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Some problems following tangential excision and skin grafting in dermal burns
96
Burns, 3, 96-99
Printed in Grert &item
Some problems following tangential excision and skin grafting in dermal burns Som N. Tandon Department of Plastic Surgery, The Christ Hospital, Cincinnati, Ohio
Anne B. Sutherland Consultant Plastic Surgeon, Sick Children’s Hospital, Edinburgh Summery
In the authors’ opinion, primary tangential excision and skin grafting offers an excellent approach for the treatment of deep dermal and some subdermal burns by reducing the morbidity (i.e. reducing the incidence of hypertrophic and keloid scar formation). Some of the local problems associated could be eliminated by adequate precautions. INTRODUCTION THE DERMAL burn is a problem both in treatment
and diagnosis. It may take several weeks to heal, perhaps requiring late skin grafting and often producing severe, irritable, hypertrophic scars. In the smaller injury, morbidity can be prolonged. Janzekovic (1968) suggested that, for this type of injury, early surgical removal of the involved skin by shaving and immediate skin cover improved the results. Jackson (1969, 1972) investigated the method in more detail, and with minor modifications, concluded that it had a definite and valuable place in treatment, but also emphasized its limitations. While our experience is still limited, this series presents some problems from the purely clinical aspect. MATERIAL AND METHOD Sixty patients are included with an age range of 9 months to 59 years. Only those with an injury involving 10 per cent or less of the body surface were treated in this way, and all were admitted primarily to our care. On admission an attempt was made to assess burn depth by three simple tests: (a) clinical appearance; (b) appreciation of pin-prick;
(c) capillary return, which is absent in deep dermal bums. If the diagnosis was of deep dermal injury, the area was cleansed and dressed with tulle gras and absorptive dressing, shaving and autogenous skin grafting being performed in 48-72 hours. If the burn appeared more superficial but still of doubtful depth, the initial care was the same but the dressing was left undisturbed for 7 days and a reassessment made at that time. In a few patients shaving and grafting was performed as late as the tenth day. The procedure, under general anaesthesia and without tourniquet, was carried out with a Watson knife, and tissue removed until punctate
Fig. 1. Exposure method of skin grafting in the hand using a plastazote splint. A reverse cock-up position provides maximum surface area for skin grafting.
Tandon and Sutherland : Tangential Excision bleeding was obtained. Following haemostasis with hot saline packs and pressure, immediate skin grafting was carried out. In the majority, the grafts were dressed, redressing being done at 5-7 days. In a few, the grafts were left exposed from the beginning (Fig. 1). Exposure was found to be most useful in the hand, allowing earlier movement.
RESULTS AND DISCUSSION In these smaller burns there seems little doubt that the period of in-patient care was reduced. Absolute figures and retrospective comparisons are not presented because of the many variables, not the least being accurate assessment of depth. It appeared, however, that many of the patients treated were ready for discharge at the time when, previously, treatment would only have reached the stage of preparing a’ surface for grafting (around 3 weeks post burn). Further, with more aggressive primary care, earlier movement was possible, especially in the burned hand where movement could be started about 5 days after the procedure. In those patients where the followup has been possible for a longer period, it does appear that the hypertrophic and irritable scars are seen less frequently. Some problems were encountered, both at the time of initial admission and at follow-up. So far, there has been no publication of problems of this technique. Hence this brief account is reported. Initial admission The early problems encountered
were as follows:
Depth of injury The lack of an easy, accurate method of assessing a deep dermal burn is a major problem. One may, therefore, use this method on an injury which would heal with conservative local care. On the other hand, if the deep dermal burn is not treated promptly, it may become a full-thickness burn. ‘In this series the diagnosis of deep dermal burn has been clinical and includes the following criteria: 1. Appearance of the burn. After cleaning and ddbridement, four types of clinical appearance have been noticed. The burn looks: 1. 2. 3. 4.
Dry and grey in colour or Dry and white in colour or Deep red in colour or Moist, pale with grey areas (delayed cases).
2. Pin-prick test. Analgesia in burns implies that the nerve endings, sensitive to pin-prick, are damaged. The pin-prick test is a usual adjunct in deciding the depth of the bum. Though this test
9:
is valuable, the blunting of sensation could also be due to the presence of tissue oedema. Moreover, sometimes it is difficult to interpret this sign accurately in young children. 3. Capillary return test. When the pressure of a fingertip over a burn area is released the circulation in the capillaries returns promptly in superficial burn, but the capillary return is absent in deep dermal burn, because of the coagulation of the blood vessels. Though a combination of these signs can be used in labelling a bum ‘deep dermal’, mistakes could still be made. Time to surgery The next problem was when to operate on these burns. When the surgery was performed at more than the fifth day post burn, the shaving of the burn, especially of hands and feet, was more difficult, mainly because the initial oedema, which gave support to the knife, was no longer present. Therefore, it has been a practice to arrange for early shaving and skin grafting. In addition, bacterial colonization is less frequently encountered up till this time. Haemostasis Control of oozing was tedious in many instances, perhaps because of the depth to which we have elected to shave. The wound was covered with a saline sponge and a skin graft was taken. On removal of the sponge, some oozing was invariably present. The application of the skin graft and some pressure arrested the bleeding. Small haematomas, if formed, were evacuated by making a few holes in the skin graft. We have not used a tourniquet as indicated by Janzekovic. At follow-up There were fairly frequent complications of an annoying but mostly impermanent nature. These minor problems have been designated as ‘doublelayered skin complications’. Cyst formation Cystic problems are more common following skin grafting at the mid-dermal level, probably because of abundant sebaceous glandular tissue (Fig. 2). Hence, these lesions are sebaceous cysts. Cyst formation below the graft was common, developing about 4 weeks after surgery and persisting in some for several months (8-9 months), varying in size from 2 to 20 mm. Their appearance is similar to inclusion cysts and they are caused by blockage of ducts of adnexal glands. These cysts either discharge spontaneously or, in more severe cases, requiresurgical derooting.
Burns Vol. ~/NO. 2
EPIDERMIS
SUPERFICIAL
DERMIS
DEEP DERMIS
SUBCUTANEOUS
FAT
Fig. 2. Diagrammatic representation of the various structures exposed after tangential excision at various
depths. As illustrated, a greater amount of adnexal glandular tissue becomes open at middermal level.
Fig. 4. Cyst formation and step at the junction of graft and normal skin. Note the multiple tiny cysts all over the skin graft.
Fig. 3 Shows the appearance of a skin graft after the cysts have opened up.
In addition, there were tiny cystic lesions, which, although they did not bother the patients, were unsightly. Eventually they cleared spontaneously (Figs. 3 and 4). The postoperative follow-up of tangential excision by skin graft and grafting of donor sites has a great deal in common. The following interesting conclusions have been reported from the histological study of grafted donor sites (Thompson, 1960). 1. The hair follicles mostly undergo epidermoid cyst formation and subsequently disintegrate, whether situated in the graft or the host dermis.
2. The sebaceous gland cells are present for up to six weeks. 3. The sweat glands persist as a functioning unit only if the continuity between the superficial and deep structures is reestablished. The remaining epithelial elements buried under the graft form microscopic epidermoid cysts, which undergo spontaneous dissolution in about a Year. The above findings have been observed in clinical follow-up of our patients. Stepping
at the graft margins
A step at the junction of the graft and adjacent normal skin was noted frequently (Fig. 4). It varied in a single area, being more obvious in some parts than others, perhaps because of
Tandon and Sutherland : Tangential Excision
a Fig. 5. a, This is a dermal bum of the forearm in a young lady. Tangential excision was followed by application
of dry gauze. Complete spontaneous healing occurred in 20 days. b, Three months after surgery. Note the smooth-scar with no hypertrophic scarring. _ differences in the depth of shaving or in the varying thickness of the skin graft. In an attempt to improve this appearance the edges of the shaved areas were incised and the graft then sutured edge to edge. Any advantage was doubtful, the junctional scars so produced being slow to settle. In several, the stepping of the graft improved spontaneously with time. Scar contracture Scar contracture of sufficient severity to require further surgery was seen in three patients. Other minor problems There were other minor problems. Some wrinkling and thickening of the graft occurred, but improved with time. Pin-head dark spots in the graft were seen occasionally. These had the appearance of inspissated secretions and were treated effectively by meticulous local cleansing. Skin tags, bridges and overhanging edges were noticed in some cases. In the beginning, perhaps, we applied somewhat thicker skin grafts, but since using thinner skin grafts, our results were not only superior cosmetically but were associated with fewer local complications. Hence we will recommend the use of thinner grafts following tangential excision.
CONCLUSIONS From the experience gained in this small series, there is little doubt in our own minds that this form of excision is a suitable method of treatment for the deep dermal burn. The removal of dead tissue lessens the chances of infection penetrating into the deeper layers of skin. It does appear to shorten the period of hospitalization
and morbidity. Selection of patients with inJury suitable for the method of treatment is at times difficult because of the lack of an accurate method of assessing the depth of bum. Little damage will be done if the bum is deeper, for, as pointed out by Jackson (1972), surgery can proceed to formal excision, but if the bum is more superficial the patient will have undergone needless surgery. Provided its limitations are appreciated, and its use restricted to this depth of injury, it does offer a good alternative method of care. At present this technique seems to be a practical method of early diagnosis of deep dermal burn until some better technique of assessment is discovered. It may be possible that some of these selected mid-dermal bums could be treated by shaving only and heal spontaneously, like a donor area. We have treated a few cases by this technique with excellent results (Fig. 5). After shaving, the wound was covered with dry gauze only and healed spontaneously by the twentieth day post bum. Later, we used lyophilized porcine dressing with similar success. Another alternative to autogenous skin grafts may be the use of synthetic materials such as Opsite, but we have no experience of this. REFERENCES
Jackson D. MacG. (1969) Second thoughts on the burn wound. J. Trauma 9, 839. Jackson D. MacG. (1972) Tangential excision and grafting of bums. Br. J. Pias. Surg. 25,416. Janzekovic Z. (1968) In: Derganz M. (cd.) Present Clinical Asp&s of Burns: a~Sympo&n. Maribor, C. P. Mariborskitisk. . DD. __ 99-215. Thompson N. (1960) The subcutaneous dermis graft. A clinical and histologic study in man, Plast. J. Reconstr. Surg. 26, 1.
Requests for reprints should be a&iressed to: Miss A. B. Sutherland. FRCS, Bangour General Hospital, Bmxbum, West Lathian, Scotland.
Burns, 3, 96-99
Printed in Grert &item
Some problems following tangential excision and skin grafting in dermal burns Som N. Tandon Department of Plastic Surgery, The Christ Hospital, Cincinnati, Ohio
Anne B. Sutherland Consultant Plastic Surgeon, Sick Children’s Hospital, Edinburgh Summery
In the authors’ opinion, primary tangential excision and skin grafting offers an excellent approach for the treatment of deep dermal and some subdermal burns by reducing the morbidity (i.e. reducing the incidence of hypertrophic and keloid scar formation). Some of the local problems associated could be eliminated by adequate precautions. INTRODUCTION THE DERMAL burn is a problem both in treatment
and diagnosis. It may take several weeks to heal, perhaps requiring late skin grafting and often producing severe, irritable, hypertrophic scars. In the smaller injury, morbidity can be prolonged. Janzekovic (1968) suggested that, for this type of injury, early surgical removal of the involved skin by shaving and immediate skin cover improved the results. Jackson (1969, 1972) investigated the method in more detail, and with minor modifications, concluded that it had a definite and valuable place in treatment, but also emphasized its limitations. While our experience is still limited, this series presents some problems from the purely clinical aspect. MATERIAL AND METHOD Sixty patients are included with an age range of 9 months to 59 years. Only those with an injury involving 10 per cent or less of the body surface were treated in this way, and all were admitted primarily to our care. On admission an attempt was made to assess burn depth by three simple tests: (a) clinical appearance; (b) appreciation of pin-prick;
(c) capillary return, which is absent in deep dermal bums. If the diagnosis was of deep dermal injury, the area was cleansed and dressed with tulle gras and absorptive dressing, shaving and autogenous skin grafting being performed in 48-72 hours. If the burn appeared more superficial but still of doubtful depth, the initial care was the same but the dressing was left undisturbed for 7 days and a reassessment made at that time. In a few patients shaving and grafting was performed as late as the tenth day. The procedure, under general anaesthesia and without tourniquet, was carried out with a Watson knife, and tissue removed until punctate
Fig. 1. Exposure method of skin grafting in the hand using a plastazote splint. A reverse cock-up position provides maximum surface area for skin grafting.
Tandon and Sutherland : Tangential Excision bleeding was obtained. Following haemostasis with hot saline packs and pressure, immediate skin grafting was carried out. In the majority, the grafts were dressed, redressing being done at 5-7 days. In a few, the grafts were left exposed from the beginning (Fig. 1). Exposure was found to be most useful in the hand, allowing earlier movement.
RESULTS AND DISCUSSION In these smaller burns there seems little doubt that the period of in-patient care was reduced. Absolute figures and retrospective comparisons are not presented because of the many variables, not the least being accurate assessment of depth. It appeared, however, that many of the patients treated were ready for discharge at the time when, previously, treatment would only have reached the stage of preparing a’ surface for grafting (around 3 weeks post burn). Further, with more aggressive primary care, earlier movement was possible, especially in the burned hand where movement could be started about 5 days after the procedure. In those patients where the followup has been possible for a longer period, it does appear that the hypertrophic and irritable scars are seen less frequently. Some problems were encountered, both at the time of initial admission and at follow-up. So far, there has been no publication of problems of this technique. Hence this brief account is reported. Initial admission The early problems encountered
were as follows:
Depth of injury The lack of an easy, accurate method of assessing a deep dermal burn is a major problem. One may, therefore, use this method on an injury which would heal with conservative local care. On the other hand, if the deep dermal burn is not treated promptly, it may become a full-thickness burn. ‘In this series the diagnosis of deep dermal burn has been clinical and includes the following criteria: 1. Appearance of the burn. After cleaning and ddbridement, four types of clinical appearance have been noticed. The burn looks: 1. 2. 3. 4.
Dry and grey in colour or Dry and white in colour or Deep red in colour or Moist, pale with grey areas (delayed cases).
2. Pin-prick test. Analgesia in burns implies that the nerve endings, sensitive to pin-prick, are damaged. The pin-prick test is a usual adjunct in deciding the depth of the bum. Though this test
9:
is valuable, the blunting of sensation could also be due to the presence of tissue oedema. Moreover, sometimes it is difficult to interpret this sign accurately in young children. 3. Capillary return test. When the pressure of a fingertip over a burn area is released the circulation in the capillaries returns promptly in superficial burn, but the capillary return is absent in deep dermal burn, because of the coagulation of the blood vessels. Though a combination of these signs can be used in labelling a bum ‘deep dermal’, mistakes could still be made. Time to surgery The next problem was when to operate on these burns. When the surgery was performed at more than the fifth day post burn, the shaving of the burn, especially of hands and feet, was more difficult, mainly because the initial oedema, which gave support to the knife, was no longer present. Therefore, it has been a practice to arrange for early shaving and skin grafting. In addition, bacterial colonization is less frequently encountered up till this time. Haemostasis Control of oozing was tedious in many instances, perhaps because of the depth to which we have elected to shave. The wound was covered with a saline sponge and a skin graft was taken. On removal of the sponge, some oozing was invariably present. The application of the skin graft and some pressure arrested the bleeding. Small haematomas, if formed, were evacuated by making a few holes in the skin graft. We have not used a tourniquet as indicated by Janzekovic. At follow-up There were fairly frequent complications of an annoying but mostly impermanent nature. These minor problems have been designated as ‘doublelayered skin complications’. Cyst formation Cystic problems are more common following skin grafting at the mid-dermal level, probably because of abundant sebaceous glandular tissue (Fig. 2). Hence, these lesions are sebaceous cysts. Cyst formation below the graft was common, developing about 4 weeks after surgery and persisting in some for several months (8-9 months), varying in size from 2 to 20 mm. Their appearance is similar to inclusion cysts and they are caused by blockage of ducts of adnexal glands. These cysts either discharge spontaneously or, in more severe cases, requiresurgical derooting.
Burns Vol. ~/NO. 2
EPIDERMIS
SUPERFICIAL
DERMIS
DEEP DERMIS
SUBCUTANEOUS
FAT
Fig. 2. Diagrammatic representation of the various structures exposed after tangential excision at various
depths. As illustrated, a greater amount of adnexal glandular tissue becomes open at middermal level.
Fig. 4. Cyst formation and step at the junction of graft and normal skin. Note the multiple tiny cysts all over the skin graft.
Fig. 3 Shows the appearance of a skin graft after the cysts have opened up.
In addition, there were tiny cystic lesions, which, although they did not bother the patients, were unsightly. Eventually they cleared spontaneously (Figs. 3 and 4). The postoperative follow-up of tangential excision by skin graft and grafting of donor sites has a great deal in common. The following interesting conclusions have been reported from the histological study of grafted donor sites (Thompson, 1960). 1. The hair follicles mostly undergo epidermoid cyst formation and subsequently disintegrate, whether situated in the graft or the host dermis.
2. The sebaceous gland cells are present for up to six weeks. 3. The sweat glands persist as a functioning unit only if the continuity between the superficial and deep structures is reestablished. The remaining epithelial elements buried under the graft form microscopic epidermoid cysts, which undergo spontaneous dissolution in about a Year. The above findings have been observed in clinical follow-up of our patients. Stepping
at the graft margins
A step at the junction of the graft and adjacent normal skin was noted frequently (Fig. 4). It varied in a single area, being more obvious in some parts than others, perhaps because of
Tandon and Sutherland : Tangential Excision
a Fig. 5. a, This is a dermal bum of the forearm in a young lady. Tangential excision was followed by application
of dry gauze. Complete spontaneous healing occurred in 20 days. b, Three months after surgery. Note the smooth-scar with no hypertrophic scarring. _ differences in the depth of shaving or in the varying thickness of the skin graft. In an attempt to improve this appearance the edges of the shaved areas were incised and the graft then sutured edge to edge. Any advantage was doubtful, the junctional scars so produced being slow to settle. In several, the stepping of the graft improved spontaneously with time. Scar contracture Scar contracture of sufficient severity to require further surgery was seen in three patients. Other minor problems There were other minor problems. Some wrinkling and thickening of the graft occurred, but improved with time. Pin-head dark spots in the graft were seen occasionally. These had the appearance of inspissated secretions and were treated effectively by meticulous local cleansing. Skin tags, bridges and overhanging edges were noticed in some cases. In the beginning, perhaps, we applied somewhat thicker skin grafts, but since using thinner skin grafts, our results were not only superior cosmetically but were associated with fewer local complications. Hence we will recommend the use of thinner grafts following tangential excision.
CONCLUSIONS From the experience gained in this small series, there is little doubt in our own minds that this form of excision is a suitable method of treatment for the deep dermal burn. The removal of dead tissue lessens the chances of infection penetrating into the deeper layers of skin. It does appear to shorten the period of hospitalization
and morbidity. Selection of patients with inJury suitable for the method of treatment is at times difficult because of the lack of an accurate method of assessing the depth of bum. Little damage will be done if the bum is deeper, for, as pointed out by Jackson (1972), surgery can proceed to formal excision, but if the bum is more superficial the patient will have undergone needless surgery. Provided its limitations are appreciated, and its use restricted to this depth of injury, it does offer a good alternative method of care. At present this technique seems to be a practical method of early diagnosis of deep dermal burn until some better technique of assessment is discovered. It may be possible that some of these selected mid-dermal bums could be treated by shaving only and heal spontaneously, like a donor area. We have treated a few cases by this technique with excellent results (Fig. 5). After shaving, the wound was covered with dry gauze only and healed spontaneously by the twentieth day post bum. Later, we used lyophilized porcine dressing with similar success. Another alternative to autogenous skin grafts may be the use of synthetic materials such as Opsite, but we have no experience of this. REFERENCES
Jackson D. MacG. (1969) Second thoughts on the burn wound. J. Trauma 9, 839. Jackson D. MacG. (1972) Tangential excision and grafting of bums. Br. J. Pias. Surg. 25,416. Janzekovic Z. (1968) In: Derganz M. (cd.) Present Clinical Asp&s of Burns: a~Sympo&n. Maribor, C. P. Mariborskitisk. . DD. __ 99-215. Thompson N. (1960) The subcutaneous dermis graft. A clinical and histologic study in man, Plast. J. Reconstr. Surg. 26, 1.
Requests for reprints should be a&iressed to: Miss A. B. Sutherland. FRCS, Bangour General Hospital, Bmxbum, West Lathian, Scotland.