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Pedicled flaps are first choice in the reconstruction of hot air sauna burns
burns 34 (2008) 1047–1050
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Case report
Pedicled flaps are first choice in the reconstruction of hot air sauna burns Virve Koljonen * Department of Plastic Surgery, Helsinki University Hospital, P.O. Box 266, FIN 00029 HUS, Finland
article info Article history: Accepted 10 August 2007
1.
Introduction
Hot air sauna burns are rare but result in potentially fatal injuries with subsequent rhabdomyolysis [1]. Fortunately, hot air sauna burns are relatively rare, even among the avid sauna bathing Finnish population [2]. The mechanism of hot air sauna burns involves prolonged exposure to hot air, due of immobility or loss of consciousness [1,3]. If the victim is found lying on left side, the burned areas are typically on the contralateral side of the body, thus leaving the other side unaffected. The burned areas are always those areas exposed at the highest level [1,3]. Therefore, Ghods et al. suggested the term ‘‘Apex burns’’ when referring to the hot air sauna burns. This type of heat exposure results in a complex injury in which full-thickness skin damage occurs concurrently with deeper tissue destruction (Fig. 1). According to our experience in the Helsinki Burn Centre, we noticed two typical patterns of skin necrosis, either ‘‘mesh’’ pattern, with islands of intact skin between necrotic areas or ‘‘uniform’’ pattern of larger necrotic areas (Fig. 2). Due to the growing popularity of sauna bathing around the world, it is to be expected that the number of hot air sauna burns will rise as well. Care for these burn victims poses a unique clinical challenge. This article presents two cases of hot air sauna burn victims operated in 2006 in the Helsinki Burn Center, based on our department’s long experience of this type of burn.
2.
Case 1
A 48-year-old man was transported to our burn centre after hot air sauna burns on a midsummer day. A few hours earlier, he fell unconscious in the sauna due to alcohol use. The temperature in the steam room was 80–100 8C, and the time spent unconscious in the sauna was approximately 1 h. He was found lying on his left side. On admission he presented with 20% TBSA, on the right side of the body; flank, gluteal, thigh and leg region were affected. On the second day after injury, a fascial excision was performed to the burnt areas (Fig. 1). In the leg, the upper parts of the muscles were necrotic and portions had to be sacrificed. On the leg, allograft skin was used and in the upper body, the defect was covered with split thickness autologous skin grafts. One week after the injury, the patient was scheduled for reoperation. In this operation, the muscles in the anterior leg compartment were excised tangentially. Peroneal longus and brevis muscle were removed. In addition, parts of the lateral head of the gastrocnemius muscle were excised. The defect was covered with autografts. Two weeks after the injury, the kneecap was found to be partially necrotic, and patient was scheduled again for operation, whereby partial patellectomy is performed and the defect was covered with pedicled medial gastrocnemius muscle flap. The muscle flap was covered with a splitthickness skin graft and the donor site was closed primarily
* Correspondence address: Department of Plastic Surgery, To¨o¨lo¨ Hospital, P.O. Box 266, FIN 0029 HUS, Finland. Tel.: +358 50 427 1983; fax: +358 9 471 87 217. E-mail address: [email protected]. 0305-4179/$34.00 # 2007 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2007.08.010
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burns 34 (2008) 1047–1050
with split thickness autologous skin grafts. The burnt areas in the breasts were excised with direct closure. On the ninth day after injury, the mummified fingers and the thumb from the right hand were amputated at the distal metacarpal level. Two days after this operation a re-revision was scheduled. In this operation, the dorsum of the right hand was excised and intrinsic muscles were removed. On the 16th day, reconstruction with a reversed island radial forearm flap was performed to maintain wrist function. The donor site was covered with skin graft (Fig. 4). The rest of the hospital stay was uneventful and she was discharged to regional hospital 39 days later. At outpatient clinic visits, no complications were noted and she returned to home and is able to do small daily chores.
Fig. 1 – Fascial excision showing the depth of the tissue damage.
(Fig. 3). After this operation, the rest of the hospital stay was uneventful. The patient was discharged to a regional hospital after 27 days. In the outpatient clinic visits, there have been no complications, and the patient returned to work 8 months after the initial injury.
3.
Case 2
73-year-old female was found unconscious in the sauna. The temperature in the steam room was 80 8C, her total bathing time was approximately 2 h but the time of unconsciousness was not known. Previously she had been diagnosed with high blood pressure and was on medication for this. Four months earlier, she suffered from mild brain infarction, and was on anticoagulation therapy. On admission, she presented with 22% TBSA, on the anterior parts of the body; breasts, abdomen, both thighs and right wrist and hand. On the ventral side of the body the burnt areas were in the neck, upper parts of the back. On the sixth day after burn, fascial excision was performed to abdomen and anterior thighs. The defects were covered
4.
Discussion
Hot air exposure may cause very severe burns with exceeding mortality [1]. The treatment of these patients differs somewhat of more common flame or scald burns. The necrotic area extends deep, to the subcutaneous fat and even to the muscle. It seems that the damage extends far beyond the visible cutaneous burnt areas. Ghods et al. verified this clinical observation recently. They reported two hot air sauna burn victims, whose lower extremity hot air sauna injuries, after depridement resulted in exposed bone. In both cases the free flaps perished due to thrombosis [3]. On admission, these patients need fasciotomies in addition to escharotomies [1]. In the acute phase, an operation whereby the necrotic areas is excised fascially and grafted with autologous split thickness skin grafts is carried out. Layers of the damaged muscle are removed commonly. Areas where the level of excision is unclear are covered with temporary materials, in our department typically allograft skin. Contrary to more usual burns, these patients need several operations whereby damaged muscle tissue is excised gradually. After the demarcation line has evolved between necrotic and viable tissue, amputations are performed if necessary. As noted by Ghod et al. free flaps may fail in hot air sauna cases [3]. The reason for this is that the injured area exceeds the visible burned skin; heat exposure damages the proximal
Fig. 2 – Two typical skin patterns of the hot air sauna burn. (A) ‘‘mesh’’ – pattern, islands of intact skin are surrounded by full thickness skin damage (B) ‘‘uniform’’ – pattern. The patient was found lying on her back with the right arm flexed to her stomach, hence the hand shaped unburned skin area in the stomach.
burns 34 (2008) 1047–1050
1049
Fig. 3 – (A) Pedicled gastrocnemius muscle flap 2 months postoperatively. (B) Six months post-operatively. The small distal areas of necrosis in the digits were treated conservatively. (C) The fascial excision and autografts 6 months postoperatively.
and distal recipient vessels. However, pedicled flaps harvested from the unaffected parts of the body survive well. The characteristic pattern of the burned areas leaves the contralateral side of the body unaffected, and available for reconstruction. Amputations have negative impact to the patient’s working ability and reduce the ability to cope with normal everyday
routines and thus diminish his or her quality of life [4,5]. To preserve the function in a wrist joint in a hand with all fingers amputated, we prefer to use the reversed radial forearm island fasciocutaneous flap. In the lower extremities, deep tissue injury generally leaves the knee joint exposed. Our choice is the pedicled gastrocnemius muscle flap. In women the breasts are frequently affected. We prefer to excise the burned areas
Fig. 4 – (A) Right hand after serial revisions and finger amputations, the reversed radial forearm flap is raised. (B) One month postoperatively. (C) Five months postoperatively.
1050
burns 34 (2008) 1047–1050
and suture the defect instead of grafting. In the reconstruction of hot air sauna burns, pedicled flaps provide multiple advantages such as composite coverage substance, functional transfer and earlier and faster rehabilitation as compared to amputations. Flaps used in this article, namely, the gastrocnemius muscle flap and radial forearm flap, are considered the workhorse for providing soft tissue coverage, despite the various reconstructive choices for knee and hand defects. These are simple and one-stage procedures requiring no microsurgical technique. The flaps are safe with robust blood supply. Both of these flaps have stood the test of time, even in the era of microsurgery. Use of the gastrocnemius muscle flap has proved to be effective in the management of knee defects of various etiologies because of the flap’s reliable vascular pedicle, the ease of the procedure, the minimal functional deficit, and the donor site is usually closed primarily [6–8]. It can be raised based on the medial or lateral sural artery, depending of the location of the defect. The main weakness of this muscle is its shape. The gastrocnemius muscle narrows distally, and the volume of the distal part is relatively small and sometimes unable to provide enough coverage defects at the suprapatellar region. The reverse transposition of the radial forearm island flap, based on a distal vascular pedicle consisting of the radial artery and its venae comitantes for hand reconstruction, was first reported by Lu [9]. The reversed radial forearm flap provides excellent coverage for distal upper-limb defects [10]. It consists of thin, pliable, hairless, good-quality skin. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. There is also the potential that this flap can be used as an innervated flap [10]. Donor site morbities are usually related to skin grafting, a displeasing scar deformity may result if split-skin grafts are used for closure.
5.
Conclusions
There are several distinct features in the hot air sauna burns. These injuries require extensive recourses for treatment and
entail significant morbidity and mortality. Hot air sauna burn victims require early and aggressive surgical intervention to treat the rhabdomyolysis. Amputations are common as well as excision of the affected muscle. Contrary to other types of burns these patients need flap coverage during the acute surgery phase.
Conflict of interest statement There is no conflict of interest.
references
[1] Koski A, Koljonen V, Vuola J. Rhabdomyolysis caused by hot air sauna burn. Burns 2005;31(6):776–9. [2] Papp A. Sauna-related burns: a review of 154 cases treated in Kuopio University Hospital Burn Center 1994–2000. Burns 2002;28(1):57–9. [3] Ghods M, Corterier C, Zindel K, Kiene M, Steen M. Hot air sauna burns. Burns 2007. doi: 10.1016/j.burns.2006.08.027. [4] van der Schans CP, Geertzen JH, Schoppen T, Dijkstra PU. Phantom pain and health-related quality of life in lower limb amputees. J Pain Symptom Manage 2002;24(4):429–36. [5] Sagiv P, Shabat S, Mann M, Ashur H, Nyska M. Rehabilitation process and functional results of patients with amputated fingers. Plast Reconstr Surg 2002;110(2):497–503 (discussion 04-5). [6] Gravvanis AI, Iconomou TG, Panayotou PN, Tsoutsos DA. Medial gastrocnemius muscle flap versus distally based anterolateral thigh flap: conservative or modern approach to the exposed knee joint? Plast Reconstr Surg 2005;116(3):932–4. [7] McCraw JB, Fishman JH, Sharzer LA. The versatile gastrocnemius myocutaneous flap. Plast Reconstr Surg 1978;62(1):15–23. [8] Moscona AR, Keret D, Reis ND. The gastrocnemius muscle flap in the correction of severe flexion contracture of the knee. Arch Orthop Trauma Surg 1982;100(2):139–42. [9] Lu KH. The forearm radial arterial turnover flap and its clinical applications. Zhonghua Wai Ke Za Zhi 1982;20(11):695–7. 704. [10] Jeng SF, Wei FC. The distally based forearm island flap in hand reconstruction. Plast Reconstr Surg 1998;102(2):400–6.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Case report
Pedicled flaps are first choice in the reconstruction of hot air sauna burns Virve Koljonen * Department of Plastic Surgery, Helsinki University Hospital, P.O. Box 266, FIN 00029 HUS, Finland
article info Article history: Accepted 10 August 2007
1.
Introduction
Hot air sauna burns are rare but result in potentially fatal injuries with subsequent rhabdomyolysis [1]. Fortunately, hot air sauna burns are relatively rare, even among the avid sauna bathing Finnish population [2]. The mechanism of hot air sauna burns involves prolonged exposure to hot air, due of immobility or loss of consciousness [1,3]. If the victim is found lying on left side, the burned areas are typically on the contralateral side of the body, thus leaving the other side unaffected. The burned areas are always those areas exposed at the highest level [1,3]. Therefore, Ghods et al. suggested the term ‘‘Apex burns’’ when referring to the hot air sauna burns. This type of heat exposure results in a complex injury in which full-thickness skin damage occurs concurrently with deeper tissue destruction (Fig. 1). According to our experience in the Helsinki Burn Centre, we noticed two typical patterns of skin necrosis, either ‘‘mesh’’ pattern, with islands of intact skin between necrotic areas or ‘‘uniform’’ pattern of larger necrotic areas (Fig. 2). Due to the growing popularity of sauna bathing around the world, it is to be expected that the number of hot air sauna burns will rise as well. Care for these burn victims poses a unique clinical challenge. This article presents two cases of hot air sauna burn victims operated in 2006 in the Helsinki Burn Center, based on our department’s long experience of this type of burn.
2.
Case 1
A 48-year-old man was transported to our burn centre after hot air sauna burns on a midsummer day. A few hours earlier, he fell unconscious in the sauna due to alcohol use. The temperature in the steam room was 80–100 8C, and the time spent unconscious in the sauna was approximately 1 h. He was found lying on his left side. On admission he presented with 20% TBSA, on the right side of the body; flank, gluteal, thigh and leg region were affected. On the second day after injury, a fascial excision was performed to the burnt areas (Fig. 1). In the leg, the upper parts of the muscles were necrotic and portions had to be sacrificed. On the leg, allograft skin was used and in the upper body, the defect was covered with split thickness autologous skin grafts. One week after the injury, the patient was scheduled for reoperation. In this operation, the muscles in the anterior leg compartment were excised tangentially. Peroneal longus and brevis muscle were removed. In addition, parts of the lateral head of the gastrocnemius muscle were excised. The defect was covered with autografts. Two weeks after the injury, the kneecap was found to be partially necrotic, and patient was scheduled again for operation, whereby partial patellectomy is performed and the defect was covered with pedicled medial gastrocnemius muscle flap. The muscle flap was covered with a splitthickness skin graft and the donor site was closed primarily
* Correspondence address: Department of Plastic Surgery, To¨o¨lo¨ Hospital, P.O. Box 266, FIN 0029 HUS, Finland. Tel.: +358 50 427 1983; fax: +358 9 471 87 217. E-mail address: [email protected]. 0305-4179/$34.00 # 2007 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2007.08.010
1048
burns 34 (2008) 1047–1050
with split thickness autologous skin grafts. The burnt areas in the breasts were excised with direct closure. On the ninth day after injury, the mummified fingers and the thumb from the right hand were amputated at the distal metacarpal level. Two days after this operation a re-revision was scheduled. In this operation, the dorsum of the right hand was excised and intrinsic muscles were removed. On the 16th day, reconstruction with a reversed island radial forearm flap was performed to maintain wrist function. The donor site was covered with skin graft (Fig. 4). The rest of the hospital stay was uneventful and she was discharged to regional hospital 39 days later. At outpatient clinic visits, no complications were noted and she returned to home and is able to do small daily chores.
Fig. 1 – Fascial excision showing the depth of the tissue damage.
(Fig. 3). After this operation, the rest of the hospital stay was uneventful. The patient was discharged to a regional hospital after 27 days. In the outpatient clinic visits, there have been no complications, and the patient returned to work 8 months after the initial injury.
3.
Case 2
73-year-old female was found unconscious in the sauna. The temperature in the steam room was 80 8C, her total bathing time was approximately 2 h but the time of unconsciousness was not known. Previously she had been diagnosed with high blood pressure and was on medication for this. Four months earlier, she suffered from mild brain infarction, and was on anticoagulation therapy. On admission, she presented with 22% TBSA, on the anterior parts of the body; breasts, abdomen, both thighs and right wrist and hand. On the ventral side of the body the burnt areas were in the neck, upper parts of the back. On the sixth day after burn, fascial excision was performed to abdomen and anterior thighs. The defects were covered
4.
Discussion
Hot air exposure may cause very severe burns with exceeding mortality [1]. The treatment of these patients differs somewhat of more common flame or scald burns. The necrotic area extends deep, to the subcutaneous fat and even to the muscle. It seems that the damage extends far beyond the visible cutaneous burnt areas. Ghods et al. verified this clinical observation recently. They reported two hot air sauna burn victims, whose lower extremity hot air sauna injuries, after depridement resulted in exposed bone. In both cases the free flaps perished due to thrombosis [3]. On admission, these patients need fasciotomies in addition to escharotomies [1]. In the acute phase, an operation whereby the necrotic areas is excised fascially and grafted with autologous split thickness skin grafts is carried out. Layers of the damaged muscle are removed commonly. Areas where the level of excision is unclear are covered with temporary materials, in our department typically allograft skin. Contrary to more usual burns, these patients need several operations whereby damaged muscle tissue is excised gradually. After the demarcation line has evolved between necrotic and viable tissue, amputations are performed if necessary. As noted by Ghod et al. free flaps may fail in hot air sauna cases [3]. The reason for this is that the injured area exceeds the visible burned skin; heat exposure damages the proximal
Fig. 2 – Two typical skin patterns of the hot air sauna burn. (A) ‘‘mesh’’ – pattern, islands of intact skin are surrounded by full thickness skin damage (B) ‘‘uniform’’ – pattern. The patient was found lying on her back with the right arm flexed to her stomach, hence the hand shaped unburned skin area in the stomach.
burns 34 (2008) 1047–1050
1049
Fig. 3 – (A) Pedicled gastrocnemius muscle flap 2 months postoperatively. (B) Six months post-operatively. The small distal areas of necrosis in the digits were treated conservatively. (C) The fascial excision and autografts 6 months postoperatively.
and distal recipient vessels. However, pedicled flaps harvested from the unaffected parts of the body survive well. The characteristic pattern of the burned areas leaves the contralateral side of the body unaffected, and available for reconstruction. Amputations have negative impact to the patient’s working ability and reduce the ability to cope with normal everyday
routines and thus diminish his or her quality of life [4,5]. To preserve the function in a wrist joint in a hand with all fingers amputated, we prefer to use the reversed radial forearm island fasciocutaneous flap. In the lower extremities, deep tissue injury generally leaves the knee joint exposed. Our choice is the pedicled gastrocnemius muscle flap. In women the breasts are frequently affected. We prefer to excise the burned areas
Fig. 4 – (A) Right hand after serial revisions and finger amputations, the reversed radial forearm flap is raised. (B) One month postoperatively. (C) Five months postoperatively.
1050
burns 34 (2008) 1047–1050
and suture the defect instead of grafting. In the reconstruction of hot air sauna burns, pedicled flaps provide multiple advantages such as composite coverage substance, functional transfer and earlier and faster rehabilitation as compared to amputations. Flaps used in this article, namely, the gastrocnemius muscle flap and radial forearm flap, are considered the workhorse for providing soft tissue coverage, despite the various reconstructive choices for knee and hand defects. These are simple and one-stage procedures requiring no microsurgical technique. The flaps are safe with robust blood supply. Both of these flaps have stood the test of time, even in the era of microsurgery. Use of the gastrocnemius muscle flap has proved to be effective in the management of knee defects of various etiologies because of the flap’s reliable vascular pedicle, the ease of the procedure, the minimal functional deficit, and the donor site is usually closed primarily [6–8]. It can be raised based on the medial or lateral sural artery, depending of the location of the defect. The main weakness of this muscle is its shape. The gastrocnemius muscle narrows distally, and the volume of the distal part is relatively small and sometimes unable to provide enough coverage defects at the suprapatellar region. The reverse transposition of the radial forearm island flap, based on a distal vascular pedicle consisting of the radial artery and its venae comitantes for hand reconstruction, was first reported by Lu [9]. The reversed radial forearm flap provides excellent coverage for distal upper-limb defects [10]. It consists of thin, pliable, hairless, good-quality skin. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. There is also the potential that this flap can be used as an innervated flap [10]. Donor site morbities are usually related to skin grafting, a displeasing scar deformity may result if split-skin grafts are used for closure.
5.
Conclusions
There are several distinct features in the hot air sauna burns. These injuries require extensive recourses for treatment and
entail significant morbidity and mortality. Hot air sauna burn victims require early and aggressive surgical intervention to treat the rhabdomyolysis. Amputations are common as well as excision of the affected muscle. Contrary to other types of burns these patients need flap coverage during the acute surgery phase.
Conflict of interest statement There is no conflict of interest.
references
[1] Koski A, Koljonen V, Vuola J. Rhabdomyolysis caused by hot air sauna burn. Burns 2005;31(6):776–9. [2] Papp A. Sauna-related burns: a review of 154 cases treated in Kuopio University Hospital Burn Center 1994–2000. Burns 2002;28(1):57–9. [3] Ghods M, Corterier C, Zindel K, Kiene M, Steen M. Hot air sauna burns. Burns 2007. doi: 10.1016/j.burns.2006.08.027. [4] van der Schans CP, Geertzen JH, Schoppen T, Dijkstra PU. Phantom pain and health-related quality of life in lower limb amputees. J Pain Symptom Manage 2002;24(4):429–36. [5] Sagiv P, Shabat S, Mann M, Ashur H, Nyska M. Rehabilitation process and functional results of patients with amputated fingers. Plast Reconstr Surg 2002;110(2):497–503 (discussion 04-5). [6] Gravvanis AI, Iconomou TG, Panayotou PN, Tsoutsos DA. Medial gastrocnemius muscle flap versus distally based anterolateral thigh flap: conservative or modern approach to the exposed knee joint? Plast Reconstr Surg 2005;116(3):932–4. [7] McCraw JB, Fishman JH, Sharzer LA. The versatile gastrocnemius myocutaneous flap. Plast Reconstr Surg 1978;62(1):15–23. [8] Moscona AR, Keret D, Reis ND. The gastrocnemius muscle flap in the correction of severe flexion contracture of the knee. Arch Orthop Trauma Surg 1982;100(2):139–42. [9] Lu KH. The forearm radial arterial turnover flap and its clinical applications. Zhonghua Wai Ke Za Zhi 1982;20(11):695–7. 704. [10] Jeng SF, Wei FC. The distally based forearm island flap in hand reconstruction. Plast Reconstr Surg 1998;102(2):400–6.