Plastic reconstructive surgery. History of it’s development.
Classiffication of transplantation. Types of
tissue transference. Particularities of patient’s care after plastic surgery.
“ We
restore, repair and make whole those parts … which nature has given but which
fortune has taken away, not so much that they may delight the eye but that they
may buoy up the spirit and help the mind of the afflicted.”
Gaspar Tagliacozzi 1597
Plastic surgery is the restoring of
normal appearance and function of the body parts. The task of plastic surgery
is to treat congenital and acquired defects that can appear after traumas,
diseases, tumors or operations ( so called reconstructive surgery) and also to
improve some particularities of the patient’s body which he or she wants to (
cosmetic surgery). Reconstructive surgery is restoring the patient back to normalcy, and
cosmetic surgery is superseding the normal.
History
Operations similar to modern plastic
ones were held 600 years before Christ , when in
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In
XVII-XVIII centuries there were no moves in plastic surgery, cause in that
times people thought that tissues of slaves could be used for transplantation.
Now we know about reaction of immune system and so on. The progress in this
field started in 1814 year, when the surgeon Josef Carpu from
Then
the Great War I was started and that was the great impulse for the development
of plastic surgery, because the need for treating wounds especially of face
appeared and specific surgical centers were organized.
The
founder of modern plastic surgery is English surgeon Harold Delf Gillis that
worked as a plastic surgeon in the Queen Mary’s hospital in
In 1917 Filatov provided the method
of skin plastic with help of a round migrated stalk.
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Pedzet in 1939 proposed for a taking
of autodermografts a dermatome. In 1946 Colocolov also designed in
“Gold
years “of plastic surgery are 60-s, 70-s, 80-s years. Cosmetic surgery appeared
as independent field on those years. Tord Skoog was founded the International
Association Of Plastic Surgeons , which first session was on 1955y. in
Basic techniques of plastic surgery
Excision of
skin lesions
Factors in
obtaining a fine line scar:
1.
a traumatic technique
2.
placement of the scar in the same direction as
skin lines
3.
the age of the patient
4.
the region of the body
5.
the type of skin
6.
complicating factors – skin disorders,
infection
1. Careful handling of tissues is
essential if one is to obtain a fine linear scar and maintain function. Skin
and the subcutaneous tissues that have been crushed, dried by exposure to the
air, damaged with hot sponges, or strangled by a suture under too much tension
will undergo some degree of necrosis. The necrotic cells may serve as a culture
medium for infection and at least will be replaced by scar. Sharp knives, scissors, needles, and
skin hooks, as well as sutures of the proper size, swaged to a needle, are all
important to minimizing this trauma. By the way, it is better to use surgical
pincers only for fixation of those areas of skin, that will be removed during the operation.
2. Scars are at least conspicuous when they follow the
wrinkle lines, contour lines, lines of dependency, or are concealed by the hair
of the scalp or eyebrow.
The wrinkle
lines of the skin generally lie perpendicular to the long axis of the
underlying muscles and are caused by the
wrinkling that accompanies muscular contraction . Wrinkle lines of the face,
known as the lines of expression. This lines are accentuated with smiling,
grimacing, frowning, pursing the lips, and closing the eyes tightly.
Contour lines
are the lines of division at the juncture of body planes. Examples are found at
the juncture of the cheek with the nose, the cheek with the ear, the scalp with
the ear, the cheek and neck skin in the submundibular region.
The lines
of dependency occur in older people due to the effect of gravity on loose skin
and fatty tissue. The “turkey gobbler fold” in the submental region and the
more laterally located jowl lines of the submundibular region are typical lines
of dependency.
3. Children’s scars can remain erythematous and
hypertrophy for prolonged periods of time, and the final result may be less
satisfactory under these circumstances. In general, such scars have a less
desirable final appearance than scars of person of middle age and older.
4. Scars resulting from excisions or incisions in the
eyelids, palms, soles, and in the vermilion or mucous membranes are usually
finer and less conspicuous than those seen elsewhere.
5. Some patients have thick, oily skin which contains
hypertrophied and overactive sebaceous glands. Wounds in this type of skin may
heal with a very noticeable depressed scar skin with these characteristics may
be present over the distal half of the nose, the middle portion of cheeks, and
the forehead.
6. Patients who have abnormalities in their fibrous and
elastic tissues often develop wide scars.
Operative
technique of suturing skin wounds
Methods of wound suture
Buried
sutures aid in closing a wound in layers. The periosteum or perichondrium, the
muscular fascia, and the subcutaneous tissue layer should each be closed by
suture. It is wise in the subcutaneous layer to insert the suture so that the
knot is tied deeply, away from the skin surface.
Another method sometimes used for closing the subcutaneous tissue is the
continuous alternating suture. The ends of this suture can be left permanently
in the subcutaneous tissue or passed to the surface so that the suture can be
removed after 2 or 3 weeks.
Skin suture can
be of several types
1. The simple interrupted suture should be inserted so
that the needle enters the skin of the first side at an angle of 90 degrees or
greater. As the needle passes through a comparable amount of subcutaneous
tissue on the second side, it begins to angle back toward the wound edge.
Ideally, the angle of exit for the needle is the as its angle of entrance.
2. The vertical mattress
suture is used principally to assure aversion of skin edges and is unsurpassed
for this purpose.
3. The horizontal mattress suture provides close
approximation of the skin edges with some aversion. This can be helpful in
closing skin wounds in the hand that are under tension.
4. The half-buried horizontal mattress suture is very
effective for closing the point of V-shaped
wound. The use of this suture
often prevents necrosis of the tip of the V, which may follow the use of a
simple interrupted suture. This suture is also advantageous for suturing a skin
flap into place. The buried portion of the suture lies within the flap so that
it effectively holds the flap in place, and yet the danger of damaging the skin
by inserting sutures through it is avoided.
5. The subcuticular (continuous intradermal) suture is
very practical and useful. The needle passes horizontally through the dermis. This suture
can usually be left in place for 2 to 3 weeks.
The classification of transplantation according to the sourñe
-
Autoplastic(iso) – from the same organism
-
Alloplastic(homo)- from the human to human
-
Xenoplastic(hetero)- from animal to human
Check internet page: www.kombustiolog.com.ua
The classification of plastic operations
1.
Main groups of plastic operations:
a)
plastic by local tissues
b)
plastic by far located tissues
c)
free transplantation of skin
2.
Transplantation of different tissues
a)
tendons, bones, fascias
b)
cartilages, cornea, vessels
c)
fat, nerves
3.
Transplantation of organs
a)
kidneys, liver, heart
b)
pancreas, lungs, fingers
SURGICAL
MANAGEMENT. Surgical management is restorative rather than
preventive. Surgical
techniques for contracture
release are most commonly performed in the neck, axilla, elbow flexion areas, and hand. Specific
surgical procedures to
improve movement vary for each client. Reconstructive and cosmetic
surgery can be performed for many years after the burn injury. Restoration of function and improvement of
physical appearance through surgical techniques often increase the client's
feelings of self-worth and promote a positive body image. Many clients have
unrealistic expectations of reconstructive
surgery and envision an appearance identical or equal in quality to the preburn state.
Types
of tissues transference
It is very important to choose the
method which will give us the best functional and esthetic effect. Firstly, you
should try to close the defect with the help of neighboring tissues (plastic by
local tissues, flap on the peduncle from the tissues that are situated near –
Indian method of plastic). These methods
give the best functional and aesthetic result, because skin of nearly located
areas is used. Such skin has similar properties to the skin of defected area.
If there is no such possibility the question about closing the defect by
usage of Italian plastic, or migrated flap.
Types
of methods of local plastic
1)
The V-Y
advancement technique has numerous applications. Rather a V-shaped incision is
made in the skin, after which the skin on each side of the V is advanced and
the incision closed as a Y. This V-Y technique can be used to lengthen such
structures as the nasal columella, in certain instances, close the donor site
of a skin flap.
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2)
Z-plastic –
is simply a technique by which two triangular flaps are interchanged, one by
another. It has three major uses: to increase the length of the skin in a
desired direction, to change the direction of a scar so that it will lie in the
same direction as the skin lines, and to rotate the axis of the tissue included
in the Z-plastic flaps. It is often used in case of after burn deformations of
different localizations.
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Joint
contracture
Z-plastic
Contracture
Z-plastic
Z-plastic
3)
Indian
plastic – is the closing of defects by skin flap. It consists of skin and
subcutaneous tissue that is moved from one part of the body to another with a
vascular pedicle or attachment to the body being maintained for
nourishment. In this method it has to be
taken from the nearest areas. It is used for closing of wounds of 3-angle,
4-angle, and round form. If there is a need the rotation or transposition could
be done. Sometimes there is a need to close tendons, bones, joints which need
the external nutrition and in that cases rotated skin-fat flaps are used. And
secondary defects that will appear should be closed by free graft. It is
combine plastic, the main point of which is skin-fat rotated flap.
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Free plastic
Wounds deficient in surface covering
require closure by a skin graft or skin flap. In case of free plastic the skin
grafts are used. Skin graft is a segment of dermis and epidermis which has been
completely separated from its blood supply and donor-site attachment before
being transplanted to another area of the body, its recipient site. Skin grafts
consist of the epidermis and a portion of the dermis if they are of the split-thickness
skin grafts. The full- thickness type contains the epidermis and all of the
dermis. All such grafts contain varying portions of the sweat glands, sebaceous
glands, hair follicles, and capillaries of the skin, depending on their
thickness. Skin grafts can be used to close any wound in the body which has a
blood supply sufficient to produce the growth of granulation tissue. The most
notable exceptions are cortical bone, cartilage, tendon, nerve. Most skin
grafts are used to serve as permanent coverage for a wound. By the way
split-thickness skin grafts are preferred for replacing the skin lost from
burned surfaces. When thin split-thickness skin grafts are used, a new “crop”
of skin can be taken from the same donor site about every 2 or 3 weeks. 15 or
16 days is the best time to take a second thin split-thickness skin grafts.
The color, texture, vascularity, thickness, and hair-bearing nature of
skin varies markedly from one area of the body to another. In general, the
nearer the donor site is to the recipient site, the more closely will the skin
match. Skin grafts to the face from above the clavicle will retain their
natural blush state, whereas those from below the clavicle will take on a
yellowish or brownish hue. The post auricular surface of the ear and adjoining
mastoid area serve as excellent sources for grafts of full-thickness skin which
match the skin of the face. It’s color and texture are similar to that of
facial skin.
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Vascularization of skin grafts.
There are three definite events: 1. Absorbtion
of plasma in the graft
2. Inosculation of blood vessels
Good contact between a skin
graft and its recipient bed is essential for vascularization of a graft and its
survival. The thin fibrin network that begins to form almost immediately
between the graft and its bed seems to serve as a glue to hold the surfaces
together and prevent one from slipping on the other. Factors preventing proper
contact between the graft and its recipient bed are improper tension on the
graft, a collection of fluid beneath it, and movement between the graft and its
bed.
Cutting the skin graft.
Three basic types of instruments have
been designed for removing a graft of split-thickness skin from its donor site:
the Humby knife, the drum-type dermatome, and the electrical dermatome. The
principle on which all of these instruments are based is that of a sharp blade
moving back and forth to cut a piece of skin whose thickness is controlled by a
calibrated setting on the instrument or by the surgeon himself.
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Postoperative Care of skin grafts
1) removal of hematomas and seromas
2) care of the infected skin grafts
3) hyperbaric oxygen
Care of the donor site
After the split-thickness skin graft
has been removed from a donor site, it heals by a process of
reepithelialization. We use xenotransplants in this cases.
Characteristics of grafted skin that
should be taken into account:
-
contraction
of grafted skin (primary, secondary)
-
color of
grafted skin
-
accessory
skin structures in grafted skin
-
sensation
of grafted skin
-
durability
and grows of grafted skin
The
plastic from far located tissues
Italian plastic and Filatov’s (migrated) flap
It means the usage of skin flaps that
can be constructed at a distance from the defect and then transferred to it,
either directly (e.g., by raising a skin flap on the chest wall and positioning
the defect on a hand under the flap) or indirectly (e.g. by raising a skin flap
on the anterior aspect of the trunk and then using the wrist as a carrier to
transfer it to surface a large defect on the face).
Direct flaps are usually obtained from,
or transferred to, an extremity, because the mobility of the extremity is an
important advantage in this surgery. Some examples of direct flaps from a
distance are direct flaps from the trunk usually transferred to the upper
extremity, direct flaps from an upper extremity for repairing the contra lateral
upper extremity or the face, direct flaps from a lower extremity used on the
opposite leg.
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Indirect flaps are rather seldom and
are transferred to a distant site by a carrier (e. g., the wrist) or by
migration. Such flaps are almost always tubed. Some examples of these indirect
flaps are indirect flaps from the trunk, indirect flaps from the neck, and from
the lower extremity. The anterior surface of the trunk is the preferred site
for forming large skin flaps, cause it
can supply great amounts of tissues to any part of the body.
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Our progression in choosing the type of skin coverage
should be from skin graft, to local skin flap, to distant skin flap – from the
simple to the most complex.
Correction
of scars
Scars (also called cicatrices)
are areas of fibrous tissue that replace normal skin (or other tissue)
after injury. A scar results from the biologic process of wound repair in the skin and other tissues
of the body. Thus, scarring is a natural part of the healing process.
With the exception of very minor lesions, every wound (e.g. after accident, disease, or surgery) results
in some degree of scarring. Scar tissue is not identical to the tissue that it
replaces and is usually of inferior functional quality. For example, scars in
the skin are less resistant to ultraviolet radiation, and sweat
glands and hair follicles do not grow back within scar tissue. A
myocardial infarction, commonly known as a
heart attack, causes scar formation in the heart muscle, which
leads to loss of muscular power and possibly heart
failure. However, there are some tissues (e.g. bone) that can heal
without any structural or functional deterioration.
Fig.18 A very minor scar from a cut to the forearm,
approx. one year since wound.
The word scar was derived from the Greek word eschara, meaning place
of fire (fireplace).
A scar is a natural part of the healing process. Skin scars occur when the
deep, thick layer of skin (the dermis) is damaged. The worse the damage is, the worse the
scar will be.
Most skin scars are flat, pale and leave a trace of the original injury that caused
them. The redness that often follows an injury to the skin is not a scar, and
is generally not permanent. The time it takes for it to go away may, however,
range from a few days to, in some serious and rare cases, a few years. Various
treatments can speed up the process in serious cases.
Scars form differently based on the location of the injury on the body and
the age of the person who was injured.
A Cesarean section scar visible 7 weeks after childbirth.
To mend the damage, the body has to lay down new collagen fibres
(a naturally occurring protein that is produced by the body). Recent research has
implicated the gene osteopontin in scarring and developed a gel that inhibits
the process [2].
This process results in a fortuna scar. Because the body cannot re-build
the tissue exactly as it was, the new scar tissue will have a different texture
and quality than the surrounding normal tissue. An injury does not become a
scar until the wound has completely healed.
Transforming Growth Factors (TGF) play a critical role in scar development
and current research is investigating the manipulation of these TGFs for drug
development to prevent scarring from the emergency adult wound healing process.
As well, a recent American study implicated the protein Ribosomal s6 kinase (RSK) in the formation of
scar tissue and found that the introduction of a chemical to counteract RSK
could halt the formation of Cirrhosis. This treatment also has the potential to reduce
or even prevent altogether other types of scarring.[3]
Type of grows of scar tissue |
||
1 |
Norma trophy |
Stable |
2 |
Atrophic |
Stable, with thin areas |
3 |
Hyper trophy |
Are growing |
4 |
Keloid |
Are growing with
invasion to neighboring
tissues |
Spreading of scar tissue |
||
1 |
Line scars |
Surgical excision |
2 |
Scar areas |
Combine therapy |
3 |
Scar contractures |
|
4 |
Scar deformations |
Two types of scars are the result of the body overproducing collagen, which
causes the scar to be raised above the surrounding skin. Hypertrophic scars take the form of a red
raised lump on the skin, but do not grow beyond the boundaries of the original
wound, and they often improve in appearance after a few years.
Fig. 20
Fig. 21
Fig.
22
Keloid scars
are a more serious form of scarring, because they can carry on growing
indefinitely into a large, tumorous (although benign) growth.
Keloid scars can be caused by burns, surgery, an accident, by acne
or, sometimes, from body piercings. In some people, keloid scars form
spontaneously.
Although they can be a cosmetic problem, keloid scars are only inert masses
of collagen and therefore completely harmless and non-contagious. However, they
can be itchy or painful in some individuals. They tend to be most common on the
shoulders
and chest.
Fig. 23
Alternately, a scar can take the form of a sunken recess in the skin, which
has a pitted appearance. These are caused when underlying structures supporting
the skin, such as fat
or muscle, are
lost. This type of scarring is commonly associated with acne, but can be caused
by chickenpox,
surgery or an accident.
Scars can also take the form of stretched
skin. These are called striae and
are caused when the skin is stretched rapidly (for instance during pregnancy,
significant weight gain or adolescent growth
spurts), or when skin is put under tension during the healing process,
(usually near joints).
This type of scar usually improves in appearance after a few years.
Contracture scars. If your skin has been burned, you may have a contracture scar, which
causes tightening of skin that can impair your ability to move; additionally,
this type of scar may go deeper to affect muscles and nerves.
Fig. 24
Fig. 25
Atrophic scars appear mostly in older patients.
Fig. 26
Factors that are dealing with scar growth
1. Total
1.1. Age
1.2. Heredity
1.3. Race
1.4. Immune
status
1.5. Pathology that caused
trauma
2. Local (that are not dealing with surgeon)
2.1. Localization of injury
2.2. Character and depth of injury
2.3. Area of injury
2.4. Infection of wounds
3. Local (that are dealing with
surgeon)
3.1. Localization of suture to skin
lines
3.2. Method of surgical closing or
conservative treatment
of wound
3.3. Right usage of standard of
treatment
Scar
treatment
Primary scar
treatment standard
Methods of first line:
“Wait and Look”
Noninvasive care
12 month
Pressure therapy |
Gel sheeting |
Corticosteroids ointments application |
Static and dynamic splints |
Antihistamine drugs |
Hydrotherapy |
Methods of second line:
Noninvasive and Invasive care
After 12 month
Peel, dermabrasion |
Laser therapy, |
Cryosurgery, |
Excision
(revision surgery), |
Radiotherapy |
Combination therapy |
Methods of third line
Invasive care
After 24 month +
Post operative correction
Excision
(revision surgery) |
Cryosurgery |
Reconstructive surgery |
Combination therapy |
Exception:
surgical technique of incision or excision is possible and should be done on early stages, when scars prevent grows of
children or cause acute limiting of moves in joints, it means in case of risk of
secondary degenerative changes of deeper organs ( bones, joints).
4. THE
CHARACTERISTICS OF LYOPHILIZED XENODERM GRAFTS
Lyophilized
xenoderm grafts (the size - 100-200-250-300 cm², the thickness - 0,3-
After microscopic investigations of the
lyophilized skin, the signs of autolytic and necrobiotic alterations and their
deep structural abnormalities have not been found in the epidermis and in the
papillary layer of the dermis. Well-preserved nuclei and epidermocyte and
fibroblast cytoplasm are present in the majority of the cells; pycnosis and vacuolization
are only detected episodically. The cell membranes are not distorted; the
exfoliation of the epidermis from the dermis is absent. The collagen dermal
fibers of the grafts are contoured, forming the network and being placed
loosely in the papillary layer. The edema and homogenization of some parts of
the collagen fibers and, in some cases, - their fragmentation is present in the
deep layers of the dermis.
At picrofuxin staining by Weigert Van
Gieson, the collagen fibers are mostly stained intensively red with fuchsin.
The part of the elastic network is interwoven with clear contoured fine elastic
fibers.
The vitality of the of xenoderm grafts
is determined microscopically. All the
investigations clearly reveal plasma membranes, intercellular junctions of the
growing layer of the epidermis. Euchromatin dominates in the nuclei signifying
the activity preservation of the epitheliocyte nuclear apparatus. The
fibroblasts, which are characterized by the developed protein synthesis apparatus
and insignificant mitochondria distortions, predominate in the cells of the
papillary dermis. The nuclear contours are regular and a lot of granules of the
ribosomal origin can be seen in the nuclei. But destabilization and destruction
of the plasma, nuclear and organic membranes are present episodically in some
cells; heterochromatin is predominant in the nuclei signifying the reduced
function.
The morphologic investigations have proved
that lyophilized xenoderm grafts developed and manufactured by our enterprise
are not significantly different from the xenoderm grafts before the
conservation. (Figure 1, 1a)
Fig. 1. Stratified epidermocyte
placement is preserved concerning regular basal membrane. Basophilic nuclei, vacuolization of separate cells.
Fig. 1à. The microscopic organization of the basal layer
epidermocytes. Desmosomal junctions are preserved; Intercellular spaces are significantly
widened. Moderate karyolemma invaginations and homogeneous nuclear karyoplasm, the
destruction of the separate organelles.
1.
THE INDICATIONS FOR THE LYOPHILIZED XENODERM
GRAFTS
Lyophilized porcine xenoderm grafts are used
as temporary skin substitutes in the treatment of the burns (
At the application of xenoderm grafts in
the complex therapy of the patients with burns the general state of the patients,
their sleep and appetite improve; the body temperature is normalized; the deficiency
of the homeostasis indices is reduced; the indices of the blood serum toxicity are
decreased; the epithelization of the superficial burns, boundary and insular epithelization
of the deep burns is accelerated leading to the decrease of the granular
lesions by 23%. The hospitalization of the patients is reduced to 16-18 days;
the mortality of the major burn patients is reduced by 30 %.
The number of the lyophilized xenoderm grafts
necessary for the skin coverage depends on the surface area, depth of the burns
and the age of the patient. (Table 1).
Table
1
The number of the lyophilized
xenoderm grafts necessary for the treatment of the burn patients depending on the
age of the patient
¹ |
Age |
The necessary
number of the lyophilized xenoderm grafts (cm2) at the burn surface area 1 % |
1. |
Infants |
20 |
2. |
6 months - 2 years |
35 |
3. |
2-3 years |
45 |
4. |
4-5 years |
60 |
5. |
6-8 years |
85 |
6. |
9-13 years |
110 |
7 |
14 years < |
180-220 |
2.
THE PREPARATION OF THE APPLICATION OF THE LYOPHILIZED
XENODERM GRAFTS
2.1. Before the application
of the xenoderm grafts, the package integrity and the expiration date
stamped on the package are checked.
2.2. In the dressing or operating room, the package is
antisepticised with the special burn solution and incised; the xenoderm grafts are
removed from the package and placed in the container with warm physiologic solution
(15-20ºÑ) with
the antibiotic for 10-15 minutes taking into account wound microflora susceptibility.
2.3. The xenoderm grafts are taken out from the container;
4-6 perforations of 100 cm2 are performed on them with a scalpel; the grafts are
applied to the clean wounds with the epidermal side upwards; the wounds are wrapped
with antisepticised gauze pads and fixed with a dressing.
3. THE APPLICATION OF THE XENODERM
GRAFTS
3.1. Superficial burns (²²-²²²À degree)
After the patient hospitalization and hemodynamic
stabilization, the wounds are antisepticised at narcosis in the clean dressing or
operating room. The skin around the burn is debrided and cleaned with antiseptic
solutions – iodine, povidone-iodine, chlorhexidine, dexane. In case of significant
contamination (home or industrial dust, soot, smut), the burn area should be sprinkled
with antiseptic sterile solutions. After the wound antiseptics, most II degree burn
areas are likely to be covered with the perforated lyophilized xenoderm grafts.
It relieves the graft modulation at joint areas. The wound epithelization under the lyophilized
xenoderm grafts terminates on the 10-12 days. (Figure 2)
Fig. 2 The wound epithelization
(46 %) under the lyophilized xenoderm grafts
In case of III degree burns the skin dermal
layer undergoes partial necrosis (the vital sebaceous and sudoriferous glands and
their excretory ducts are preserved), creating preconditions for wound suppuration
caused by the development of the pathogenic microflora in the necrotically
changed superficial skin tissues. To create the conditions for the active insular
and marginal epithelization with the application of the preserved skin derivatives
it is necessary to debride the wound and to conquer wound infections. Thus, sequential (superficial) necrotomy and the
wound coverage with lyophilized xenoderm grafts have to be performed to the patients
with IIIA degree burns during the early stage after the trauma (2-3 days) (Fig.
3). It prevents the burn disease development, accompanied complications, the
scar formation and frequent painful dressings and also promotes wound healing.
Figure
3 III degree burns. The performance of the early necrotomy (the 2nd
day after the trauma).
The xenoderm grafts are closely applied to
the skin, resulting in the improvement of the patient’s general state, significant
reduction or liquidation of the pain syndrome, the body temperature normalization.
The first dressing is applied the next
day after the tangential and sequential necrotomy with xenoplasty. The following
dressing are applied daily or once in two days respectively depending on the
character of engraftment. When hematomas or accumulated purulent discharge
occur under the xenoderm grafts, the grafts are removed, the wound is cleansed
and the new xenoderm grafts or wet to dry drying dressings are applied. On the
8-9 day after the trauma the xenoderm grafts dry up at the ends of the wound;
the graft rejection and the epithelization of the wound surface are observed.
In the other areas of the wound the xenoderm grafts are closely fixed to the
adjacent tissues.
On
the 11-12 days the xenoderm grafts thicken and fall off. The wound surface is
covered with well-developed epithelial regenerator. (Fig. 4)
Thus, the application of the lyophilized xenoderm grafts in the treatment of the surface burns shortens the patient hospitalization (from 6
to 8 days), reduces the risk of the hypertrophic and keloid scar formation by
38%
Fig. 4 The wound epithelization under xenoderm grafts (12 day after the trauma).
Taking
into account that the number of patients
with ²²-²²²À degree
burns makes up 70 % of all the burnt, the application of the lyophilized xenoderm
grafts allows to avoid painful daily dressings, promotes wound healing, prevents
wound purulence, facilitates the course of the disease without the loss of proteins,
water and electrolytes. The expenditures on the purchase of the lyophilized xenoderm
grafts are less than those on the purchase of ointments, bandages, solutions,
narcotic drugs etc. Thus, the described treatment method is said to be not only
clinically but also economically efficient.
3.2. Deep burns (²²²B-IV degree)
The deep burns can be treated with the
application of the early necrotomy or without it.
3.2.1. The application of the early necrotomy
The final aim of the local treatment of the
deep burns lies in operative restoration of the burnt cutaneous covering. The early
surgical interventions fully correspond with the principles of the preventive surgery.
During surgical interventions, necrotic tissues
are removed tangentially or perifascially on the area up to 10-15 % of the body
surface; the formed wounds are temporarily covered with the lyophilized xenoderm
grafts that are removed in 2-3 days and after additional necrotomy the wounds are
covered with the autodermal grafts
The repeated
interventions are performed in 2-3 days. Afterwards daily dressings are applied
at narcosis and xenoderm and autodermal grafts are cleansed on the wounds.
The application of the lyophilized
xenoderm grafts allows to increase the area of the one-phase removal of the
necrotic tissues, to reduce the traumatism of the interventions, to detect the
areas of the incomplete debridement and it also creates conditions for quick
compensation of the postoperative homeostasis violations.
Additional debridement of the unvital tissues
promotes better autodermal engraftment. The
application of the early necrotomy with xenodermoplasty prevents progressive intoxication
of the lesion focus and the development of the wound infection, reduces the
possibility of the burn disease development and promotes skin restoration
within a short time.
Fig. 5 The ²²-²²²AB degree burn of the
left side of the trunk, upper extremity, 26 (18) % of the body surface. Early
necrotomy. Xenoplasty. Autodermoplasty.
3.2.2. The treatment of the deep burns without the application of the early necrotomy
The main task of the burn treatment is
the preparation of the burn lesions to autodermoplasty. Spontaneous necrotic tissue rejection lasts
4-5 weeks. The presence of the specially wet eschar on the burn and the wound microflora
vegetation (frequently as gram-positive or gram-negative flora) often lead to the
burn complications
The deep burns are treated without the
application of the early necrotomy in the late evacuated patients with purulent
wounds and also in the patients with the complicated disease course and
accompanied diseases that limit the application of the early necrotomy.
After the chemical and phased necrotomy
and deep wound debridement the autodermoplasty is performed. During the
autodermoplasty the wounds that remain uncovered with the autodermal grafts,
donor wounds and perforated autoskin grafts are covered with the lyophilized
xenoderm grafts.
Fig. 6 IIIB-IV degree
burns, 70 % of the body surface. Auto- and xenoplasty.
The xenoderm grafts can remain fixed up
to 2,5-3,5 weeks. The application of the lyophilized xenoderm grafts reduces pain
syndrome, plasma loss and the
frequency of the wound purulence.
At the same time the granular tissue
with the cells of the histogenic and haematogenic origin (fibroblasts and
histiocytes) ripens under the xenotransplants.
The hypertrophy of the protein synthesis
structures and energy exchange are detected microscopically in the fibroblast
cells. (Figure 7).
Fig. 7 The ultrastructure
of the active fibroblast and the formation of the intercellular substance components
of the connective
After the xenoderm grafts removal autodermoplasty
can be performed (Figure 8).
Fig. 8 ²²² B – IV degree burn wounds after the xenoderm grafts removal.
The 14th day after xenoplasty. The granular tissue is well
manifested.
Simultaneously with the granular tissue
formation the wound surface is epithelized more actively; the local epithelization
in the form of wide cell growth from the preserved skin derivatives occurs together
with the marginal epithelization (Figure 9). It promotes reducing the wound surface
due to the absence of the secondary wound deepening and necrosis and intensifies
the marginal and insular epithelization of the deep burn lesions under the xenoderm
grafts.
Fig. 9 ²²²À-B degree burns covered with the xenoderm
grafts. The 12th day after xenoplasty. Active proliferation of the
epitheliocytes in the preserved hair follicles and sebaceous glands. The
formation of the epidermal layer on the wound surface.
3.3. The coverage of the donor lesions
The xenoderm grafts are efficiently used
in the treatment of the donor lesions. Thus, there is no necessity in dressings.
The epithelization of the donor lesions under the xenoderm grafts occurs on the
6-8 day. So the application of the xenoderm grafts in the coverage of the donor
lesions promotes faster epithelization ((4±1) day) and if necessary earlier autotransplant
removal for the recurrent plasty.
3.4. The coverage
of the perforated autodermal grafts
The perforated autodermal grafts on the
wounds can be covered with the xenoderm grafts. There is no need to remove
xenoderm grafts during dressings; the epithelization of the wounds in the
autografts occurs under the xenoderm grafts. After the complete wound
epithelization between the membranes of the perforated autodermal grafts, the
xenoderm grafts dry out and fall off.
3.5. The treatment of the scalping lesions
and trophic ulcers.
Clean scalping lesions and trophic ulcers
are covered with the xenoderm grafts. The reduction of the inflammatory process,
the activation of the marginal and insular epithelization promoting wound self-healing
can be observed under the engrafted xenoderm grafts. When the lesion area is big,
the xenografts have to be substituted with the autodermal grafts on the 7-8 day
(the local blood circulation in the wound is the best during this period).
3.6. The treatment of the lesions after the scar cryodestruction
Cryotherapy
Indications: persistent scars in phase of
heighten over the skin, keloid scars.
Onetime 30 sec freezing by liquid nitrogen of hypertrophy and colloid scars
Action
n physical depressing
2
nd stage of wound process
n Activation of functional activity
of fibroblasts
n remodel zing of extra cellular matrix (collagen 1 type)
On the 2 day after the cryodestruction, the area (the serous cyst and the skin around it) is cleaned with antiseptic solutions – iodine, povidone-iodine, chlorhexidine, dexane; the serous cyst is removed; the wound is dried up with the sterile pads
and the lyophilized xenoderm grafts are applied.
On
the 6-7-8 day after the procedure, the drying of the xenoderm
graft at the wound edges, its rejection and
complete epithelization can be observed. The period of the epithelization depends
on the size of the lesion formed after cryodestruction
Fig. 10 Posttraumatic keloid scars. The cryodestruction with the
further xenoplasty.
HOME CARE MANAGEMENT
The client
with severe bums is often discharged from the acute care setting when life-threatening complications are
resolved and minimal wound
areas remain open. During the initial weeks at home after discharge, the client usually continues to require at least daily wound care,
rehabilitative therapy, nutritional
support, symptom management, and drug therapy.
Although the
client usually views the prospect of going home
in a positive light, the difficulties associated with physical care and the
psychological stresses associated with changes in appearance, role, function, and lifestyle are numerous and may
overwhelm the client and family. Successful discharge depends on extensive
planning and preparation of the client, family, and home environment through education and the involvement of appropriate support agencies and
services.
Preparation for discharge includes assessment of the family and home
care situation from physical and social perspectives. The nurse considers the
needs of the client when evaluating
the environment for cleanliness; access to bathing facilities, electricity, and running water; stairways;
number of occupants;
temperature control; and safety. If the bum injuries are a result of a fire at home, a new residence may
need to be established.
HEALTH TEACHING
Education about burn care and
living with the consequences of burn injuries begins when the client is
admitted to the hospital or bum center. A weekly plan for client education is
outlined; the primary goal is progression toward independence for the client and family. Critical for this goal
is teaching clients, family members,
or significant others to perform specific care tasks, such as dressing
changes. Clients and family members first observe the nurse changing the
dressings, then assist in performing
the changes, and finally change the dressings independently under the supervision of the bum care nurse.
Before
discharge, all people who will be involved in the client's home care participate in discharge planning
and teaching
sessions. In addition to details about
dressing changes, the nurse
or doctor explains the following:
•
Signs and symptoms of
infection
•
Medication
regimens
•
Proper use of prosthetic
and positioning devices
•
Correct application and
care of pressure garments
•
Comfort measures to
reduce pruritus
•
Dates
for follow-up appointments
IMPAIRED PHYSICAL MOBILITY
INTERVENTIONS. Interventions
aim to maintain the client's
preburn range of joint motion and prevent contracture formation.
NONSURGICAL MANAGEMENT. Nonsurgical management includes positioning, range-of-motion exercises,
ambu-lation, and
pressure dressings.
POSITIONING. Positioning is critical for clients with burn injuries because the position of comfort for the
client is often one of joint
flexion, which predisposes him or her to the development of contractures. Care is taken to maintain
the client in a neutral body
position with minimal flexion.
Splints and other
conforming devices may assist in maintaining position. These devices are used most frequently
on the joints of the hands, elbows, knees, neck,
and axillae.
RANGE-OF-MOTION
EXERCISES. Range-of-motion
exercises are performed actively
at least three times a day. If the client cannot move a joint actively, the
nurse performs passive range-of-motion exercises. Burned hands are given
special attention. The client
is encouraged to perform active range-of-motion exercises for the hand, thumb,
and fingers every hour while
awake.
AMBULATION.
Ambulation is started
as soon as possible after the fluid
shifts have resolved. Clients with a variety of attached equipment (IV
catheters, nasogastric tubes, electro-cardio graphic leads, extensive
dressings) can ambulate with preparation and assistance. Ambulation is
performed two or three times a day and progresses in length each time. Ambulation
inhibits the loss of bone density, strengthens muscles, stimulates immune
function, promotes ventilation, and prevents a wide variety of complications.
PRESSURE DRESSINGS. After the graft heals,
pressure dressings are implemented to assist
in the prevention of contractures
and tight hypertrophy scars, which can inhibit mobility. These dressings also
inhibit venous engorgement and edema
formation in areas with decreased lymphatic outflow. Pressure dressings may be elastic wraps or
specially designed, custom-fitted,
elasticized clothing that provide continuous and uniform pressure over burned
surfaces. Figure 2 illustrates such garments. For maximal effectiveness, pressure garments should be worn at least 23 hours
a day, every day, until the scar
tissue is mature (12 to 24 months). Pressure
garments generally cause an increase in warmth and itchiness and often are seen as very uncomfortable
by the client. The nurse must
reinforce to the client that wearing pressure
garments is extremely beneficial in maintaining mobility and reducing hypertrophy scarring.
Figure 2 Models wearing pressure garments. (Courtesy Beiersdorf-Jobst, Inc., |
Besides special silicon plates could
be used with the same aim for the prevention and treatment of postburn scars
and contractures (read below).
More detail about pressure therapy of
scars and contractures below.
SURGICAL
MANAGEMENT. Surgical management is restorative rather than preventive. Surgical techniques for contracture release are most commonly performed
in the neck, axilla, elbow
flexion areas, and hand. Specific surgical procedures to improve movement vary for each client.
DISTURBED BODY IMAGE
PLANNING: EXPECTED OUTCOMES. Following intervention, the client
with a burn injury in the acute phase is expected to have a positive perception of his or her own appearance and body functions as evidenced by a
willingness to touch the affected body part, adjustment to
changes in body function, a willingness to use strategies to enhance appearance and function, a successful progression
through the grieving process, and the use of support systems.
INTERVENTIONS.
Nonsurgical and surgical
interventions can assist clients who experience body image disturbances as a
result of burn injury.
NONSURGICAL MANAGEMENT.
Understanding the stages of grief is helpful
for the client, family. It has to be assessed
which stage of grief the client is currently experiencing and helps interpret his or her behaviors. The client often is unaware of or is confused by his or her
feelings. Feelings of grief, loss, anxiety, anger, fear, and guilt are normal. The client
may be grieving the loss of body parts, appearance, role identity, and social
identity.
It has
to be accepted the physical and psychological characteristics of the client. Clients and families are
presented with realistic
expected outcomes for the client's functional capacity and physical appearance. Information sessions and
counseling for the family or
significant others can identify previous and current patterns of support that
are effective for the client and family.
Engaging
in decision making and independent activities fosters feelings of self-worth, which are closely
linked to body image. To this
end, it has to be planed and encouraged the client's participation in self-care
activities. Family members are
assisted in understanding that it is more beneficial for the client to perform
these activities than to have them performed by someone else. Families are encouraged to include
the client in family
decision making to the same degree that he or she participated in this process before the injury.
SURGICAL MANAGEMENT. Reconstructive and cosmetic surgery can be performed for many years after the
burn injury. Restoration
of function and improvement of physical appearance through surgical techniques
often increase the client's feelings of self-worth and promote a positive body
image. Many clients have unrealistic expectations of reconstructive surgery and envision an appearance
identical or equal in quality to
the preburn state.
Instructions for Patients
Do's and Don'ts:
IV. References:
Essential reading:
2.
Green's operative hand surgery—6th ed. / [edited by]
Scott W. Wolfe, Robert N. Hotchkiss, William C. Pederson, Scott H. Kozin, 2011.
3.
Siemionow, Maria Z.; Eisenmann-Klein, Marita (Eds.)
Plastic and Reconstructive Surgery—1st Edition., 2010, XVIII, 778 p.
4.
Siemionow, Maria Z. (Ed.) The Know-How of Face
Transplantation—1st Edition., 2011, XVIII, 494 p.
Further
reading: