- Email: [email protected]
Iatrogenic burns
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burns 35 (2009) 1047–1056
This case demonstrates that, during control of the expander, the base of the port should be carefully examined for a possible leakage and checked by pressurising a full expander before any insertion.
references
Fig. 1 – Serum drainage observed in the metal base of the port with swelling of the plastic cover.
[1] Argenta LC. Tissue expansion. In: Goldwyn RM, Cohen MN, editors. The unfavorable result in plastic surgery. Philadelphia, PA: Lippincott Williams &Wilkins; 2001. p. 221–9. [2] Cunha MS, Nakamoto HA, Herson MR, Faes JC, Gemperli R, Ferreira MC. Tissue expander complications in plastic surgery. A 10 year experience. Rev Hosp Clin Fac Med Sao Paulo 2002;57:93–7. [3] Hoffmann JF. Tissue expansion in the head and neck. Facial Plast Surg Clin North Am 2005;13:315–24. [4] Shagets FW, Panje WR. Complications of tissue expander use plastic and reconstructive surgery of the head and neck. In: Proceedings of the Fifth International Symposium; 1991. p. 215–21. [5] Manders EK, Schenden MJ, Furrey JA, Hetzler PT, Davis TS, Graham WP. Soft tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493–506.
Nesrin Tan Baser* Unzile Balci Akbuga Hikmet Karayel Gurcan Aslan Ankara Training and Research Hospital, Department of Plastic Surgery, 499 Sokak, Ari Sitesi 46, Umitkoy, Ankara, Turkey *Corresponding author. Tel.: +90 312 595 3662 E-mail address: [email protected] (N.T. Baser) 4 December 2008 0305-4179/$36.00 . # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.12.003
Letter to the Editor Iatrogenic burns Dear Editor,
Fig. 2 – (A) An undamaged port was attached to the expander and the port base was punctured with a needle. (B) After needle insertion, the full expander was pressurised. No leakage was observed from the puncture.
Lately, we became aware of a letter to the editor [1] commenting on our manuscript [2] entitled ‘‘Congenital burns?’’ in the journal Burns. The comment made by Mr. Kanchan is not critical of the suggestion made by us, but instead seeks to provide another term ‘iatrogenic congenital burns’, which we believe is a tautology. As already emphasized, case reports of rarity certainly serve as a valuable knowledge bank to the clinical fraternity and help the practicing clinicians in the management of similar rare clinical cases encountered during their medical practice [3]. There is no denying the fact that the case report published by
burns 35 (2009) 1047–1056
Mr. Suliman [4] is one such case of importance. The circumstances of iatrogenic burns as observed by Mr. Suliman are undoubtedly worth reporting in the present era of increasing litigation against doctors.
references
[1] [2] [3] [4]
Kanchan T. Iatrogenic congenital burns. Burns 2009;35:148. Rao PPJ, Menezes RG. Congenital burns? Burns 2009;35:150. Rao PPJ, Menezes RG. Vanity burns. Burns 2008;34:1213. Suliman MT. Congenital burns. Burns 2004;30:197–8.
P.P. Jagadish Rao* Ritesh G. Menezes Department of Forensic Medicine and Toxicology, Kasturba Medical College, Mangalore 575001, India *Corresponding author E-mail address: [email protected] (P.P.J. Rao) 0305-4179/$36.00. # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.12.010
Letter to the Editor Epithelial bridge: A cosmetic problem associated with early excision and grafting of burned hands, that indicates burn depth misdiagnosis Successful management of the burned hand is of paramount importance. Because of the high mobility and importance of their functions, excising and grafting of hands present a unique challenge [1,2]. Optimal time for excision and grafting is not a consensus. Bacterial and fungal infection may deepen a dermal burn wound, causing delays in healing or even conversion of partial thickness to full-thickness burns and after 3–5 days, gram-negative organisms, which spread mainly via lymphatics, predominate. More virulent strains are able to penetrate deeply into the injured tissue where normal cellular barriers and delivery of host defense mechanisms are impaired [3] on the other hand patients with early excision required a shorter duration of antibiotic treatment and less positive wound cultures [4]; So early surgery, shortens the healing time, lessens the hospital stay, minimizes reconstructive surgery and leads to a good functioning hand with a reasonable aesthetic appearance, enabling the affected patient to return quickly to work and normal routine life [5]. Also early wound closure reduces, septic complications, and the need for major reconstruction, while decreasing hospital costs [6]. However, other studies showed no significant difference in functionality of the hand in the non-
1049
operative, conservative method versus the excision and grafting method [7–9]. In today’s practice, all burn wounds unlikely to achieve closure on its own within approximately 3 weeks are excised and grafted [10,11], but, evaluation by an experienced surgeon as to whether a partial-thickness burn will heal in 3 weeks is about 70% accurate [12]. In our center patients with upper extremity burns were evaluated by the experienced surgeon and those with deep burns were chosen to be treated with early excision and grafting (E&G); the tourniquet was used to control the bleeding, then tangential excision was done, but after each slice the tourniquet deflated to inspect the bed; If the bed does not bleed briskly, the tourniquet was inflated again and another slice of the same depth was taken until a viable bed was reached, in this situation the tourniquet kept inflated and skin graft performed. During routine follow up in many patients after 2–3 months we found multiple skin bridges in grafted areas especially on the palms (Fig. 1). Tangential excision addressed the challenges for determining the extent of dead tissue by enabling the surgeons to determine tissue viability intra-operatively [13,14], It seems that in our management superficial partial-thickness burns initially were confused with deep burns or there were some parts with superficial partial-thickness burns in the area of full-thickness burns that in early excision (tangential excision) and grafting, were tangentially excised but the basal layer remained intact due to underestimation of surgeon and skin graft was applied over them; so epithelialization occurred under the skin graft caused these area not to attach to the skin graft and to remain as small (about 1 cm) epithelial bridges between other deep parts that took the skin graft. Due to hygienic and cosmetic problems we were forced to excise these lesions under local or even general anesthesia. We hypothesized that if the width of these viable basal layers was less than 1 cm, the epithelial bridges survived by marginal blood supply to both sides of epithelial bridge with successful graft take; in order to prevent this complication we recommend to treat burns of the palms more conservatively or if some area smaller than 1 cm with suspicious depth are
Fig. 1 – Epithelial bridge in the palm, 6 months after early excision and grafting.
burns 35 (2009) 1047–1056
This case demonstrates that, during control of the expander, the base of the port should be carefully examined for a possible leakage and checked by pressurising a full expander before any insertion.
references
Fig. 1 – Serum drainage observed in the metal base of the port with swelling of the plastic cover.
[1] Argenta LC. Tissue expansion. In: Goldwyn RM, Cohen MN, editors. The unfavorable result in plastic surgery. Philadelphia, PA: Lippincott Williams &Wilkins; 2001. p. 221–9. [2] Cunha MS, Nakamoto HA, Herson MR, Faes JC, Gemperli R, Ferreira MC. Tissue expander complications in plastic surgery. A 10 year experience. Rev Hosp Clin Fac Med Sao Paulo 2002;57:93–7. [3] Hoffmann JF. Tissue expansion in the head and neck. Facial Plast Surg Clin North Am 2005;13:315–24. [4] Shagets FW, Panje WR. Complications of tissue expander use plastic and reconstructive surgery of the head and neck. In: Proceedings of the Fifth International Symposium; 1991. p. 215–21. [5] Manders EK, Schenden MJ, Furrey JA, Hetzler PT, Davis TS, Graham WP. Soft tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493–506.
Nesrin Tan Baser* Unzile Balci Akbuga Hikmet Karayel Gurcan Aslan Ankara Training and Research Hospital, Department of Plastic Surgery, 499 Sokak, Ari Sitesi 46, Umitkoy, Ankara, Turkey *Corresponding author. Tel.: +90 312 595 3662 E-mail address: [email protected] (N.T. Baser) 4 December 2008 0305-4179/$36.00 . # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.12.003
Letter to the Editor Iatrogenic burns Dear Editor,
Fig. 2 – (A) An undamaged port was attached to the expander and the port base was punctured with a needle. (B) After needle insertion, the full expander was pressurised. No leakage was observed from the puncture.
Lately, we became aware of a letter to the editor [1] commenting on our manuscript [2] entitled ‘‘Congenital burns?’’ in the journal Burns. The comment made by Mr. Kanchan is not critical of the suggestion made by us, but instead seeks to provide another term ‘iatrogenic congenital burns’, which we believe is a tautology. As already emphasized, case reports of rarity certainly serve as a valuable knowledge bank to the clinical fraternity and help the practicing clinicians in the management of similar rare clinical cases encountered during their medical practice [3]. There is no denying the fact that the case report published by
burns 35 (2009) 1047–1056
Mr. Suliman [4] is one such case of importance. The circumstances of iatrogenic burns as observed by Mr. Suliman are undoubtedly worth reporting in the present era of increasing litigation against doctors.
references
[1] [2] [3] [4]
Kanchan T. Iatrogenic congenital burns. Burns 2009;35:148. Rao PPJ, Menezes RG. Congenital burns? Burns 2009;35:150. Rao PPJ, Menezes RG. Vanity burns. Burns 2008;34:1213. Suliman MT. Congenital burns. Burns 2004;30:197–8.
P.P. Jagadish Rao* Ritesh G. Menezes Department of Forensic Medicine and Toxicology, Kasturba Medical College, Mangalore 575001, India *Corresponding author E-mail address: [email protected] (P.P.J. Rao) 0305-4179/$36.00. # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.12.010
Letter to the Editor Epithelial bridge: A cosmetic problem associated with early excision and grafting of burned hands, that indicates burn depth misdiagnosis Successful management of the burned hand is of paramount importance. Because of the high mobility and importance of their functions, excising and grafting of hands present a unique challenge [1,2]. Optimal time for excision and grafting is not a consensus. Bacterial and fungal infection may deepen a dermal burn wound, causing delays in healing or even conversion of partial thickness to full-thickness burns and after 3–5 days, gram-negative organisms, which spread mainly via lymphatics, predominate. More virulent strains are able to penetrate deeply into the injured tissue where normal cellular barriers and delivery of host defense mechanisms are impaired [3] on the other hand patients with early excision required a shorter duration of antibiotic treatment and less positive wound cultures [4]; So early surgery, shortens the healing time, lessens the hospital stay, minimizes reconstructive surgery and leads to a good functioning hand with a reasonable aesthetic appearance, enabling the affected patient to return quickly to work and normal routine life [5]. Also early wound closure reduces, septic complications, and the need for major reconstruction, while decreasing hospital costs [6]. However, other studies showed no significant difference in functionality of the hand in the non-
1049
operative, conservative method versus the excision and grafting method [7–9]. In today’s practice, all burn wounds unlikely to achieve closure on its own within approximately 3 weeks are excised and grafted [10,11], but, evaluation by an experienced surgeon as to whether a partial-thickness burn will heal in 3 weeks is about 70% accurate [12]. In our center patients with upper extremity burns were evaluated by the experienced surgeon and those with deep burns were chosen to be treated with early excision and grafting (E&G); the tourniquet was used to control the bleeding, then tangential excision was done, but after each slice the tourniquet deflated to inspect the bed; If the bed does not bleed briskly, the tourniquet was inflated again and another slice of the same depth was taken until a viable bed was reached, in this situation the tourniquet kept inflated and skin graft performed. During routine follow up in many patients after 2–3 months we found multiple skin bridges in grafted areas especially on the palms (Fig. 1). Tangential excision addressed the challenges for determining the extent of dead tissue by enabling the surgeons to determine tissue viability intra-operatively [13,14], It seems that in our management superficial partial-thickness burns initially were confused with deep burns or there were some parts with superficial partial-thickness burns in the area of full-thickness burns that in early excision (tangential excision) and grafting, were tangentially excised but the basal layer remained intact due to underestimation of surgeon and skin graft was applied over them; so epithelialization occurred under the skin graft caused these area not to attach to the skin graft and to remain as small (about 1 cm) epithelial bridges between other deep parts that took the skin graft. Due to hygienic and cosmetic problems we were forced to excise these lesions under local or even general anesthesia. We hypothesized that if the width of these viable basal layers was less than 1 cm, the epithelial bridges survived by marginal blood supply to both sides of epithelial bridge with successful graft take; in order to prevent this complication we recommend to treat burns of the palms more conservatively or if some area smaller than 1 cm with suspicious depth are
Fig. 1 – Epithelial bridge in the palm, 6 months after early excision and grafting.