Acute management of thermal and electrical burns of the upper extremity.

Acute management of upper extremity thermal and electrical injuries requires an aggressive treatment protocol which combines meticulous wound care, intensive hand therapy, and early stable wound coverage to salvage upper extremity function. Electrical injuries inflict severe deep-tissue destruction that frequently results in major limb amputation.

Total eyelid reconstruction with free dorsalis pedis flap after deep facial burn.

A case of severe facial and corneal burns with complete loss of upper and lower eyelids is reported together with the acute management and surgical options for total eyelid defects secondary to thermal injury. An acutely burned man with 78 percent total burn surface area presented with complete exposure of the left cornea. Because of the severe thermal injury, no facial tissues were available as donor sources for reconstructing the eyelid. A free dorsalis pedis flap was used to cover the exposed cornea after bilateral conjunctival advancement flaps, with septal cartilage graft for structural support. A conjunctivodacryocystorhinostomy was performed at the time of the coverage. The patient was unable to perform an exact visual acuity test; however, his gross vision was intact.

Free-tissue transfer for limb salvage in Purpura fulminans.

A series of 13 patients is described to demonstrate the experience of the authors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a loss of flap in one patient. The flaps were used for lower-extremity salvage in six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as meningococcus and pneumococcus. Clotting derangements and systemic vasculitis often lead to widespread tissue necrosis in the extremities. Local tissue is usually not available to cover vital structures in these complex wounds. In these situations, free-tissue transfer is necessary to achieve limb salvage. Microsurgical reconstruction in patients with purpura fulminans is a formidable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platelet counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be beneficial. The systemic nature of the vascular injury does not permit microvascular anastomosis to be performed outside the "zone of injury." Extensive vascular exposure, even at a great distance from the wound, does not reveal a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-to-end anastomosis may salvage free-tissue transfers in cases in which intimal damage is too severe to sustain a patent anastomosis. Patients often have peripheral neuropathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage.

Tissue expanders in the lower face and anterior neck in pediatric burn patients: limitations and pitfalls.

Radovan's 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems. We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

The 1999 clinical research award. Cultured skin substitutes combined with Integra Artificial Skin to replace native skin autograft and allograft for the closure of excised full-thickness burns.

Prompt and permanent closure of excised full-thickness burns remains a critical factor in a patient's recovery from massive burn injuries. Hypothetically, Integra Artificial Skin (Integra) may replace the need for allografts for immediate wound coverage, and cultured skin substitutes (CSS) that contain stratified epithelium may replace the need for autografts for definitive wound closure. To test this hypothesis, 3 patients with full-thickness burns of greater than 60% of their total body surface areas had their eschar excised within 14 days of admission. Integra was applied, and a skin biopsy was collected from each patient for the preparation of CSS. At 3 weeks or more after the application of the Integra and the collection of skin biopsies, the outer silastic cover of the Integra was removed and CSS were grafted. The CSS were irrigated with nutrients and antimicrobials for 6 days and then dressed with antimicrobial ointment and cotton gauze. Treated wounds were traced on days 14 and 28 after the grafting of CSS for determination of engraftment and wound closure, respectively. Cost analysis was not performed. Engraftment on postoperative day (POD) 14 was 98%+/-1% (mean +/- standard error of the mean), the ratio of closed:donor areas on POD 28 was 52.3+/-5.2, and no treated sites required regrafting. The histology of the closed wounds showed stable epithelium that covered a layer of newly formed fibrovascular tissue above the reticulated structure of the degrading Integra. The clinical outcomes of the closed wounds after POD 28 demonstrated smooth, pliable, and hypopigmented skin. Two patients who had received CSS grafts over Integra on their backs were positioned supine on air beds from POD 8 or POD 9 with minimal graft loss because of mechanical loading. One patient with a full-thickness burn of 88% of the total body surface area was covered definitively at 55 days postburn. These results demonstrate that the combination of CSS and Integra can accomplish functionally stable and cosmetically acceptable wound closure in patients with extensive full-thickness burns. This combination of alternatives to the conventional grafting of split-thickness skin permits the substitution of cadaveric allograft with Integra and the substitution of donor autograft with CSS. This approach to the closure of excised full-thickness burns is expected to reduce greatly the time to definitive closure of burn wounds and to reduce the morbidity associated with the harvesting of donor sites for split-thickness skin autografts.

Current management of purpura fulminans: a multicenter study.

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Reconstruction of the burned thumb.

The thumb accounts for 40 to 50% of hand function. Reconstruction of soft-tissue contractures include release and coverage with skin grafts or various local, regional, distant, or free flaps. Thumb length, so important for prehension and opposition, can be restored by phalangealization, pollicization, or toe-to-thumb transfer. Secondary techniques such as metacarpal distraction-lengthening or osteoplastic reconstruction are rarely indicated.

Treatment outcomes for keloid scar management in the pediatric burn population.

INTRODUCTION: Keloids scars are challenging problems facing many reconstructive surgeons and have proven to be resistant to many treatments. This is evident by the broad range of treatments available and implemented with inconsistent results. We reviewed our experience to better define the disorder and to evaluate the impact of specific treatment options as related to our patient population. METHODS: After obtaining Institutional Review Board approval, we examined the medical records of pediatric patients who were evaluated at our pediatric burn center between 2000 to 2008. All study subjects were identified as having keloid scars confirmed by clinical evaluation (raised scar extending beyond the margins of the original wound [1,2]). Treatments included excision and grafting [split thickness autograft (STAG) or full thickness autograft (FTAG)], excision and grafting with steroid injection, excision and primary closure, or excision and primary closure with steroid injection. Patients were included only if there was follow-up of 12 months or greater. RESULTS: One hundred and ten subjects with a diagnosis of a keloid scar were identified. Twenty-six were treated with excision and skin grafting and 8 were treated with a steroid and surgery regimen. Of the patients treated with surgery and steroids, the treatment varied from an intra-operative injection to post-operative injections at 6-week intervals. The number of injections was determined by the administering surgeon and varied from one to three. Clinical end points were determined by the administering surgeon and included: (1) no further improvement in scar maturation or (2) absence of improvement. Recurrence was defined as return of a raised scar consistent with a keloid scar. The recurrence rate was 87.5% for patients treated with surgery and steroids and 80.0% for surgery only. This difference was not statistically significant. CONCLUSIONS: Our data demonstrate that steroids do not significantly decrease recurrence in pediatric burn related keloids as compared to previously published series involving non-burn related keloids [3,5]. This further emphasizes that burn related keloids respond differently to conventional treatments that have proven successful in keloid scars from other mechanisms of injury. A consistent and effective treatment algorithm should be implemented in treating keloid scars from burn wounds.

Pacinian neurofibroma of the hand: a case report and literature review.

Pacinian neurofibroma is a rare, benign tumor not associated with von Recklinghausen's disease (neurofibromatosis). Histologically, it is composed of a proliferation of structures resembling normal pressure receptors. A case of pacinian neurofibroma of the hand in a 4-year-old child is presented, along with a review of the literature.

Technical successes and functional failures after free tissue transfer to the tibia.

A retrospective study evaluated functional outcome in 59 patients with 61 successful free tissue transfers performed after open tibial fractures. Twenty-one patients had transfers done within 7 days, 13 between 7 and 21 days, and 25 were done greater than 3 weeks after injury. All 59 patients had Type III injuries as classified by Gustilo and Anderson. Nineteen patients (32%) were identified as late functional failures. Each of these patients underwent as average of 10 procedures. In this group chronic osteomyelitis was noted in 13 of 19 patients and chronic venous insufficiency with skin ulceration in 9 of 19 patients. Fracture nonunion was seen in 8 of 19. Degenerative joint problems and foot deformities were identified in 7 or 19 patients. Seven patients (12%) ultimately required below-knee amputation. Functional failure did not correlate with the timing of flap application, but rather with the severity of the initial injury. Free tissue transfer is not a panacea. It is but one step in the overall reconstruction of complex tibial wounds.

Use of free fasciocutaneous and muscle flaps for reconstruction of the foot.

Seventeen free flaps were used to reconstruct severe injuries to the foot over the last 36 months at the University of Cincinnati College of Medicine. The type of free flaps used included six fasciocutaneous free flaps and eleven free muscle flaps with split-thickness skin grafts. The fasciocutaneous flaps were either radial forearm or scapular flaps. The muscle flaps used were gracilis, rectus, or latissimus dorsi muscle flaps. Each type, with their specific advantages, disadvantages, and indications for use as they apply to the anatomical areas of the foot, are described. Regardless of the type of free flap used, careful preoperative planning, attention to the size and location of the anatomical defect, and correct contouring and insetting should allow for maximal functional result and minimize postoperative morbidity.