By: Dr. Mahmoud El-Oteify, M.D.
Burned patient's, with severe burns, need the care of a qualified burn surgeon, due to their medical needs from the burns. The patient usually needs the surgeons care till the end of the full course the treatment and even after that for many years later.
The burn surgeon should know how to do escharotomy for cases of circumferential deep burns of the chest or limbs. Escharotomy helps to prevent problems due to inadequate chest expansion during inspiration or peripheral ischemia in the limbs. This should be done immediately after admission to the burn unit and before the edema occurs. Edema can jeopardize the blood supply to the periphery of the areas that were burned.
The word deep burn means full thickness skin burn, which is also called 3rd degree burns. A superficial burn or partial thickness skin burn, 2nd degree burns, usually will not need escharotomy because the elastic fibers which are already present naturally in the depth of the skin is not burned. It well permit skin expansion during inspiration or due to edema. A partial thickness burn usually heals within 3 weeks & does not need any grafting procedures.
Immediate Excision and Grafting:
Burn Units offers the intensive care and patient monitoring needed to help them recover. This type of care allows the burn surgeon to perform escharectomy and immediate skin grafting within a 5 to 7 days after the accident. The burn victim becomes haemodynamically stable at this time. This usually shortens the hospital stay and prevents the toxemia, which can occur due to the toxic absorption of the dead proteins and the infection, which usually present in the sub-eschar plane.
Spontaneous Separation of Eschar & Delayed Grafting:
In the low facilities burn units the surgeon generally hesitates to perform the excision because it needs a lot of blood transfusion and good patient monitoring. The alternative is waiting 2-3 weeks for the spontaneous separation of the eschar. At that time, the raw area of the skin is ready for grafting.
In order to perform skin graft on a burned area of the body, the surgeon usually takes the a superficial layer of the skin from a non burned area. It is important to have a very thin sheet because the thinner the graft the better the take by the body. The deeper skin layers, the donor area of the body, usually regenerates faster, approximately 10 days after the surgery, if the graft which was harvested is very thin.
The ideal skin graft in this case is the auto-graft and the classical donor site is the thigh. We may put the skin as it is "sheet graft" or we mesh it to do multiple fenestrations with the special mesher machine. The main benefit of this meshing is the expansion of the skin in order to cover a bigger area than the donor site. This type of work is called a meshed graft. A Meshed graft produces a mosaic appearance after healing. If the patient's
general condition does not permit auto-grafting or if there is limited donor sites, the alternative is to cover the wound by skin homo graft or any type of skin substitute.
The auto-grafting procedure, in this stage, is considered as primary burn surgery prior to the complete healing of the burn wound.
Secondary Burn Surgery
A few months after the healing, the burn survivor may notice skin hypertrophy (thickening) especially in the areas which healed spontaneously without grafting. If this occurs 2-3 weeks after the healing, it means that the burn was a deep 2nd degree burn. We may notice also some contractures either linear or broad anywhere in the body. You may also find leukoderma, alopecia scalp or any other scarring or abnormal pigmentation. All of the above can be corrected surgically in the future. This type of surgery is called secondary burn surgery. Secondary burn surgery is usually postponed for at least 6 months after healing in order to allow the burn scar to be supple. This will make it less vascular and easier to manipulate.
The exception for this policy is the ectropion of the eyelids. This is the inability to close the eye due to the cornea. It can be affected if left exposed (exposure keratitis). In this case urgent surgery is usually recommended.
When a young female is burned, we usually post pone any surgery to the female breast until puberty. If this type of surgery is performed we may loose everything in that part of the body. Due to that, we usually wait until after the full development of the female body. If medically it would be harmful to the patient to postpone the surgery, we will perform the necessary procedures.
These types of contractures and deformities are very common in Upper Egypt due to the ignorance, negligence and poor resources. A qualified burn surgeon is present in very few hospitals in Upper Egypt. These type of surgeons are needed for immediate skin grafting on burns. The surgery needs to be performed within the 1st month and before contractures occur. The majority of hospitals leave the patient without any grafting procedures until severe contractures develop. These patients usually arrive at Assiut University Hospital for secondary burn surgery.
Techniques In Secondary Burn Surgery:
Basically in any contracture we must remove the whole fibrous tissue and cover the defect with a skin graft. The graft in this area is usually partial thickness in order to permit spontaneous healing of the donor site. The graft is relatively thicker than the graft used for Post Burn Raw Area (PBRA). The surgically denuded surface carry better chances of accepting the graft. Usually the thicker the graft, the better is the color matching and
the less the contracture later on. In some cases especially in the face we prefer to put full thickness skin grafts. This type of skin graft usually gives a better appearance post surgery. We can harvest the skin from the abdomen or the groin and close the defect by a skin edge approximation because the skin is redundant and permit.
In some areas of the body release and skin graft procedures are not the best type of surgery to be used. This is due to either darker pigmentation or re-contracture especially in the neck or over the joints e.g.: in front of the elbow and the back of the knee. Because of that, the skin flap is the ideal choice. It will never contract and keep the same color match.
The skin flap is an area of the skin with the subcutaneous tissue to protect its blood supply. It is to be moved to the skin defect either locally or from a distance. Of course it is not always available, but with experience the burn surgeon can choose what is the best for every situation.
Over the last 30 years I corrected many thousands of cases of Post Burn Contracture (PBC) allover the body without exceptions. I have special interest PBC neck and PB in a deformed hand. This interested is because occur frequent in my area.
I have performed lectures and special publications during my career that you might be interested in looking at:
- "My 1st publication was in 1981 in the British journal of plastic surgery. It is titled "Versatile Method For Release of Post Burn Scar Contracture"
- "I presented a lecture at the ISBI meeting in Paris, France in 1994 on Post Burn and hand deformities.
- "I presented a preliminary report in Yokohama, Japan in 1995 and a second presentation in San Francisco, California in 1999 about the special flap release for Post Burn band contracture.
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