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Survival of an extensively burned child following use of fragments of autograft skin overlain with meshed allograft skin
Burns (1985) 11,429-433
Printedin
429
Great Britain
Survival of an extensively burned child following use of fragments of autograft skin overlain with meshed allograft skin Yukimasa Sawada Department of Plastic and Reconstructive Hospital, Yamagata, Japan Summary This report describes the survival of an extensively hurned child following the use of fragments of autograft skin overlain with meshed allograft skin. This proccdure is thought to he very useful for treating extensively and deeply hurncd patients. especially children with limited autograft donor sites.
INTRODUCTION PAwf:iws with very extensive deep burns pose many problems during treatment, not the least of which is the limited availability of unburned skin for grafting on to the burned area. Various methods of intermingling autogenous and homologous skin have been recommended including use of small pieces of each type applied on to the wound (Jackson, 1954) or use of widely meshed autograft skin overlain with less widely meshed homograft skin (Alexander et al., 1981) or insertion of fragments of autograft skin through evenly spaced holes cut in a sheet of homograft skin (Yang et al.. 1980, 1982). The following case report describes another method where fragments of autogenous skin are placed on the wound followed by a covering of meshed homograft skin taken from a close relative.
CASE RE30RT A Y-year-old girl
was admitted with flame burns covering 70 per cent of the body surface area, 50 per cent 01 which was full thickness skin loss and the remainder partial thickness skin loss (Fig’. la. h). Resuscitation with crystalloid solutions using the Baxter formula rcaultcd in an uneventful shock phase. By day 30 after
Surgery,
Yamagata
Prefectural
Central
burning the partial thickness skin loss had healed and the full thickness skin loss wound was covered with granulation tissue. At operation the eschar on the hack amounting to 20 per cent of the body surface arca was excised and small fragments (approximately 3x3 mm) of autogenous skin taken from her scalp were placed on the dehrided wound with spaces of about 1Omm hctween each fragment. The wound was then covcrcd with homograft skin taken from a close relative that had been meshed to douhlc its arca (Fig. 2). Although about 20 per cent of the grafted area was lost hccausc 01 a pressure sore. the remaining grafted area looked dry and there vvas no clinical evidence of infcctron (/?,q. 3). The wound had healed completely hcforc the homograft was rejected. This started ahout 3 weeks after the operation and continued for a further 2 weeks. Bcncath the rejected homograft the autogenous skin fragments had ‘taken’ and expanded to form islands up to IO mm in diameter. A few weeks later these autograft island\ merged and the final appearance at complete healing was a wound which appeared to have heen covcrcd with patch grafts 2&30 mm in diamctcr. By 2 months after operation scar tissue ahout 5 mm wide surrounded each cpithelial island (Fifi.5). Although a similar operation was carried out on the front of the patient’s body on day 43 after hurning. again with the application of fragments of autogenous skin no meshed homograft skin was availahle for this operation so the wound could not he covered. This lack of covering was obviously deleterious to the prolifcration of the fragments of autogcnous skin since they had not merged 3 weeks after application-as found when the wound on the patient’s hack had been covered with meshed homograft skin. Some of the fragments of autogenous skin did not survive and further grafting with meshed autograft skin was required heforc the anterior surface wound healed completely. The full thickness skin loss on the arms and legs was repaired
Burns (1985) Vol. 11INo. 6
b Fig. 1 a, b. A 9-year
old girl with 70 per cent burn on her trunk,
both upper
Fig. 2. Thirty days after injury, autografts from her scalp, more in size, were placed on the wound at 10 mm intervals, meshed homograft.
arms,
thighs
and inguinum.
about 3x3 mm or and covered with
Sawada: Autograft and allografl
Fig. 3. About 7 days after operation, clthough 20 per cent of the grafted materials had not survived due to a pressure sore, the other grafted skin showed good ‘take’ and no discharge or infection was seen.
Fig. 4. u, h. About
18 months after injury.
431
432
Fig. 5. Close-up of ‘epithelial islands’ about 20-30mm in diameter on her flank, looking as if patch autograft skin had been used. with meshed autograft taken from the scalp and recently healed partial thickness skin loss burns on the legs. All the burned areas had completely healed 4 months after injury. At review 18 months after burning scar tissue was still obvious but contractures were minimal (Fig. 4~. h). However, body growth will almost certainly require further grafting to replace inelastic scar tissue under the chin, around the axillae and for breast development.
DISCUSSION
Homografts provide not only temporary wound coverage which seals the wound and minimizes fluid and protein loss through it but also limits or prevents infection and aids the formation of granulation tissue (Silverstein and Pruitt, 1973). Furthermore homografts have been used to stimulate the growth of grafted autogenous skin. The technique that combines homografts with autografts has produced greatly improved results especially for extensively burned patients with limited areas of unburned skin (Jackson, 1954; Alexander et al., 1981; Yang et al., 1980, 1982). Recently Yang et al. (1980, 1982) have described a procedure which involves placing small pieces of autograft skin spaced about 10mm
Burns (1965) Vol. ll/No.
6
apart through holes cut in a sheet of homograft and the long term results of the healing process were satisfactory. With this technique the transplanted autograft skin expanded to over six times its original size. On the other hand, Alexander et al. (1981) described the technique of using frozen or postage stamp sized pieces of autograft skin beneath it. According to these authors the merits of the procedure are-typing of the donor site is unnecessary, stable coverage is achieved with a minimum of autogenous donor sites and both the cosmetic and functional results have been satisfactory during a follow up period of 1 year. However, Alexander and his colleagues only used this procedure when the burned area covered less than 15 per cent of the body surface area. Comparing these two techniques, Alexander’s procedure requires a smaller area of homograft skin and a larger area of autogenous skin than Yang’s procedure. So that if late severe scar contractures are to be avoided a combination of Yang’s autograft and Alexander’s homograft technique is one of the options for treating extensively burned patients with only limited areas of unburned skin available for grafting. This report describes our use of these two procedures in combination, which appeared to have the following additional advantage that the homograft skin stimulated the rate of spread of the grafted autogenous skin fragments. This was deduced from the observation that the homograft-protected autograft skin fragments on the patient’s back healed faster than the unprotected autograft skin fragments on the patient’s anterior surface. In terms of the results of grafting apparent at review 18 months after injury, the protection provided by the homograft could be discerned because of the relatively large autograft islands which were surrounded by only small amounts of scar tissue. Such a relative paucity of scar tissue when healing has involved the use of a mixture of homo- and autograft skin has not been stressed by Jackson (1954), Alexander et al. (1981) and Yang et al. (1980, 1982), although it is particularly important in extensively burned children because of the limits imposed on normal body growth by extensive contractures (Ritsila et al., 1976). Repair of these contractures in the future is made easier when there is minimal scarring of skin close to the site of the contracture. Acknowledgements
The skilled typing of Mrs Jean gratefully acknowledged.
S. Clark
is
Sawada: Autograft and allograft
433
REFERENCES Alexander J. W., MacMillan B. G., Law E. et al. (1981) Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay. J. Truuma 21, 433. Jackson D. (1954) Clinical study of the use of skin homografts for burns. Br. J. Plast. Surg. 7, 26. Ritsila V.. Sundell B.and Alhopuro S. (1976) Severe growth retardation of the upper extremity resulting from burn contracture and its full recovery after release of the contracture. Br. J. Plast. Surg. 29, 53. Silverstein P. and Pruitt B. A. Jr. (1973) Allograft coverage of the burn wound. In: Lynch J. B. and
Lewis S. R. (eds) Symposium on the Treatment of Rurn.s. St. Louis: Moshy. Yang C. C.. Shih T.S., Chu T. A. et al. (1980) The intermingled transplantation of auto and homo-grafts in severe burns. Burns 6, 141. Yang C. C., Shih T. S. and Xu W. S. (1982) A Chinese concept of the treatment of extensive third degree burns. Plasm. Reconstr. Surg. 70. 23X.
Paper accepted
29 April
1985.
AWARD OF THE G. WHITAKER INTERNATIONAL BURNS PRIZE - PALERMO, ITALY FOR 1985 In the course of a meeting held on 23 February 1985 at the headquarters of the G. Whitaker Foundation, Palermo, after examining the scientific activity in the field of research, teaching, clinical organization, prevention and cooperation among the nations, presented by various candidates, in the light of the considerations guiding the analysis of the high level of the candidates, the Adjudicating Committee unanimously decided to award the Prize for 1985 to Bruce Mac
Millan
M.D., Chief of Shriners Cincinnati, Ohio, USA
Burns Institute,
for his particular contribution to the solution of the difficult physiopathological problems of burns in children. The official prize-giving of this prestigious award will be held on 13 June 1985 in Palermo at the headquarters of the G. Whitaker Foundation in the course of a ceremony in the presence of authorities and representatives of the academic, scientific and cultural world.
Printedin
429
Great Britain
Survival of an extensively burned child following use of fragments of autograft skin overlain with meshed allograft skin Yukimasa Sawada Department of Plastic and Reconstructive Hospital, Yamagata, Japan Summary This report describes the survival of an extensively hurned child following the use of fragments of autograft skin overlain with meshed allograft skin. This proccdure is thought to he very useful for treating extensively and deeply hurncd patients. especially children with limited autograft donor sites.
INTRODUCTION PAwf:iws with very extensive deep burns pose many problems during treatment, not the least of which is the limited availability of unburned skin for grafting on to the burned area. Various methods of intermingling autogenous and homologous skin have been recommended including use of small pieces of each type applied on to the wound (Jackson, 1954) or use of widely meshed autograft skin overlain with less widely meshed homograft skin (Alexander et al., 1981) or insertion of fragments of autograft skin through evenly spaced holes cut in a sheet of homograft skin (Yang et al.. 1980, 1982). The following case report describes another method where fragments of autogenous skin are placed on the wound followed by a covering of meshed homograft skin taken from a close relative.
CASE RE30RT A Y-year-old girl
was admitted with flame burns covering 70 per cent of the body surface area, 50 per cent 01 which was full thickness skin loss and the remainder partial thickness skin loss (Fig’. la. h). Resuscitation with crystalloid solutions using the Baxter formula rcaultcd in an uneventful shock phase. By day 30 after
Surgery,
Yamagata
Prefectural
Central
burning the partial thickness skin loss had healed and the full thickness skin loss wound was covered with granulation tissue. At operation the eschar on the hack amounting to 20 per cent of the body surface arca was excised and small fragments (approximately 3x3 mm) of autogenous skin taken from her scalp were placed on the dehrided wound with spaces of about 1Omm hctween each fragment. The wound was then covcrcd with homograft skin taken from a close relative that had been meshed to douhlc its arca (Fig. 2). Although about 20 per cent of the grafted area was lost hccausc 01 a pressure sore. the remaining grafted area looked dry and there vvas no clinical evidence of infcctron (/?,q. 3). The wound had healed completely hcforc the homograft was rejected. This started ahout 3 weeks after the operation and continued for a further 2 weeks. Bcncath the rejected homograft the autogenous skin fragments had ‘taken’ and expanded to form islands up to IO mm in diameter. A few weeks later these autograft island\ merged and the final appearance at complete healing was a wound which appeared to have heen covcrcd with patch grafts 2&30 mm in diamctcr. By 2 months after operation scar tissue ahout 5 mm wide surrounded each cpithelial island (Fifi.5). Although a similar operation was carried out on the front of the patient’s body on day 43 after hurning. again with the application of fragments of autogenous skin no meshed homograft skin was availahle for this operation so the wound could not he covered. This lack of covering was obviously deleterious to the prolifcration of the fragments of autogcnous skin since they had not merged 3 weeks after application-as found when the wound on the patient’s hack had been covered with meshed homograft skin. Some of the fragments of autogenous skin did not survive and further grafting with meshed autograft skin was required heforc the anterior surface wound healed completely. The full thickness skin loss on the arms and legs was repaired
Burns (1985) Vol. 11INo. 6
b Fig. 1 a, b. A 9-year
old girl with 70 per cent burn on her trunk,
both upper
Fig. 2. Thirty days after injury, autografts from her scalp, more in size, were placed on the wound at 10 mm intervals, meshed homograft.
arms,
thighs
and inguinum.
about 3x3 mm or and covered with
Sawada: Autograft and allografl
Fig. 3. About 7 days after operation, clthough 20 per cent of the grafted materials had not survived due to a pressure sore, the other grafted skin showed good ‘take’ and no discharge or infection was seen.
Fig. 4. u, h. About
18 months after injury.
431
432
Fig. 5. Close-up of ‘epithelial islands’ about 20-30mm in diameter on her flank, looking as if patch autograft skin had been used. with meshed autograft taken from the scalp and recently healed partial thickness skin loss burns on the legs. All the burned areas had completely healed 4 months after injury. At review 18 months after burning scar tissue was still obvious but contractures were minimal (Fig. 4~. h). However, body growth will almost certainly require further grafting to replace inelastic scar tissue under the chin, around the axillae and for breast development.
DISCUSSION
Homografts provide not only temporary wound coverage which seals the wound and minimizes fluid and protein loss through it but also limits or prevents infection and aids the formation of granulation tissue (Silverstein and Pruitt, 1973). Furthermore homografts have been used to stimulate the growth of grafted autogenous skin. The technique that combines homografts with autografts has produced greatly improved results especially for extensively burned patients with limited areas of unburned skin (Jackson, 1954; Alexander et al., 1981; Yang et al., 1980, 1982). Recently Yang et al. (1980, 1982) have described a procedure which involves placing small pieces of autograft skin spaced about 10mm
Burns (1965) Vol. ll/No.
6
apart through holes cut in a sheet of homograft and the long term results of the healing process were satisfactory. With this technique the transplanted autograft skin expanded to over six times its original size. On the other hand, Alexander et al. (1981) described the technique of using frozen or postage stamp sized pieces of autograft skin beneath it. According to these authors the merits of the procedure are-typing of the donor site is unnecessary, stable coverage is achieved with a minimum of autogenous donor sites and both the cosmetic and functional results have been satisfactory during a follow up period of 1 year. However, Alexander and his colleagues only used this procedure when the burned area covered less than 15 per cent of the body surface area. Comparing these two techniques, Alexander’s procedure requires a smaller area of homograft skin and a larger area of autogenous skin than Yang’s procedure. So that if late severe scar contractures are to be avoided a combination of Yang’s autograft and Alexander’s homograft technique is one of the options for treating extensively burned patients with only limited areas of unburned skin available for grafting. This report describes our use of these two procedures in combination, which appeared to have the following additional advantage that the homograft skin stimulated the rate of spread of the grafted autogenous skin fragments. This was deduced from the observation that the homograft-protected autograft skin fragments on the patient’s back healed faster than the unprotected autograft skin fragments on the patient’s anterior surface. In terms of the results of grafting apparent at review 18 months after injury, the protection provided by the homograft could be discerned because of the relatively large autograft islands which were surrounded by only small amounts of scar tissue. Such a relative paucity of scar tissue when healing has involved the use of a mixture of homo- and autograft skin has not been stressed by Jackson (1954), Alexander et al. (1981) and Yang et al. (1980, 1982), although it is particularly important in extensively burned children because of the limits imposed on normal body growth by extensive contractures (Ritsila et al., 1976). Repair of these contractures in the future is made easier when there is minimal scarring of skin close to the site of the contracture. Acknowledgements
The skilled typing of Mrs Jean gratefully acknowledged.
S. Clark
is
Sawada: Autograft and allograft
433
REFERENCES Alexander J. W., MacMillan B. G., Law E. et al. (1981) Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay. J. Truuma 21, 433. Jackson D. (1954) Clinical study of the use of skin homografts for burns. Br. J. Plast. Surg. 7, 26. Ritsila V.. Sundell B.and Alhopuro S. (1976) Severe growth retardation of the upper extremity resulting from burn contracture and its full recovery after release of the contracture. Br. J. Plast. Surg. 29, 53. Silverstein P. and Pruitt B. A. Jr. (1973) Allograft coverage of the burn wound. In: Lynch J. B. and
Lewis S. R. (eds) Symposium on the Treatment of Rurn.s. St. Louis: Moshy. Yang C. C.. Shih T.S., Chu T. A. et al. (1980) The intermingled transplantation of auto and homo-grafts in severe burns. Burns 6, 141. Yang C. C., Shih T. S. and Xu W. S. (1982) A Chinese concept of the treatment of extensive third degree burns. Plasm. Reconstr. Surg. 70. 23X.
Paper accepted
29 April
1985.
AWARD OF THE G. WHITAKER INTERNATIONAL BURNS PRIZE - PALERMO, ITALY FOR 1985 In the course of a meeting held on 23 February 1985 at the headquarters of the G. Whitaker Foundation, Palermo, after examining the scientific activity in the field of research, teaching, clinical organization, prevention and cooperation among the nations, presented by various candidates, in the light of the considerations guiding the analysis of the high level of the candidates, the Adjudicating Committee unanimously decided to award the Prize for 1985 to Bruce Mac
Millan
M.D., Chief of Shriners Cincinnati, Ohio, USA
Burns Institute,
for his particular contribution to the solution of the difficult physiopathological problems of burns in children. The official prize-giving of this prestigious award will be held on 13 June 1985 in Palermo at the headquarters of the G. Whitaker Foundation in the course of a ceremony in the presence of authorities and representatives of the academic, scientific and cultural world.