydrofiber, a texturized carboxymethylcellulose frame including and delivering silver have been successfully proposed in the local management of second degree L. Téot, MD, PhD burn wounds. Silicone coated dressings (safetac tech- Montpellier University, France nology), aiming at reducing pain during dressing e-mail: [email protected] changes, are often used in superficial burns (Heymans).

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_2, © Springer-Verlag Berlin Heidelberg 2010 Primary Wound Management CHAPTER 2 7

Indication for use Acute second degree Clear superficial Clear deep second Third degree (1–3 days) second degree degree Silversulfadiazine ++ ± ++ ± Modern dressing (foam, ± ++ ± ± silicone) Flammacerium − − − + (waiting solution before grafting) Excision skin grafting − − + ++ Negative pressure after − − − ++ if noble tissue is excision exposed

tools for pain are numerous and should be selected depending on the condition of the patient. The visual assessment scale is the most common mode of quantify- ing pain when the patient can communicate. Other scales may be suggested when the patient is under general anaesthesia. Pain is more pronounced when the burns are superficial, granulation tissue is present, and repetitive dressings are done. Pain at dressing change is a specific issue, more easily managed when using adapted modern dressings.

Surgery ⊡⊡Fig. 2.2 Before, during and after the debridement of deep electrical burns wound using high power hydrojet The aim of surgery is to remove potentially infected materials from the wound, cover the exposed tissues using skin grafting and reduce the length of stay in the hospital. This coverage can be done using either split- thickness skin graft, full-thickness skin graft or step by step reconstruction of the skin using bioengineered tissues like artificial dermis (Fig. 2.4).

Dermis and/or Skin Substitutes

Early excision and skin grafting is the most traditional method, where a skin graft is harvested on different possible areas (skull, thigh, legs, back, abdomen). Depending on the extent of surfaces to cover, the skin graft may be Fig. 2.3 Before, during and after the debridement of ⊡⊡ amplified using mesh grafts (×1.5, 2, 4, 6). The unifor- deep electrical burns wound using high power hydrojet mity and regularity of the scar obtained with these methods mostly varies with the possibility to use Pain Management unmeshed skin grafts. In moderate surfaces, the colour matching of the skin graft is also an issue and is better Pain should be correctly managed during the first hours matched when harvested close to the recipient zone. after accident, then regularly reassessed. Assessment When using a skin graft coming from further away, such 8 CHAPTER 2 Primary Wound Management

⊡⊡Fig. 2.5 Mesh grafting (×2) over the lower limb burns

⊡⊡Fig. 2.4 Non-cellularized dermal substitute before skin grafting after deep burns of the lower limb. Revascularization patient is in poor general health, thereby limiting the can be sped up by the use of negative pressure therapy possibility of general anaesthesia. Autografts can be extensively meshed (×6) and covered using ×2 meshed allografts (Fig. 2.5). Keratinocyte Autologous Cell cul- tures provide hope for the future, if a functional dermis as thigh skin to resurface a cheek, the risk of having a has been obtained (Rheinwald, Compton, Boyce). bad colour match is higher, leading to a permanent The use of xenograft has also been proposed, either to hyperchromia of the transferred skin. replace dermal components or to secure skin grafts. The use of dermal substitutes will be dealt with in Early skin grafting may be contraindicated, due to Chap. 13. various situations such as contraindications for surgery, Scar improvement was observed when using double exposure of joints, tendons or vascular bundles. layer dermal substitutes (Integra, Purdue, Heimbach, Flammacerium (silver sulfadiazine plus 2% cerium Renoskin, Hyalomatrix Pelnac), and more recently with nitrate) was proposed in the 90s, and was mainly used over single layer dermal substitutes (Matriderm™) being imme- extensive surfaces of third degree burns where surgery diately covered using thin skin grafts (Van Zuijlen). cannot be performed on a single occasion. Flammacerium Cadaver skin can safely be used, especially to cover presents the unique possibility of combining with necrotic temporarily deep burns wound (Sheridan). The use of tissue, transforming it into a calcified tissue strongly adher- these materials is dependent on the availability, which is ing to the wound edges for a very long period of time. This an issue linked to tissue banks which are necessary to powerful antimicrobial agent should be used only over store them under adapted freezing conditions. Allografts limited surfaces (no more than 30% TBSA), the risk of can be used as a sandwich technique when autograft inducing methemoglobinaemia being a real and life- donor sites are limited (extensive TBSA) or when the threatening complication (Fig. 2.6) (Wassermann). Primary Wound Management CHAPTER 2 9

Negative pressure therapy is not the treatment of choice for burns, but presents some interesting capacities to promote granulation tissue over noble exposed tissues like joints, tendons or vascular pedi- cles, after complete surgical excision of the burnt tissues. This technique has indications when doubts persist on the vitality of the exposed tissues before skin grafts.

Conclusion

Burns management is mainly based on excision and grafting techniques, in deep burns with the recent intro- ⊡⊡Fig. 2.6 Late result of skin grafting of the plantar aspect duction of the use of dermal substitutes and on the use of the skin. Elasticity is required and the use of dermal sub- of antimicrobials in superficial burns, with the recent stitute may help use of modern dressings. 10 CHAPTER 3 Debridement of the Burn Wound

hans-oliver rennekampff and mayer tenenhaus

Rationale for Debridement antibiotics may not reach the nonperfused tissues. Local bioburden does not only pose a risk for delayed wound At first glance, the rational for debriding a wound, a healing and further tissue loss but may also systemically burn wound for example, seems evident. Nonviable, compromise the patient when sepsis occurs. A biobur- necrotic cells and tissue debris should be removed, and a den of more than 105 bacteria/gram of tissue is consid- clean, viable, and well-vascularized wound bed be estab- ered to be an invasive infection, which impairs wound lished allowing for subsequent wound closure; and yet, healing, leads to graft loss, and may similarly impair the what concrete evidence do we have to justify this successful application of temporary wound dressings. approach? Steed et al. [1] analyzed wound healing rates The successful reduction of bioburden below concentra- in diabetic patients. In this study, he was able to demon- tions of 105 bacteria/gram of tissue is a key element of strate that when compared to conservative management, surgical wound debridement [3]. radical surgical debridement led to improved rates of The effects of burn tissue on both local complication healing. In the case of burn wounds, biochemical and generalized outcome were analyzed by Davis et al. changes in the wound affect not only the rate of wound and Deitch et al. [4, 5]. In their review, they were able to healing, but may pose systemic risk to the patient. demonstrate that a burn wound which took longer than Several experimental burn wound models have 21 days to heal posed a hypertrophic scar development clearly demonstrated that toxic products are released risk of nearly 80%. Furthermore, they were able to show from burned skin, and that these substances manifest a that early skin grafting could reduce the incidence of negative and potentially lethal systemic effect. A lipo- hypertrophic scaring as compared to late grafting of the protein complex with high toxicity has subsequently debrided wound. been isolated from the thermally injured skin, and neu- trophils derived from the burn wound have been shown to produce Leukotoxins which have been associated Debridement of Blisters with both morbidity and mortality in the burn patient. Hansbrough et al. were able to show that the presence of The management of burn blisters has been a source of thermally injured skin has a systemic immunosuppres- ongoing debate for many years [6]. While others have sive effect on the individual [2]. suggested that intact burn blisters may act as biologic Necrotic, nonperfused tissue may serve as a nidus for bandages, keeping the underlying tissues safe from fur- bacteria and fungi, and as such, debridement of such tis- ther trauma and desiccation, numerous researchers and sue can potentially reduce the incidence of wound infec- clinicians have shown that blister fluid derived from the tion. While topical antimicrobial ointments may burn wound setting, in contradistinction to dermatologic penetrate into the nonviable burned skin, systemic and immunologically induced blisters, contains products which are inflammatory and vasoconstrictive in nature. In vitro testing has similarly shown inhibition of various H.-O. Rennekampff, MD, PhD (*) key cellular elements involved in the epithelialization Klinik für Plastische, Hand- und Wiederherstellungchirurgie, process. These findings have generally promoted the Medizinische Hochschule Hannover, Carl Neubergstraße 1, 30625 Hannover, Germany trend toward early debridement and cytoprotective strat- e-mail: [email protected] egies. This affords a proactive approach to the evaluation M. Tenenhaus, MD of depth of injury, while promoting standard wound Division of Plastic Surgery, Medical Center, healing strategies. This is particularly true of cases in University of California San Diego, USA which the mechanism of injury is known to have been

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_3, © Springer-Verlag Berlin Heidelberg 2010 Debridement of the Burn Wound CHAPTER 3 11 deep in nature, i.e., contact burns in aesthetically and overall biologic burden as quickly as safe. This usually functionally critical areas or when presented with large amounts to the whole chest and/or back, as well as clear- and fragile blisters as well as blisters which have broken. ing areas critical for vascular and pulmonary access (peri-clavicular, neck, and groin sites) as needed. Two teams of surgeons communicating closely with anesthe- Timing of Debridement sia can perform rather large surface area excisions very quickly and efficiently, while minimizing obviate blood Is there an optimal time for debridement? Groundbreaking and temperature loss. Critical aesthetic and functional work by Janzekovic [7] demonstrated the clinical advan- areas pose their own significant challenges as it often tage of early debridement (3–5 days postinjury) and takes longer to establish absolute depth and extent of grafting vs. conservative management with 2–3 weeks of injury in these locations, and they often take much lon- autolytic debridement, antimicrobial dressings and finally ger to meticulously excise and cover. For patients who skin grafting. In a number of subsequent studies [8, 9], have suffered extensive injuries, we prefer to address early debridement was shown to reduce length of stay; these areas on the second surgical intervention after the however, no difference in mortality was found as com- majority of the biologic and bacterial burden has been pared to late debridement. In contrast to these studies, addressed. We do feel that this should be done rather Herndon et al. [10] could demonstrate that in the group quickly, and yet expertly, to minimize collateral injury, age 17–30, without inhalation injury, an early interven- the effects of prolonged inflammation, and edema while tion (<72 h post burn) could reduce mortality. Caldwell expediting coverage so gentle range of motion, pressure, et al. [11] stated that early autologous grafting and subse- and rehabilitative therapies can be applied. Skin graft quent wound closure could be of greater importance than donor sites are carefully planned and designed to pre- early excision without autologous grafting. Important serve and restore critical aesthetic and functional studies [12] in pediatric patients investigated the advan- requirements while expediting general coverage. tage of early excision. A significant reduction in length of Blood losses can prove particularly challenging in stay, infectious complications, and metabolic demands larger excisions and this is especially true when there is a was shown. However, overaggressive excision of indeter- delay in presentation [17]. Inflamed and infected wounds minate burn depth areas should be avoided. Conservative tend to bleed more during tangential excision. As always, wound management can reduce the overall need for skin clinical judgment and experience should guide this deci- grafting in selected patients [13–15]. sion. Numerous methods are employed, often in combination, to optimize hemostasis and minimize blood losses during burn surgery. These include meticulous Technical Considerations attention to maintaining the patients’ core body temperature. Burn surgery is commonly performed in a very The decision to perform extensive excisions in a single warm environment and isolated surgical fields are pat- setting vs. staged procedures is dependent upon hemo- terned to minimize losses from wide-span exposure. The dynamic stability of the patient, availability of resources, use of Bair huggers (warm air blankets), warming lights, and meticulous coordination of all parties involved in warm and humidified air circuits for inhalation anesthe- the care of the patient. No difference in survival has been sia, and even actively warming peripheral and core intra- shown when comparing either strategy. Single-stage venous fluids are all measures to this end. Efforts to excisions have been shown to shorten length of stay, and minimize blood losses include the use of cautery, the major excisions by simultaneous experienced teams can application of topical epinephrine solutions, topical be performed safely and efficiently when well coordi- thrombin solutions, topical H2O2 solutions, topical fibrin nated [16]. Planning the sequence of excisions in exten- sealants, and injecting dilute epinephrine solution below sive surface area burns is an art and philosophy onto its the eschar, all of which have their advocates. Excision of own, dependent to a degree upon training, familiarity, burns from the extremities under tourniquet control can surgical team size, injury distribution, the existence of significantly minimize bleeding with the added benefit of concomitant injuries (i.e., cervical spine stability consid- improving critical structural visualization. This tech- eration), and pulmonary and hemodynamic consider- nique does, however, require a learning curve as it can be ations. In these cases, our general practice has been to quite challenging early on differentiating vital from non- excise and provisionally cover the largest areas of burn vital tissue without the generally relied upon end point of distribution as soon as possible, effectively reducing the punctuate bleeding. 12 CHAPTER 3 Debridement of the Burn Wound

Debridement of Hand Burns the wound bed with a dermal substitute, e.g., Matriderm™ in an effort to improve subsequent graft take and poten- Debridement of the hand requires special attention. tially minimizing contracture. Limited availability of specialized soft tissue coverage, Indeterminate and superficial depth burns can be the challenging contour of the hand and fingers with tangentially debrided and covered with a temporary skin complex curves and concavities, and the superficial substitute, e.g., Biobrane, in an effort to promote reepi- nature of critical neuromuscular elements make this thelialization. If reepithelialization cannot be achieved area among the most difficult to judiciously excise. Full within 21 days, an additional excisional debridement thickness injuries require excision and auto grafting as and skin grafting is necessary. Burns to the palmar hand soon as possible (see above) with the best available have to be carefully assessed. The specialized anatomy of autologous skin. When grafting, the skin is preferentially palmar skin and its underlying fascial expansion is not placed as sheet grafts, pie-crusted, or 1:1 meshed (non- readily replaced by a skin graft and resultant contrac- expanded), and placed at maximal length. While fascial tures are particularly difficult to manage. Debridement excision is often required for very deep burns to the dor- should include removal of blisters and general wound sum the hand, precise preservation of the paratenon as a management principles applied. A thickened palmar graftable bed is sometimes difficult to accomplish epithelium and deeply buried keratinocytes stem cells (Fig. 3.1). Whenever viable fat or dermal remnants are favor conservative management of palmar burns. still present (Fig. 3.2), we try to preserve this and cover However, if healing will not occur within 3 weeks,

a b

⊡⊡Fig. 3.1 Full thickness burn to the dorsum of the hand (a). Fascial excision was intended. In some areas like the extensor hood of the fifth finger, the paratenon could not be preserved; part of the extensor hood had to be debrided (b)

a b

⊡⊡Fig. 3.2 Deep partial to full thickness burn to the dorsum of the hand (a). Tangential excision was performed down to viable tissue. Dermal remnants and subcutaneous tissue were preserved (b) Debridement of the Burn Wound CHAPTER 3 13 subcutaneous debridement and grafting with a skin graft is necessary. Splits are generally advocated to minimize shear and maintain optimal joint and capsular position during engraftment. Negative pressure systems can similarly be employed to maintain protective positioning and encourage graft take. ⊡⊡Fig. 3.3 The Goulian/Weck knife (above) and Humby knife (below) with attached guards which allow for defined levels of tissue excision Debridement in Facial Burns

As in the case of the burned hand and fingers, the management of the burned face requires specialized attention. Optimal aesthetic and functional outcomes challenge the burn surgeon in both the acute and reconstructive phases. Despite the critical nature of these areas, a critical review of the literature reveals a rather limited subset of articles describing a formal reconstructive plan while demonstrat- ing subsequent results [18, 19]. The initial management generally encompass the removal of blisters and loose debris followed by the application of topical antimicrobial wound care. Areas which are likely to heal within 3 weeks are debrided with the Versajet system and Biobrane applied as a temporary dressing. Full thickness wounds should be ⊡⊡Fig. 3.4 Tangential excision with the Gouilan knife is performed until punctuate bleeding is observed. Hemostasis is addressed in the first week postburn with excision and performed with topical application of epinephrine-soaked allografting if the patient is stable enough. Indeterminate towels and partial thickness facial wounds should be reassessed at approximately postburn day #10 to determine which areas will not heal within 3 weeks postburn. It is classically advo- is that preserving vital dermis under a split thickness cated that those areas which will not heal within 3 weeks skin graft will improve functional outcome and reduce require debridement and grafting. The concept of acute scar formation. It has similarly been reported [4] that aesthetic unit excision vs. only excising the burned areas early judicious tangential excision accelerates reepitheli- continues to be a source of ongoing debate. Many practi- alization in partial thickness wounds by reducing the tioners acutely preserve as much specialized tissue as pos- biologic burden effects of the overlying eschar and its sible, leaving formal aesthetic reconstructional strategies byproducts. An inadequately excised wound is more for later, while others (Klein/Engrav) have advocated com- likely to become infected and is unsuitable for flap or plete acute excision of aesthetic units if the deeply burned skin graft take, necessitating further surgery. Tangential area constitutes greater than 80% of the aesthetic unit. debridement is generally performed with the Humby- or Debridement of the necrotic skin is performed with Goulian knife (Figs. 3.3 and 3.4), which have attached the Goulian knife, scalpel, scissors, and the Versajet sys- fixed depth guards. tem (see below). Application of allogeneic skin is advocated by some to allow for reassessment the following day and assure a more hemostatic wound bed at the time Fascial Excision of autologous skin grafting. Fascial excision involves the complete excision of all skin and subcutaneous tissues down to the muscle fascia Tangential Excision layer where defined vascular perforators are individually controlled minimizing blood loss (Fig. 3.5). Experienced Tangential excision describes the sequential and layered surgeons can perform this form of excision very quickly excision of devitalized tissues to a vital wound bed, gen- using the electrocautery, and as a result, this technique erally recognized by punctuate bleeding. The hypothesis can prove life saving when faced with very deep injuries 14 CHAPTER 3 Debridement of the Burn Wound

⊡⊡Fig. 3.5 Fascial excision is performed down to the muscle fascia b

in a hemodynamically challenged patient. While skin grafting on fascia or muscle is generally very successful, this technique results in a permanently disfiguring cavi- tary appearance. Fascial excision and grafting is inferior to skin grafting on the subcutaneous level with respect to late functional outcome, and as such, is usually reserved for massive burns.

Hydrosurgical System Versajet ⊡⊡Fig. 3.6 Delayed presentation of a partial thickness burn In our experience [20], the use of waterjet debridement to the hand (a). The Versajet is used to debride down to viable (Versajet, Smith and Nephew) has proven to be a great dermis (b). Debridement is stopped as soon as punctuate asset in wound bed preparation and surgical debride- bleeding is observed. The wound is then grafted with a split ment by improving precision and control of debride- thickness skin graft ment. Our clinical results demonstrate that the Versajet™ System can precisely and safely ablate burned necrotic vacuum to debride at the faster speeds required for full tissue in vivo (Fig. 3.6). A controllable high power water thickness wounds results in a continuous decrease in stream allows adjustment to the clinically anticipated cutting precision. We and others have found the Versajet™ depth of necrosis. In areas where the skin is of critical System, in its present form, inadequate for the excision thickness like the hand and the face, a tool like the of full thickness and prefer leathery dried eschar instead Versajet™ System is likely to spare vital tissue. It is these of using sharp surgical excision. protected and vital skin appendages which are necessary Middermal level burn wounds are effectively debri- for timely wound healing and the subsequent reduction ded using the Versajet™ System with the Exact handpiece of scarring as it is well established that the process of (Fig. 3.6). We advocate beginning at very low setting lev- successful reepithelialization is dependent upon the els till comfort and efficacy is established. In general, presence of an appropriate dermal substrate on which several passes at settings ranging from five to seven are keratinocytes can migrate. In comparison with the diffi- required to treat these deeper wounds. Deep partial culties often incurred during the use of a cold knife, a thickness wounds require multiple passes with settings cutting width of 14 mm allows for a very precise and ranging from seven to ten to obtain complete debride- contoured debridement in areas like the web spaces of ment. After debridement, all deep partial thickness the hand and foot, as well as in areas of the face like the wounds are grafted with split thickness skin grafts. In nasiolabial fold and eyelids. In larger areas necessitating our experience, the result of engraftment and the quality rapid necrectomy, the maximum cutting width of 14 mm of healing have proven comparable to that obtained with poses a potential disadvantage. An increase in the standard debridement techniques. 16 CHAPTER 4 Application of VAC Therapy in Burn Injury

joseph a. molnar

Burn Wound Paradigm multifactorial and involves cytokines, free radicals, clotting cascade, and other factors involved with tissue damage and One of the great frustrations in burn care is the phenom- the inflammatory response that leads to progressive loss enon of burn wound progression. In this process, the of blood flow and more tissue ischemia [3–6]. While depth of burn worsens in the first few days after injury infection will hasten this process, it is not a requirement even with optimal medical care. Jackson [1, 2] explained for burn wound progression. this phenomenon with three zones of injury (Fig. 4.1). One harmful byproduct of burn injury that leads to By this paradigm, the zone of coagulation in the center progressive tissue damage is edema. When tissue is dam- of the wound is the deepest and consists of a zone of aged by burn injury, there is a capillary leak that results nonviable tissue. The outermost zone, the zone of hyper- in interstitial edema [3–6]. The edema alters cell shape emia, is a superficial injury much like a first degree burn and cellular activities leading to progressive cellular and will go on to heal uneventfully almost regardless of injury [7]. In addition, the increase in tissue volume the treatment provided. Between these two zones is the results in decreased vascular density, increased diffusion zone of stasis. In this zone, the tissue is severely meta- distances, and ultimately stretching of the vessels, bolically compromised due to poor blood flow (stasis) decreased blood flow, and altered colloid osmotic pres- leading to progressive tissue damage and ultimate burn sure (Fig. 4.2). These factors are also an integral part of wound progression. The etiology of this phenomenon is the progressive tissue damage in burn injury [8].

⊡⊡Fig. 4.1 Jackson’s paradigm of burn injury. Zone of The central zone of coagulation coagulation is nonviable and cannot be recovered. The outer zone of hyperemia Zone of will heal almost regardless stasis of the treatment. The zone related to burn wound progression is the interme- Zone of diate zone of stasis. How the hyperaemia wound and patient are managed may result in improvement or worsening of this zone

J. A. Molnar, MD, PhD Wake Forest University School of Medicine, USA e-mail: [email protected]

H. Hyakusoku et al. (eds.), Color Atlas of Burn Reconstructive Surgery, DOI: 10.1007/978-3-642-05070-1_4, © Springer-Verlag Berlin Heidelberg 2010 Application of VAC Therapy in Burn Injury CHAPTER 4 17

Normal wounds resulted in improved blood flow and decreased tissue damage when compared to standard wound care [13] (Figs. 4.3 and 4.4). The results were also better if the device was placed earlier suggesting an effect on Edema the early response to burn injury (Fig. 4.5). Based on this initial success in the animal model, this technique was applied to acute human burn wounds. After initial anecdotal success with a partial thickness flashburn, the device was evaluated in a prospective fashion in two studies (Fig. 4.6) [8, 14–16]. Patients with bilateral hand burns were evaluated so that each patient could be at his or her own control allowing for optimal statistical power. In the initial study, it appeared that 2003 WFUSM Plastic Surgery Collection hands treated with SAP had less edema and improved range of motion (Fig. 4.7). The device was also very use- ⊡⊡Fig. 4.2 In a “normal” state the number of vessels is in ful to splint the hands in the “intrinsic plus” position to balance with the needs of the tissue. “Edema” results in an optimize range of motion in patients who are not able to enlargement of tissue volume, and of necessity, a decreased actively participate in therapy. vascular density and increased diffusion distances. Ultimately, In a prospective, randomized, controlled, blinded, the vessels stretch and decrease flow, and with altered osmotic pressures, there is worsening of tissue ischemia multicenter trial of the effect of SAP on the burn wound, evaluation of the size of the burn wound was accomplished with a standardized digital photography tech- Subatmospheric Pressure Wound Therapy nique and edema was measured by volume displacement [16, 17]. This study indicates that SAP treatment of acute In the 1990s, Argenta and Morykwas developed a new burns has a positive and statistically significant effect to device to treat chronic wounds. The device was a simple minimize burn wound progression and minimize closed cell polyurethane sponge placed in the wound that edema. Areas of burn wound progression were decreased was sealed off with an adherent drape and then subatmo- by approximately 15%. Similar findings have been dem- spheric pressure (SAP) (−125 mmHg) was applied. While onstrated by others [18, 19]. the original concept was primarily to contain and remove wound exudate, subsequent studies demonstrated that SAP treatment of wounds resulted in increased blood Summary flow, decreased edema, decreased bacterial counts, and earlier wound closure [8–10]. The mechanism for this Studies, to date, suggest that SAP has a positive effect to effect on wounds is unclear, but may involve macrode- minimize burn wound progression and may be an formations and microdeformations, as well as the appropriate alternative dressing for acute burns. While removal of inflammatory mediators and other yet unde- decreased edema has been observed with this technique, termined effects [10, 11]. Despite these uncertainties, it is other possible mechanisms for this positive effect include apparent that the specific nature of the sponge is impor- microdeformational changes, removal of inflammatory tant and not just the SAP exposure [10, 12]. mediators and free radicals, and improved blood flow. It was logical that such treatment would be helpful Further studies will be required to determine the mech- in the management of the burn wound. Initial studies anism of this change and the appropriate indications for in an animal model showed that SAP treatment of burn this dressing. 18 CHAPTER 4 Application of VAC Therapy in Burn Injury

a b

SAP Control SAP Control

c d

SAP Control SAP Control

⊡⊡Fig. 4.3 Histologic changes with burn injury in an animal wounds on day 9 (d), it is readily apparent that much more model [13]. Identical burns were treated with conventional tissue was salvaged using the SAP treatment (depth of con- dressings (control) or subatmospheric pressure (SAP). At trol burns = 0.885 ± 0.115 mm; SAP treated burns (0-h days 1(a), 3(b), 5(c), 9 (d), biopsies showed a relative amelio- delay) = 0.095 ± 0.025 mm). With permission: Morykwas ration of burn wound progression using SAP. With the healed et al. [13]

0.9

0.8 ⊡⊡Fig. 4.4 Graphic representation of histologic 0.7 findings with SAP applied at various time intervals after 0.6 burn injury in the swine model of Fig. 4.3. The Y axis (mm) indicates the depth of 0.5 burn. The X axis represents the delay time after burn 0.4 injury until placement of * the SAP treatment. The 0.3 differences in tissue salvage are only statistically 0.2 * different at 0 and 12 h (asterisk). As predicted, the prevention of burn wound 0.1 progression was greatest when applied early after 0 injury [13] Untreated 0 hr 12 hr 18 hr 24 hr Application of VAC Therapy in Burn Injury CHAPTER 4 19

a b

c d

⊡⊡Fig. 4.5 (a) The hand dressing as supplied by KCI, Inc. position. (d) To optimize range of motion when the dressing (b) The polyurethane sponge must have components between is discontinued, care should be taken to avoid the intrinsic the digits to avoid potential pressure damage to the skin by minus position which can cause damage to the tissue over the direct digital contact. (c) Once the sponge is sealed off and proximal interphalangeal joints SAP applied, the patient may be kept in the “intrinsic plus” 20 CHAPTER 4 Application of VAC Therapy in Burn Injury

a b

c d

⊡⊡Fig. 4.6 Acute flash burn of the right upper extremity SAP. (c, d) Ultimate complete healing without skin grafting treated with SAP [14]. (a) Acute injury suggesting deep par- viewed at 5 weeks after injury. Note healing of fingernails tial thickness injury. (b) Hand after 2 days of treatment with indicating the depth of burn