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Operative treatment of deep burns of the scalp and skull
220
Bums (1992) 18,(3), 220-223 Printedin Great Britain
Operative and skull
treatment of deep burns of the scalp
I. P. Bizhko and S. V. Slesarenko Dnepropetrovsk
Medical Institute,
General Surgical Department
Traditional surgical freafmenf of deep burns of the scalp and skull involve the excision of necroticbone and soft fissureswith frephanafion of the bone to permit g-ranulafion tissue formation and subsequent graffing. This approach prolongs wound fime, a&s aAditiona1 trauma and, even affer initial healing, necessifafessecondary soff fissue and bone recondruction. The treatment desm’bed here is an alternate and more aggressive one involving early excision of necrotic soft fissue wifhouf bone resection followed by immediate coverage with well-vascularized axial +ps from adjacent intact scalp. This method provides an opfimal environment for healing and regeneration of areas of de&u&on to the sktrll. This surgkal method was used in the freafment of .U patients with deep bums of the scalp with satisfactory clinical results. Bone regeneration wlls confirmed by roenfgenological investigations.
Introduction Deep burns of the scalp and skull are most often caused by high tension electrical injuries as well as prolonged exposure to flame, liquid or heat sources (Arev, 1966; Caldwell, 1978; Vikhriev and Burmistrov, 1986). Such injuries not only involve deep bums of the soft tissues of the scalp but also injury to the underlying skull which in severe cases may produce charring and carbonization of the skull. Skull involvement has been reported in 30 per cent of deep scalp bums (Vikhriev et al., 1985). Traditional methods of treating such injuries have involved the active debridement of all necrotic tissues (both soft tissue and bone) with trephanation of the remaining bone to stimulate granulation tissue formation which can be subsequently skin grafted. This method has been in use at the Dnepropetrovsk Regional Burn Center for many years but has been found to have several disadvantages, including additional trauma, prolonged healing and the necessity for later soft-tissue and skull reconstruction. For these reasons we adopted an alternative, more aggressive approach to these difficult burns involving excision of necrotic soft tissues only and immediate coverage with blood-bearing adjacent scalp flaps in order to permit bone healing and regeneration. We report our experiences with the use of this technique over the past 5 years at our Centre and compare the results of this treatment with the results obtained using the traditional method in a previous group of patients. 0 1992Butterworth-Heinema 0305-4179/92/03022&04
Ltd
and Regional Burn Center, Dnepropetrovsk,
Ukraine
Patients and methods Group 1 During the years 1985-1990 we have treated 22 patients with deep scalp burns with soft-tissue excision and immediate flap coverage. There were 21 males and one female in our series with ages ranging from 8 to 57 years. Twenty patients received high voltage electrical injuries, usually while at work, which caused upper and lower extremity damage as well as scalp injuries. This group of patients was treated as follows. All devitalized and necrotic soft tissue was excised leaving the exposed bone which was mechanically cleaned with 0.5 per cent chlorhexidine solution. Following cleaning, the defect was covered with a well-vascularized, full thickness flap of adjacent scalp tissue. Depending on the shape and size of the wound, one, two or three flaps were used, each with at least one nourishing vessel in its base. The nourishing vessels were the parietalis, occipital, auriculares anterior or auriculares posterior artery depending on the location of the defect. The presence of such vessels ensure excellent vascularization and permit transfer of large flaps immediately without fear of circulatory insufficiency. Flap donor areas were covered with split thickness autografts after adequate haemostasis and compressed against the underlying scalp aponeurosis by means of a knitted net bandage to assure good graft healing. After initial healing, roentgenograms were taken of the skull every 3 months for a year and then twice yearly thereafter until bone healing was complete. Group 2 The second group, the comparison group of 32 patients, were treated between 1979 and 1985 using the traditional method of necrotic tissue excision, bone trephanation and skin grafting on the resulting granulations.
Results In the first group of patients, soft-tissue and flap coverage was performed between 3 and 47 days after injury, with the average being day 13 post injury. The procedure was carried out as soon as possible, when the general condition of the
Bizhko and Slesarenko: Operative treatment of deep bums of the scalp and skull
221
Figure l.a, The scalp wound showing underlying skull which was dark yellow-brown in colour with absent periosteum. The surrounding wound edges showed partial necrosis and purulent discharge. b, The soft areas of the wound had been excised and the bone covered with two axial flaps. Skin grafts were applied to the flap donor sites.
Figure 2.a, X-ray showing some osteoporosis in the area of injury. b, X-ray examination skull and some osteoporosis at the site of injury.
permitted. In 16 patients, flaps were used with a single axial artery nourishing the flap, while in the other patients at least two arteries were included in the base. The size of the defect covered varied between 16 and 180 cm’. The patients in this group had uncomplicated courses and were discharged, on average, on day 40 post hospitalization. The patients were followed for the next 2 years with clinical and roentgenological examinations of the skull as described. Clinically, the flaps and grafts were found to remain in good condition. In some patients, the cosmetic deformities due to graft alopecia were repaired with standard reconstructive techniques or covered with a wig (Buhrer et al., 1988; Pekarski et al., 1988). On X-ray, no sequestrums or progressive bone destruction were observed, which was borne out be repeated clinical examination. In most patients, bone regeneration was observed in involved areas which showed some persistent osteoporosis.
patient
Case report A single case illustrates the use of this technique. Patient D, a o-year-old boy, was admitted to the Bum Centre 40 days after a high tension injury due to contact with a wire carrying 6000 volts.
of the skull 1 year after injury showing an intact
He had deep injuries of the scalp and hands. On admission, his general state was satisfactory although he complained of pain in the bums of the scalp and hands. The wound of the scalp exposed the underlying skull which was dark yellow-brown in colour with absent periosteum and surrounding wound edges which showed partial necrosis and purulent discharge (Figure la). On X-ray (Figure ,?a) there was some osteoporosis in the area of injury. On day 2 after admission, the soft-tissue areas of the wound were excised and the bone covered with two axial flaps with skin grafts to the flap donor sites (Fi.re lb). The patient had an uncomplicated course and was discharged on day 64 post hospitalization. At 1 year, he had been back in school for some time and his wounds were well healed (Figure 3). X-ray examination at that time showed an intact skull with some osteoporosis at the site of injury (Figurezb). The anatomical structure and functional integrity of his skull were intact.
In the second group of patients each patient had two operations: (1) excision of necrotic tissue and bone trephanation, performed on average on day 9 after injury; and (2) autogenous split-thickness skin grafts applied to the resulting granulations on average on day 38 post injury. Patients in this group were discharged on average 88 days after
222
Bums (1992) Vol. M/No.
3
Figure 3. a, b, Well healed wounds I year after injury.
injury. On follow-up, it was found that 55 per cent of the patients in the second group had local complications. Many presented with a spongy appearance of unstable scar and grafts with ulcerations due to minor trauma. Some of these patients required secondary coverage of unstable areas with adjacent scalp flaps. Six patients required skull reconstruction for defects secondary to excision of carbonized skull at the time of initial treatment.
Discussion Following deep bums and electrical injuries to the scalp and skull, the primary clinical problem is to remove the devitalized tissues as soon as possible and provide good, durable long-term coverage rapidly and safely. Small wounds of 0.5-1.0 cm2 will heal spontaneously. Somewhat larger bum defects of 2.0-3.0 cm2 can be excised and closed primarily (C&fee, 1981; Jurkiewicz and Hill, 1981). The treatment of more extensive injuries, especially those involving major scalp loss and carbonization of the skull, has been a point of discussion in the literature with no general agreement. Arev (1966) and Vikhriev et al. (1985) have recommended dressing the wound until full spontaneous separation of the soft tissues and bone occurred or operative excision of the necrotic scalp and skull. In the first case, they observed that it took 5-7 weeks for spontaneous separation of the soft tissues and as long as 6-12 months for spontaneous bone necrolysis and separation. Operations on the skull included excision of the outer table of the skull, full thickness skull excision or trephanation. All these methods depended on conservative management until granulations appear at which time autografting was carried out. Udenich and Grishkevich (1986) have recommended excision of necrotic scalp and skull as soon as the depth of destruction could be diagnosed. Some authors (Vikhriev et al., 1985; Povstyanoi and Kovalenko, 1988; Gusak et al., 1986) considered that grafts on granulations were entirely satisfactory, even though such skin cover may not be stable. Other authors (Vikhriev et al., 1985; Caffee, 1981; Malakhov et al., 1989) have recommended an aggressive approach to immediate coverage with either adjacent scalp flaps or free flaps from a distance with microvascular anastomoses - both methods which will provide a one-stage permanent repair and durable coverage. Full thickness excision of the skull with consequent exposure of the meninges was recommended to be limited to no more than X00-12Ocm’ (Arev, 1966;
Vikhriev and Burmistrov, 1988). Resection of more skull than this was considered risky because of the possibility of invasive infection in such widely exposed areas. In such cases, spontaneous separation or trephanation and grafting of granulations was recommended (Arev, 1966; Udenich and Grishkevich, 1986; Vikhriev and Burmistrov, 1986; Caffee, 1981), even though such patients required later bony skull reconstruction and flap coverage. This latter, traditional technique was used at our Bum Center until 1985, during which time we observed the following drawbacks to this method: and 1. Additional trauma was inflicted with trephanation destruction of the skull bone, especially in the case of radical skull excision and exposure .of the meninges. 2. There was a great risk of increasing the wound size and exposing the patient to the risk of invasive infection in the instances of large defects. 3. There was inadequate protection to the brain with large defects. 4. Skin grafts on granulations were cosmetically unsightly and unstable in the presence of even minor trauma. soft-tissue and bony reconstruction was 5. Secondary necessary in many cases. As a result of this experience we decided in 1985 to adopt a more aggressive approach to patients with deep bums of the scalp and skull. Since that time we have treated such patients with soft-tissue excision and immediate adjacent scalp flap coverage - a procedure described by several authors (Vikhriev et al., 1985; Littmana, 1982; Povstyanoi and Kovalenko, 1988; Sevitt, 1986; Udenich and Grishkevich, 1986; Malakhov et al., 1989). The experience reported above confirms our belief that this approach (Group 1) is definitely super& to traditional forms of treatment (Group 2). Complications are avoided, as is the necessity for later reconstruction of soft tissue and skull. The successful treatment of the Group 1 patients without complications encouraged us as to the regenerative capacity of the skull in injured areas. At operative procedures, we simply cleaned the bones and made no attempt to remove devitalized bone, leaving it as autoplastic material as a source of specialized cells for the gradual replacement and autoregeneration of damaged skull beneath a wellvascularized flap. The excellent circulation of the flaps helped insure against infection in these areas.
Bizhko and Slesarenko: Operative treatment of deep bums of the scalp and skull
Conclusions Deep bums of the scalp and skull treated at the Dnepropetrovsk Regional Bum Center since 198.5 have been aggressively treated with early excision of necrotic soft tissues, cleansing of the underlying bone without bone resection and immediate coverage with well-vascularized adjacent scalp flaps. Results and postoperative course were superior in this group of patients compared to a group of patients previously treated with soft-tissue and bone excision, trephanation and grafting on resulting granulations. Immediate flap coverage of deep bum injuries to the scalp and skull has the advantages of decreased secondary operative trauma, promotion of maximal bone regeneration and shortening the time of hospitalization and treatment.
References Arev T. Y. (1966) Thermal Burns. Leningrad: Meditsina, 704 pp. Buhrer D. F., Huang T. T., Yee H. W. et al. (1988) Treatment of bum alopecia with tissue expanders in children. Plast. Reconstr. Scrrg. 81, 512. Caffee H. H. (1981) Scalp and skull reconstruction after electrical bum. 1. Trauma 20, 87. Caldwell F. (1978) Management of full thickness thermal injuries to scalp, skull and dura. In: Transactions of fhe 5fh lnfemafional Burn Congress, Stockholm, p. 93. Gusak B. K., Pisaichuk B. C., Fistal E. Y. et al. (1986) Free transplantation of skin-fat-muscle flaps for electrical bums. C/in. Chir. 3, 70.
223
Jurkiewicz M. J. and Hill H. L. (1981) Open wounds of the scalp an account of methods of repair. 1. Trauma 21, 769. Littmana I. (1982) Operafive Surgery, 2nd edn. Budapest: Iz-Vo Academic Scientia Hungarica, 1175 pp. (in Russian). Malakhov S. F., Vikhriev B. S. and Kichemasov S. K. (1989) Axial flap plasty to deep bums and their consequences. Poster, 3rd Congress of the European Bums Association, Prague, 4-7 October. Pekarski D. E., Grigoreva T. G. and Oleinyk G. E. (1988) Dermotension techniques in reconstructive bum surgery. Klin. I&r. (3), 17. Povstyanoi N. E. and Kovalenko 0. N. (1988) Tactics and outcomes of treatment of post-traumatic soft tissue defects with exposed bone. Clin. Chir. 3, 14-16. Sevitt S. (1986) Treatment of bums of the skull. In: Transactions of the 2nd National Confwence OHBums and Reconstrucfion, Sophia, Bulgaria, p. 41. Udenich B. B. and Grishkevich B. M. (1986) Manual of Rehabilitation ofInjuties.Moscow: Meditsina, 368 pp. Vikhriev B. C. and Burmistrov M. (1986) Burns: A Manual for Practitioners, 2nd edn (also suppl.). Leningrad: Meditsina. 272 pp. Vikhriev B. S., Burmistrov V. M. and Belonogov L. I. (1985) Free skin-muscle reconstruction for deep full-thickness bums of the scalp and skull, Khirurgiia 5,~.
Paper accepted 5 November
1991.
Correspondence should be addressed to: Dr S. V. Slesarenko, Geroev av., 4/676, Dnepropetrovsk 320100, Ukraine.
The 6th European Course in Plastic Surgery Department of Plastic Surgery and Bums University Medical Center Ljubljana, Slovenia, 2X-26 September 1992 Topics to be covered in the course include aesthetic and reconstructive surgery, hand surgery, head and neck, breast, lower extremity reconstruction and microsurgery. The official language for the course will be English. The registration fee US$750 includes the costs of the social programme. Further information Surgery Ljubljana, 889.
from: Professor
& Burns, University Slovenia.
Z. M. Arnei,
Medical
Telephone:
Center
University
Ljubljana,
38 61 323 983;
Department
ZaloSka
38 61 316 898.
of Plastic
7, SLO-61000 Fax: 38 61 316
Bums (1992) 18,(3), 220-223 Printedin Great Britain
Operative and skull
treatment of deep burns of the scalp
I. P. Bizhko and S. V. Slesarenko Dnepropetrovsk
Medical Institute,
General Surgical Department
Traditional surgical freafmenf of deep burns of the scalp and skull involve the excision of necroticbone and soft fissureswith frephanafion of the bone to permit g-ranulafion tissue formation and subsequent graffing. This approach prolongs wound fime, a&s aAditiona1 trauma and, even affer initial healing, necessifafessecondary soff fissue and bone recondruction. The treatment desm’bed here is an alternate and more aggressive one involving early excision of necrotic soft fissue wifhouf bone resection followed by immediate coverage with well-vascularized axial +ps from adjacent intact scalp. This method provides an opfimal environment for healing and regeneration of areas of de&u&on to the sktrll. This surgkal method was used in the freafment of .U patients with deep bums of the scalp with satisfactory clinical results. Bone regeneration wlls confirmed by roenfgenological investigations.
Introduction Deep burns of the scalp and skull are most often caused by high tension electrical injuries as well as prolonged exposure to flame, liquid or heat sources (Arev, 1966; Caldwell, 1978; Vikhriev and Burmistrov, 1986). Such injuries not only involve deep bums of the soft tissues of the scalp but also injury to the underlying skull which in severe cases may produce charring and carbonization of the skull. Skull involvement has been reported in 30 per cent of deep scalp bums (Vikhriev et al., 1985). Traditional methods of treating such injuries have involved the active debridement of all necrotic tissues (both soft tissue and bone) with trephanation of the remaining bone to stimulate granulation tissue formation which can be subsequently skin grafted. This method has been in use at the Dnepropetrovsk Regional Burn Center for many years but has been found to have several disadvantages, including additional trauma, prolonged healing and the necessity for later soft-tissue and skull reconstruction. For these reasons we adopted an alternative, more aggressive approach to these difficult burns involving excision of necrotic soft tissues only and immediate coverage with blood-bearing adjacent scalp flaps in order to permit bone healing and regeneration. We report our experiences with the use of this technique over the past 5 years at our Centre and compare the results of this treatment with the results obtained using the traditional method in a previous group of patients. 0 1992Butterworth-Heinema 0305-4179/92/03022&04
Ltd
and Regional Burn Center, Dnepropetrovsk,
Ukraine
Patients and methods Group 1 During the years 1985-1990 we have treated 22 patients with deep scalp burns with soft-tissue excision and immediate flap coverage. There were 21 males and one female in our series with ages ranging from 8 to 57 years. Twenty patients received high voltage electrical injuries, usually while at work, which caused upper and lower extremity damage as well as scalp injuries. This group of patients was treated as follows. All devitalized and necrotic soft tissue was excised leaving the exposed bone which was mechanically cleaned with 0.5 per cent chlorhexidine solution. Following cleaning, the defect was covered with a well-vascularized, full thickness flap of adjacent scalp tissue. Depending on the shape and size of the wound, one, two or three flaps were used, each with at least one nourishing vessel in its base. The nourishing vessels were the parietalis, occipital, auriculares anterior or auriculares posterior artery depending on the location of the defect. The presence of such vessels ensure excellent vascularization and permit transfer of large flaps immediately without fear of circulatory insufficiency. Flap donor areas were covered with split thickness autografts after adequate haemostasis and compressed against the underlying scalp aponeurosis by means of a knitted net bandage to assure good graft healing. After initial healing, roentgenograms were taken of the skull every 3 months for a year and then twice yearly thereafter until bone healing was complete. Group 2 The second group, the comparison group of 32 patients, were treated between 1979 and 1985 using the traditional method of necrotic tissue excision, bone trephanation and skin grafting on the resulting granulations.
Results In the first group of patients, soft-tissue and flap coverage was performed between 3 and 47 days after injury, with the average being day 13 post injury. The procedure was carried out as soon as possible, when the general condition of the
Bizhko and Slesarenko: Operative treatment of deep bums of the scalp and skull
221
Figure l.a, The scalp wound showing underlying skull which was dark yellow-brown in colour with absent periosteum. The surrounding wound edges showed partial necrosis and purulent discharge. b, The soft areas of the wound had been excised and the bone covered with two axial flaps. Skin grafts were applied to the flap donor sites.
Figure 2.a, X-ray showing some osteoporosis in the area of injury. b, X-ray examination skull and some osteoporosis at the site of injury.
permitted. In 16 patients, flaps were used with a single axial artery nourishing the flap, while in the other patients at least two arteries were included in the base. The size of the defect covered varied between 16 and 180 cm’. The patients in this group had uncomplicated courses and were discharged, on average, on day 40 post hospitalization. The patients were followed for the next 2 years with clinical and roentgenological examinations of the skull as described. Clinically, the flaps and grafts were found to remain in good condition. In some patients, the cosmetic deformities due to graft alopecia were repaired with standard reconstructive techniques or covered with a wig (Buhrer et al., 1988; Pekarski et al., 1988). On X-ray, no sequestrums or progressive bone destruction were observed, which was borne out be repeated clinical examination. In most patients, bone regeneration was observed in involved areas which showed some persistent osteoporosis.
patient
Case report A single case illustrates the use of this technique. Patient D, a o-year-old boy, was admitted to the Bum Centre 40 days after a high tension injury due to contact with a wire carrying 6000 volts.
of the skull 1 year after injury showing an intact
He had deep injuries of the scalp and hands. On admission, his general state was satisfactory although he complained of pain in the bums of the scalp and hands. The wound of the scalp exposed the underlying skull which was dark yellow-brown in colour with absent periosteum and surrounding wound edges which showed partial necrosis and purulent discharge (Figure la). On X-ray (Figure ,?a) there was some osteoporosis in the area of injury. On day 2 after admission, the soft-tissue areas of the wound were excised and the bone covered with two axial flaps with skin grafts to the flap donor sites (Fi.re lb). The patient had an uncomplicated course and was discharged on day 64 post hospitalization. At 1 year, he had been back in school for some time and his wounds were well healed (Figure 3). X-ray examination at that time showed an intact skull with some osteoporosis at the site of injury (Figurezb). The anatomical structure and functional integrity of his skull were intact.
In the second group of patients each patient had two operations: (1) excision of necrotic tissue and bone trephanation, performed on average on day 9 after injury; and (2) autogenous split-thickness skin grafts applied to the resulting granulations on average on day 38 post injury. Patients in this group were discharged on average 88 days after
222
Bums (1992) Vol. M/No.
3
Figure 3. a, b, Well healed wounds I year after injury.
injury. On follow-up, it was found that 55 per cent of the patients in the second group had local complications. Many presented with a spongy appearance of unstable scar and grafts with ulcerations due to minor trauma. Some of these patients required secondary coverage of unstable areas with adjacent scalp flaps. Six patients required skull reconstruction for defects secondary to excision of carbonized skull at the time of initial treatment.
Discussion Following deep bums and electrical injuries to the scalp and skull, the primary clinical problem is to remove the devitalized tissues as soon as possible and provide good, durable long-term coverage rapidly and safely. Small wounds of 0.5-1.0 cm2 will heal spontaneously. Somewhat larger bum defects of 2.0-3.0 cm2 can be excised and closed primarily (C&fee, 1981; Jurkiewicz and Hill, 1981). The treatment of more extensive injuries, especially those involving major scalp loss and carbonization of the skull, has been a point of discussion in the literature with no general agreement. Arev (1966) and Vikhriev et al. (1985) have recommended dressing the wound until full spontaneous separation of the soft tissues and bone occurred or operative excision of the necrotic scalp and skull. In the first case, they observed that it took 5-7 weeks for spontaneous separation of the soft tissues and as long as 6-12 months for spontaneous bone necrolysis and separation. Operations on the skull included excision of the outer table of the skull, full thickness skull excision or trephanation. All these methods depended on conservative management until granulations appear at which time autografting was carried out. Udenich and Grishkevich (1986) have recommended excision of necrotic scalp and skull as soon as the depth of destruction could be diagnosed. Some authors (Vikhriev et al., 1985; Povstyanoi and Kovalenko, 1988; Gusak et al., 1986) considered that grafts on granulations were entirely satisfactory, even though such skin cover may not be stable. Other authors (Vikhriev et al., 1985; Caffee, 1981; Malakhov et al., 1989) have recommended an aggressive approach to immediate coverage with either adjacent scalp flaps or free flaps from a distance with microvascular anastomoses - both methods which will provide a one-stage permanent repair and durable coverage. Full thickness excision of the skull with consequent exposure of the meninges was recommended to be limited to no more than X00-12Ocm’ (Arev, 1966;
Vikhriev and Burmistrov, 1988). Resection of more skull than this was considered risky because of the possibility of invasive infection in such widely exposed areas. In such cases, spontaneous separation or trephanation and grafting of granulations was recommended (Arev, 1966; Udenich and Grishkevich, 1986; Vikhriev and Burmistrov, 1986; Caffee, 1981), even though such patients required later bony skull reconstruction and flap coverage. This latter, traditional technique was used at our Bum Center until 1985, during which time we observed the following drawbacks to this method: and 1. Additional trauma was inflicted with trephanation destruction of the skull bone, especially in the case of radical skull excision and exposure .of the meninges. 2. There was a great risk of increasing the wound size and exposing the patient to the risk of invasive infection in the instances of large defects. 3. There was inadequate protection to the brain with large defects. 4. Skin grafts on granulations were cosmetically unsightly and unstable in the presence of even minor trauma. soft-tissue and bony reconstruction was 5. Secondary necessary in many cases. As a result of this experience we decided in 1985 to adopt a more aggressive approach to patients with deep bums of the scalp and skull. Since that time we have treated such patients with soft-tissue excision and immediate adjacent scalp flap coverage - a procedure described by several authors (Vikhriev et al., 1985; Littmana, 1982; Povstyanoi and Kovalenko, 1988; Sevitt, 1986; Udenich and Grishkevich, 1986; Malakhov et al., 1989). The experience reported above confirms our belief that this approach (Group 1) is definitely super& to traditional forms of treatment (Group 2). Complications are avoided, as is the necessity for later reconstruction of soft tissue and skull. The successful treatment of the Group 1 patients without complications encouraged us as to the regenerative capacity of the skull in injured areas. At operative procedures, we simply cleaned the bones and made no attempt to remove devitalized bone, leaving it as autoplastic material as a source of specialized cells for the gradual replacement and autoregeneration of damaged skull beneath a wellvascularized flap. The excellent circulation of the flaps helped insure against infection in these areas.
Bizhko and Slesarenko: Operative treatment of deep bums of the scalp and skull
Conclusions Deep bums of the scalp and skull treated at the Dnepropetrovsk Regional Bum Center since 198.5 have been aggressively treated with early excision of necrotic soft tissues, cleansing of the underlying bone without bone resection and immediate coverage with well-vascularized adjacent scalp flaps. Results and postoperative course were superior in this group of patients compared to a group of patients previously treated with soft-tissue and bone excision, trephanation and grafting on resulting granulations. Immediate flap coverage of deep bum injuries to the scalp and skull has the advantages of decreased secondary operative trauma, promotion of maximal bone regeneration and shortening the time of hospitalization and treatment.
References Arev T. Y. (1966) Thermal Burns. Leningrad: Meditsina, 704 pp. Buhrer D. F., Huang T. T., Yee H. W. et al. (1988) Treatment of bum alopecia with tissue expanders in children. Plast. Reconstr. Scrrg. 81, 512. Caffee H. H. (1981) Scalp and skull reconstruction after electrical bum. 1. Trauma 20, 87. Caldwell F. (1978) Management of full thickness thermal injuries to scalp, skull and dura. In: Transactions of fhe 5fh lnfemafional Burn Congress, Stockholm, p. 93. Gusak B. K., Pisaichuk B. C., Fistal E. Y. et al. (1986) Free transplantation of skin-fat-muscle flaps for electrical bums. C/in. Chir. 3, 70.
223
Jurkiewicz M. J. and Hill H. L. (1981) Open wounds of the scalp an account of methods of repair. 1. Trauma 21, 769. Littmana I. (1982) Operafive Surgery, 2nd edn. Budapest: Iz-Vo Academic Scientia Hungarica, 1175 pp. (in Russian). Malakhov S. F., Vikhriev B. S. and Kichemasov S. K. (1989) Axial flap plasty to deep bums and their consequences. Poster, 3rd Congress of the European Bums Association, Prague, 4-7 October. Pekarski D. E., Grigoreva T. G. and Oleinyk G. E. (1988) Dermotension techniques in reconstructive bum surgery. Klin. I&r. (3), 17. Povstyanoi N. E. and Kovalenko 0. N. (1988) Tactics and outcomes of treatment of post-traumatic soft tissue defects with exposed bone. Clin. Chir. 3, 14-16. Sevitt S. (1986) Treatment of bums of the skull. In: Transactions of the 2nd National Confwence OHBums and Reconstrucfion, Sophia, Bulgaria, p. 41. Udenich B. B. and Grishkevich B. M. (1986) Manual of Rehabilitation ofInjuties.Moscow: Meditsina, 368 pp. Vikhriev B. C. and Burmistrov M. (1986) Burns: A Manual for Practitioners, 2nd edn (also suppl.). Leningrad: Meditsina. 272 pp. Vikhriev B. S., Burmistrov V. M. and Belonogov L. I. (1985) Free skin-muscle reconstruction for deep full-thickness bums of the scalp and skull, Khirurgiia 5,~.
Paper accepted 5 November
1991.
Correspondence should be addressed to: Dr S. V. Slesarenko, Geroev av., 4/676, Dnepropetrovsk 320100, Ukraine.
The 6th European Course in Plastic Surgery Department of Plastic Surgery and Bums University Medical Center Ljubljana, Slovenia, 2X-26 September 1992 Topics to be covered in the course include aesthetic and reconstructive surgery, hand surgery, head and neck, breast, lower extremity reconstruction and microsurgery. The official language for the course will be English. The registration fee US$750 includes the costs of the social programme. Further information Surgery Ljubljana, 889.
from: Professor
& Burns, University Slovenia.
Z. M. Arnei,
Medical
Telephone:
Center
University
Ljubljana,
38 61 323 983;
Department
ZaloSka
38 61 316 898.
of Plastic
7, SLO-61000 Fax: 38 61 316