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An easy method for preparation of postage stamp autografts
Burns 26 (2000) 741±749
www.elsevier.com/locate/burns
An easy method for preparation of postage stamp autografts Su-Shin Lee a, Chih-Cheng Tsai a,*, Chung-Sheng Lai b, Sin-Daw Lin a a
Division of Plastic and Reconstructive Surgery, Department of Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan b Department of Surgery, Kaoshiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan Accepted 14 February 2000
Abstract A modi®ed technique of postage stamp autografting is studied. By using quick cutting plates, chessboard tray, skiing technique and petrolatum gauze, skin islands can be uniformly located and correctly oriented on the gauze. Moving the skin squares on the stainless steel tray is relatively easy, and the expansion ratio can be predicted by means of the chessboard diagram. The skin island grafts adhere to the petrolatum gauze when the gauze is applied to the tray. Then, as in the modi®ed Meek technique, the ``autografting carrier'' can be used to cover the burn wound. In comparison with the modi®ed Meek technique, this method does not require expensive equipment. The quick cutting plates can take over the function of the modi®ed Meek±Wall dermatome. The stainless steel trays and the petrolatum gauze are easily available. The advantages of this method include: (1) the expansion ratio can reach up to 1:9, (2) the preparation procedures are not time consuming, (3) regular distribution of these skin islands shortens the healing time, and (4) the cost of this method is relative low. The results of this technique are comparable to that of the modi®ed Meek technique. This preliminary study reveals that this technique is an easy and economic alternative for the treatment of extensive burn patients. 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Postage stamp autograft; Modi®ed Meek technique; Extensive burns
1. Introduction Several methods of skin grafting have been used to treat extensive burns with limited autologous donor skin. Up to the present time, the gold standard for management of extensive burns has been early excision, temporary allografting and ®nal autografting [1]. Although some arti®cial dermis and cultured epithelial autografts (CEA) have been presented for burn wound coverage, the ideal replacement for the lost skin is autologous skin consisting of the epidermis and dermis. Postage stamp autograft was ®rst described by Gabarro in 1943 [2], and several variations of the postage stamp methods were presented later. In 1958, * Corresponding author. Tel.: +886-7-3208176; fax: +886-73111482.
Meek reported successful microdermagrafting using the Meek±Wall dermatome and prefolded gauzes to achieve regularly distributed autograft skin islands [3]. In 1966, Vandeput used micropore surgical type and meshgraft dermatome to create doubly expanded ultrapostage stamp skin grafts [4]. However, the postage stamp methods became eclipsed by the introduction of mesh skin grafts. Until 1993, Kreis utilized the modi®ed Meek±Wall dermatome, the prefolded gauzes and the cork cutting squares to create ninefold expanded autograft skin islands [5]. In clinical practice, the modi®ed Meek technique is a practical and reliable method for the management of extensive burn patients [6]. Unfortunately, the large expense of the modi®ed Meek±Well dermatome and the price of the prefolded gauzes and cork cutting squares may prevent the modi®ed Meek technique from being widely used. In fact, designing an ecient and simple expansion
0305-4179/00/$20.00 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 0 ) 0 0 0 5 0 - 4
742
S.-S. Lee et al. / Burns 26 (2000) 741±749
method under conditions of donor site shortage is still a problem in the clinical setting. In the last 2 years, ten extensive burn patients have been treated with the modi®ed Meek technique autografting at Kaohsiung Medical University Hospital (KMUH). The advantages of this method are highly impressive, but the expense of the materials used in the modi®ed Meek technique, such as the prefolded gauzes and cork squares, limits the application of this method. In this series, a modi®ed expansion technique for postage stamp skin grafting is presented. This method can create regularly distributed and correctly oriented postage stamp autograft skin islands. The expansion ratio can reach a practical ratio up to 1:9 (Fig. 1). The preliminary experience of this technique is presented.
2. Materials and methods Specially designed ``quick cutting plates'' with numerous parallel trenches were made by the manufacturer [Fig. 2(a)]. The distance between each of the trenches was 5 mm. The quick cutting plates were designed to hold the split thickness skin graft (STSG) tightly for accurate cutting.Two stainless steel trays marked with a chessboard diagram were prepared. One was marked with 1 cm 1 cm squares, and the other was marked with 0.5 cm 0.5 cm squares. The STSG harvesting procedure was performed in the usual way. The scalp was the principal donor site for managing extensive burns in our practice. One plastic dermacarrier was used as the cutting board. The STSG was put on the plastic dermacarrier with the dermal side downward, and the dermacarrier was hold by the quick cutting plates for further management. A wheel knife was used to cut the STSG along the trenches of the quick cutting plate, then the dermacarrier was turned 90 degrees for a second cutting procedure. The STSG was cut into 1 cm 1 cm squares or 0.5 cm 0.5 cm squares in a very few minutes [Fig. 2(b)]. About 10 c.c. normal saline was sprayed on the stainless tray to maintain the moisture of the STSG so these skin squares would not curl up. Forceps were used to slip the STSG squares individually into the proper position on the chessboard diagram. These skin squares could then be slipped back and forth smoothly and rapidly by forceps [Fig. 2(c)]. Dierent expansion ratios could easily be achieved according to the chessboard marking. When the positioning procedure was completed, a piece of petrolatum gauze was applied onto the stainless steel tray for covering these skin islands. All of the postage stamp skin islands adhered to the petrolatum gauze. Then, the gauze was gently picked up. These postage stamp skin islands were all uniformly located and correctly oriented on the gauze [Fig. 2(d)±(f)]. This ``postage stamp autograft carrier'' was then ready for the recipient sites with the desired expansion ratio. Skin staples were used to ®x the petrolatum gauzes on the wound. 3. Result
Fig. 1. According to the chessboard marking, we can easily achieve 1:4, 1:6 and 1:9 expansion ratio. Also, the largest distance between these skin islands can be predicted.
One 44 year old female patient who had suerred ¯ame burn with second to third degree burns on a 78% total burn surface area (TBSA) received the modi®ed postage stamp skin autografting (Table 1). The autografting operation for 18% of the TBSA wound took about 3 h to complete. Half of the time was spent in harvesting and washing the scalp STSG. This technique took about 10 min to cover 2% of the TBSA wound with 0.5 mm 0.5 mm skin squares at a
S.-S. Lee et al. / Burns 26 (2000) 741±749
743
Fig. 2. (a) The quick cutting plates with multiple parallel trenches. The STSG on the dermacarrier can be put into the quick cutting plates for further management. (b) The STSG after vertical and tranverse cutting. (c) 1 cm 1 cm squares were arranged on the chessboard tray with a 1:4 expansion ratio. (d) The skin squares adhere to the petrolatum gauze with regular distribution and correct orientation. (e) 0.5 cm 0.5 cm squares were arranged on the chessboard tray with a 1:9 expansion ratio. (f) 0.5 cm 0.5 cm squares were distributed on the petrolatum gauze with a 1:4 expansion ratio.
1:9 expansion ratio. These skin grafts were assessed on the ®fth day after the procedure, and the postage stamp skin islands had taken well to the burn wound. These autografts were observed for marginal epithelial creeping and con¯uence (Fig. 3).
4. Discussion In extensive burn patients, great amounts of grafting
material are needed, but the donor site is comparatively limited. Utilizing the limited donor skin with an ecient expansion method is a major challenge for surgeons. Postage stamp autograft was ®rst introduced in 1943 by Gabarro [2]. In the original postage stamp method, the irregularly distributed skin graft prolonged healing time. Also, the expansion ratio was not predictable. These technical problems and the labor intensive procedures frustrated surgeons. The mesh technique is convenient and used world
744
S.-S. Lee et al. / Burns 26 (2000) 741±749
Fig. 2 (continued)
S.-S. Lee et al. / Burns 26 (2000) 741±749
745
Fig. 2 (continued)
wide, but the limited expansion ratio makes it unsuitable for extensive burn patients. The microskin technique is excellent, and can provide a greater than 1:10 expansion ratio, but the results of microskin autografting depend on the experience and skill of the operator
[7,8]. The CEA can provide sucient skin for the extensive burn patient [9], but the CEA takes 3 weeks to create the sheet graft and this technique is not always available in every country. The modi®ed Meek technique is a practical method
746
S.-S. Lee et al. / Burns 26 (2000) 741±749
Fig. 3. (a) A 44 year old female patient with two to third degree ¯ame burns, with a burn area of 78% TBSA. (b) Modi®ed postage stamp autograft was performed with 0.5 cm 0.5 cm skin squares. (c) On the 28th day of follow up, we ®nd marginal epithelial creeping of these skin squares. (d) 47th day post-operation follow up of the chest burn wound.
S.-S. Lee et al. / Burns 26 (2000) 741±749
747
Fig. 3 (continued)
in management of extensive burn patients. The regularly distributed and correctly oriented skin islands are able to achieve primary wound coverage with limited donor skin. The greatest expansion ratio is 1:9. This technique provides sucient expansion ratio, enabling surgeons to graft patients with burns of up to 75% TBSA using only one donor site, without the necessity of CEA [5]. Furthermore, the modi®ed postage stamp preparation method also can create regularly distributed and correctly oriented skin islands on petrolatum
gauze instead of using the expensive materials and equipment of the modi®ed Meek technique (Table 2). Also, the ``postage stamp autograft carrier'' can be used to cover the burn wound just like the modi®ed Meek gauze. The time for the con¯uence of the wound depends on the size of the skin squares and the expansion ratio. The speed of the marginal epithelial creeping of these skin islands is in proportion to the summational edge length of the skin grafts. According to the chess-
748
S.-S. Lee et al. / Burns 26 (2000) 741±749
Table 1 Modi®ed postage stamp autograft of the patient Receipt site
Donor site
TBSA
Skin squares
Left leg
Scalp
18%
1 cm 1 cm
Left arm Left hand
Back
8% 1%
Chest Abdomen
Scalp
7% 11%
Expansion ratio
Operation time (h)
Wound healing time (days)
1:4
2.8
29
5 mm 5 mm 5 mm 5 mm
1:9 1:4
1.5
27 22
5 mm 5 mm 5 mm 5 mm
1:4 1:9
3.0
24 32
Table 2 Comparison of the widely expanded autograft technique Method Practical expansion ratio Average operation time for 1:9 expansion 18% TBSA autograftinga Postoperative care
Modi®ed postage stamp autograft
Modi®ed Meek technique Microskin technique [7]
1:9 3 h (for 5 mm skin squares)
1:9 3h
1:10 5h
Simply change dressing daily
Simply change dressing daily High
Complicate procedure Low
Cost
Low
a P.S.: (1) working sta limited to two doctors and one nurse for each operation; (2) according to the anesthesia records of the patients at KMUH.
board diagram, the largest distance between those skin islands is the diagonal. So, a small size of skin squares is preferred to give a shorter diagonal. With the assistance of the quick cutting plates, the STSG can be cut into 5 mm 5 mm small skin squares easily and quickly. The 5 mm 5 mm skin squares are arranged in a 1:9 expansion ratio. The largest distance between these skin islands is about 14.1 mm (Fig. 1). Again, the 5 mm 5 mm skin squares are arranged in a 1:4 expansion ratio. The largest distance between these skin islands will be reduced to 7 mm. The chessboard diagram expansion method provides a realistic expansion rate. The distances between skin islands can be predicted from the diering skin square sizes and various expansion ratios. The disadvantages of the conventional postage stamp skin graft method are: (1) more sta and greater attention are needed to cut and apply the postage stamp skin grafts to the wound, (2) the skin squares are apt to curl up during the management, (3) it is dif®cult to apply the small squares of skin to the bottom side of the extremities, and (4) the expansion ratio is dicult to predict. However, the modi®ed postage stamp preparing technique can overcome these shortcomings. First, the STSG can be cut into small squares in a few minutes. Second, the forceps are used to slip the skin squares over the water-containing stainless steel tray. Third, petrolatum gauzes are used as the carriers of the postage stamp skin grafts. The gauzes
can be applied to the bottom side of the extremities and easily ®xed with skin staples. Fourth, regular distribution and proper expansion ratio can be easily made by means of the chessboard diagram. And ®nally, the cost for this technique is relatively low. The equipment for the modi®ed Meek technique is expensive, and the prefolded gauzes and the cork cutting squares are high priced, too. On the other hand, the modi®ed postage stamp preparation technique does not need expensive equipment. The stainless steel trays can be found in every operating room, and petrolatum gauzes are readily available. The modi®ed postage stamp preparing technique has proven to be a practical and reliable method in dealing with extensive burn wounds. Our preliminary experience suggests that the results are comparable to those obtained with the modi®ed Meek technique. The modi®ed postage stamp preparation technique has become our alternative choice in the treatment of extensive burn patients.
References [1] Yang CC, Shih TS, Xu WS. A Chinese concept of treatment of extensive third-degree burns. Plast Resconstr Surg 1982;70:238± 52. [2] Gabarro P. A new method of grafting. BMJ 1943;1:723±4. [3] Meek CP. Successful microdermagrafting using the Meek±Wall microdermatome. Am J Surg 1958;96:557±8.
S.-S. Lee et al. / Burns 26 (2000) 741±749 [4] Vandeput J, Tanner JC, Carlisle JD. The ultra postage stamp skin graft. Plast Reconstr Surg 1966;38:252±4. [5] Kreis RW, Mackie DP, Hermans RP, et al. Expansion techniques for skin graft: comparison between mesh and Meek island (sandwich-) grafts. Burns 1994;20:1(Suppl):S39±S42. [6] Ra T, Hartmann B, Wagner H, et al. Experience with the modi®ed Meek technique. Acta Chirurgiae Plasticae 1996;38:142±6.
749
[7] Lin SD, Lai CS, Chou CK, et al. Microskin autografting with pigskin xenograft overlay: a preliminary report of studies on patients. Burns 1992;18:321±5. [8] Lai CS, Lin SD, Tsai CC, et al. An easy way to prepare microskin grafts. Burns 1994;20:151±3. [9] Paddle-Ledinek JE, Cruickshank DG, Masterton JP. Skin replacement by cultured keratinocyte grafts: an Australian experience. Burns 1997;23:204±11.
www.elsevier.com/locate/burns
An easy method for preparation of postage stamp autografts Su-Shin Lee a, Chih-Cheng Tsai a,*, Chung-Sheng Lai b, Sin-Daw Lin a a
Division of Plastic and Reconstructive Surgery, Department of Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan b Department of Surgery, Kaoshiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan Accepted 14 February 2000
Abstract A modi®ed technique of postage stamp autografting is studied. By using quick cutting plates, chessboard tray, skiing technique and petrolatum gauze, skin islands can be uniformly located and correctly oriented on the gauze. Moving the skin squares on the stainless steel tray is relatively easy, and the expansion ratio can be predicted by means of the chessboard diagram. The skin island grafts adhere to the petrolatum gauze when the gauze is applied to the tray. Then, as in the modi®ed Meek technique, the ``autografting carrier'' can be used to cover the burn wound. In comparison with the modi®ed Meek technique, this method does not require expensive equipment. The quick cutting plates can take over the function of the modi®ed Meek±Wall dermatome. The stainless steel trays and the petrolatum gauze are easily available. The advantages of this method include: (1) the expansion ratio can reach up to 1:9, (2) the preparation procedures are not time consuming, (3) regular distribution of these skin islands shortens the healing time, and (4) the cost of this method is relative low. The results of this technique are comparable to that of the modi®ed Meek technique. This preliminary study reveals that this technique is an easy and economic alternative for the treatment of extensive burn patients. 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Postage stamp autograft; Modi®ed Meek technique; Extensive burns
1. Introduction Several methods of skin grafting have been used to treat extensive burns with limited autologous donor skin. Up to the present time, the gold standard for management of extensive burns has been early excision, temporary allografting and ®nal autografting [1]. Although some arti®cial dermis and cultured epithelial autografts (CEA) have been presented for burn wound coverage, the ideal replacement for the lost skin is autologous skin consisting of the epidermis and dermis. Postage stamp autograft was ®rst described by Gabarro in 1943 [2], and several variations of the postage stamp methods were presented later. In 1958, * Corresponding author. Tel.: +886-7-3208176; fax: +886-73111482.
Meek reported successful microdermagrafting using the Meek±Wall dermatome and prefolded gauzes to achieve regularly distributed autograft skin islands [3]. In 1966, Vandeput used micropore surgical type and meshgraft dermatome to create doubly expanded ultrapostage stamp skin grafts [4]. However, the postage stamp methods became eclipsed by the introduction of mesh skin grafts. Until 1993, Kreis utilized the modi®ed Meek±Wall dermatome, the prefolded gauzes and the cork cutting squares to create ninefold expanded autograft skin islands [5]. In clinical practice, the modi®ed Meek technique is a practical and reliable method for the management of extensive burn patients [6]. Unfortunately, the large expense of the modi®ed Meek±Well dermatome and the price of the prefolded gauzes and cork cutting squares may prevent the modi®ed Meek technique from being widely used. In fact, designing an ecient and simple expansion
0305-4179/00/$20.00 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 0 ) 0 0 0 5 0 - 4
742
S.-S. Lee et al. / Burns 26 (2000) 741±749
method under conditions of donor site shortage is still a problem in the clinical setting. In the last 2 years, ten extensive burn patients have been treated with the modi®ed Meek technique autografting at Kaohsiung Medical University Hospital (KMUH). The advantages of this method are highly impressive, but the expense of the materials used in the modi®ed Meek technique, such as the prefolded gauzes and cork squares, limits the application of this method. In this series, a modi®ed expansion technique for postage stamp skin grafting is presented. This method can create regularly distributed and correctly oriented postage stamp autograft skin islands. The expansion ratio can reach a practical ratio up to 1:9 (Fig. 1). The preliminary experience of this technique is presented.
2. Materials and methods Specially designed ``quick cutting plates'' with numerous parallel trenches were made by the manufacturer [Fig. 2(a)]. The distance between each of the trenches was 5 mm. The quick cutting plates were designed to hold the split thickness skin graft (STSG) tightly for accurate cutting.Two stainless steel trays marked with a chessboard diagram were prepared. One was marked with 1 cm 1 cm squares, and the other was marked with 0.5 cm 0.5 cm squares. The STSG harvesting procedure was performed in the usual way. The scalp was the principal donor site for managing extensive burns in our practice. One plastic dermacarrier was used as the cutting board. The STSG was put on the plastic dermacarrier with the dermal side downward, and the dermacarrier was hold by the quick cutting plates for further management. A wheel knife was used to cut the STSG along the trenches of the quick cutting plate, then the dermacarrier was turned 90 degrees for a second cutting procedure. The STSG was cut into 1 cm 1 cm squares or 0.5 cm 0.5 cm squares in a very few minutes [Fig. 2(b)]. About 10 c.c. normal saline was sprayed on the stainless tray to maintain the moisture of the STSG so these skin squares would not curl up. Forceps were used to slip the STSG squares individually into the proper position on the chessboard diagram. These skin squares could then be slipped back and forth smoothly and rapidly by forceps [Fig. 2(c)]. Dierent expansion ratios could easily be achieved according to the chessboard marking. When the positioning procedure was completed, a piece of petrolatum gauze was applied onto the stainless steel tray for covering these skin islands. All of the postage stamp skin islands adhered to the petrolatum gauze. Then, the gauze was gently picked up. These postage stamp skin islands were all uniformly located and correctly oriented on the gauze [Fig. 2(d)±(f)]. This ``postage stamp autograft carrier'' was then ready for the recipient sites with the desired expansion ratio. Skin staples were used to ®x the petrolatum gauzes on the wound. 3. Result
Fig. 1. According to the chessboard marking, we can easily achieve 1:4, 1:6 and 1:9 expansion ratio. Also, the largest distance between these skin islands can be predicted.
One 44 year old female patient who had suerred ¯ame burn with second to third degree burns on a 78% total burn surface area (TBSA) received the modi®ed postage stamp skin autografting (Table 1). The autografting operation for 18% of the TBSA wound took about 3 h to complete. Half of the time was spent in harvesting and washing the scalp STSG. This technique took about 10 min to cover 2% of the TBSA wound with 0.5 mm 0.5 mm skin squares at a
S.-S. Lee et al. / Burns 26 (2000) 741±749
743
Fig. 2. (a) The quick cutting plates with multiple parallel trenches. The STSG on the dermacarrier can be put into the quick cutting plates for further management. (b) The STSG after vertical and tranverse cutting. (c) 1 cm 1 cm squares were arranged on the chessboard tray with a 1:4 expansion ratio. (d) The skin squares adhere to the petrolatum gauze with regular distribution and correct orientation. (e) 0.5 cm 0.5 cm squares were arranged on the chessboard tray with a 1:9 expansion ratio. (f) 0.5 cm 0.5 cm squares were distributed on the petrolatum gauze with a 1:4 expansion ratio.
1:9 expansion ratio. These skin grafts were assessed on the ®fth day after the procedure, and the postage stamp skin islands had taken well to the burn wound. These autografts were observed for marginal epithelial creeping and con¯uence (Fig. 3).
4. Discussion In extensive burn patients, great amounts of grafting
material are needed, but the donor site is comparatively limited. Utilizing the limited donor skin with an ecient expansion method is a major challenge for surgeons. Postage stamp autograft was ®rst introduced in 1943 by Gabarro [2]. In the original postage stamp method, the irregularly distributed skin graft prolonged healing time. Also, the expansion ratio was not predictable. These technical problems and the labor intensive procedures frustrated surgeons. The mesh technique is convenient and used world
744
S.-S. Lee et al. / Burns 26 (2000) 741±749
Fig. 2 (continued)
S.-S. Lee et al. / Burns 26 (2000) 741±749
745
Fig. 2 (continued)
wide, but the limited expansion ratio makes it unsuitable for extensive burn patients. The microskin technique is excellent, and can provide a greater than 1:10 expansion ratio, but the results of microskin autografting depend on the experience and skill of the operator
[7,8]. The CEA can provide sucient skin for the extensive burn patient [9], but the CEA takes 3 weeks to create the sheet graft and this technique is not always available in every country. The modi®ed Meek technique is a practical method
746
S.-S. Lee et al. / Burns 26 (2000) 741±749
Fig. 3. (a) A 44 year old female patient with two to third degree ¯ame burns, with a burn area of 78% TBSA. (b) Modi®ed postage stamp autograft was performed with 0.5 cm 0.5 cm skin squares. (c) On the 28th day of follow up, we ®nd marginal epithelial creeping of these skin squares. (d) 47th day post-operation follow up of the chest burn wound.
S.-S. Lee et al. / Burns 26 (2000) 741±749
747
Fig. 3 (continued)
in management of extensive burn patients. The regularly distributed and correctly oriented skin islands are able to achieve primary wound coverage with limited donor skin. The greatest expansion ratio is 1:9. This technique provides sucient expansion ratio, enabling surgeons to graft patients with burns of up to 75% TBSA using only one donor site, without the necessity of CEA [5]. Furthermore, the modi®ed postage stamp preparation method also can create regularly distributed and correctly oriented skin islands on petrolatum
gauze instead of using the expensive materials and equipment of the modi®ed Meek technique (Table 2). Also, the ``postage stamp autograft carrier'' can be used to cover the burn wound just like the modi®ed Meek gauze. The time for the con¯uence of the wound depends on the size of the skin squares and the expansion ratio. The speed of the marginal epithelial creeping of these skin islands is in proportion to the summational edge length of the skin grafts. According to the chess-
748
S.-S. Lee et al. / Burns 26 (2000) 741±749
Table 1 Modi®ed postage stamp autograft of the patient Receipt site
Donor site
TBSA
Skin squares
Left leg
Scalp
18%
1 cm 1 cm
Left arm Left hand
Back
8% 1%
Chest Abdomen
Scalp
7% 11%
Expansion ratio
Operation time (h)
Wound healing time (days)
1:4
2.8
29
5 mm 5 mm 5 mm 5 mm
1:9 1:4
1.5
27 22
5 mm 5 mm 5 mm 5 mm
1:4 1:9
3.0
24 32
Table 2 Comparison of the widely expanded autograft technique Method Practical expansion ratio Average operation time for 1:9 expansion 18% TBSA autograftinga Postoperative care
Modi®ed postage stamp autograft
Modi®ed Meek technique Microskin technique [7]
1:9 3 h (for 5 mm skin squares)
1:9 3h
1:10 5h
Simply change dressing daily
Simply change dressing daily High
Complicate procedure Low
Cost
Low
a P.S.: (1) working sta limited to two doctors and one nurse for each operation; (2) according to the anesthesia records of the patients at KMUH.
board diagram, the largest distance between those skin islands is the diagonal. So, a small size of skin squares is preferred to give a shorter diagonal. With the assistance of the quick cutting plates, the STSG can be cut into 5 mm 5 mm small skin squares easily and quickly. The 5 mm 5 mm skin squares are arranged in a 1:9 expansion ratio. The largest distance between these skin islands is about 14.1 mm (Fig. 1). Again, the 5 mm 5 mm skin squares are arranged in a 1:4 expansion ratio. The largest distance between these skin islands will be reduced to 7 mm. The chessboard diagram expansion method provides a realistic expansion rate. The distances between skin islands can be predicted from the diering skin square sizes and various expansion ratios. The disadvantages of the conventional postage stamp skin graft method are: (1) more sta and greater attention are needed to cut and apply the postage stamp skin grafts to the wound, (2) the skin squares are apt to curl up during the management, (3) it is dif®cult to apply the small squares of skin to the bottom side of the extremities, and (4) the expansion ratio is dicult to predict. However, the modi®ed postage stamp preparing technique can overcome these shortcomings. First, the STSG can be cut into small squares in a few minutes. Second, the forceps are used to slip the skin squares over the water-containing stainless steel tray. Third, petrolatum gauzes are used as the carriers of the postage stamp skin grafts. The gauzes
can be applied to the bottom side of the extremities and easily ®xed with skin staples. Fourth, regular distribution and proper expansion ratio can be easily made by means of the chessboard diagram. And ®nally, the cost for this technique is relatively low. The equipment for the modi®ed Meek technique is expensive, and the prefolded gauzes and the cork cutting squares are high priced, too. On the other hand, the modi®ed postage stamp preparation technique does not need expensive equipment. The stainless steel trays can be found in every operating room, and petrolatum gauzes are readily available. The modi®ed postage stamp preparing technique has proven to be a practical and reliable method in dealing with extensive burn wounds. Our preliminary experience suggests that the results are comparable to those obtained with the modi®ed Meek technique. The modi®ed postage stamp preparation technique has become our alternative choice in the treatment of extensive burn patients.
References [1] Yang CC, Shih TS, Xu WS. A Chinese concept of treatment of extensive third-degree burns. Plast Resconstr Surg 1982;70:238± 52. [2] Gabarro P. A new method of grafting. BMJ 1943;1:723±4. [3] Meek CP. Successful microdermagrafting using the Meek±Wall microdermatome. Am J Surg 1958;96:557±8.
S.-S. Lee et al. / Burns 26 (2000) 741±749 [4] Vandeput J, Tanner JC, Carlisle JD. The ultra postage stamp skin graft. Plast Reconstr Surg 1966;38:252±4. [5] Kreis RW, Mackie DP, Hermans RP, et al. Expansion techniques for skin graft: comparison between mesh and Meek island (sandwich-) grafts. Burns 1994;20:1(Suppl):S39±S42. [6] Ra T, Hartmann B, Wagner H, et al. Experience with the modi®ed Meek technique. Acta Chirurgiae Plasticae 1996;38:142±6.
749
[7] Lin SD, Lai CS, Chou CK, et al. Microskin autografting with pigskin xenograft overlay: a preliminary report of studies on patients. Burns 1992;18:321±5. [8] Lai CS, Lin SD, Tsai CC, et al. An easy way to prepare microskin grafts. Burns 1994;20:151±3. [9] Paddle-Ledinek JE, Cruickshank DG, Masterton JP. Skin replacement by cultured keratinocyte grafts: an Australian experience. Burns 1997;23:204±11.