Coverage of soft tissue defects in acute surgery for deep burns of the limbs.

Burns of the limbs affect 48.6% of burn patients. Injury mechanisms condition their depth and degree of extension. Injury of the hands and/or the joint areas entails considerable risk of retraction. Coverage is consequently doubly challenging, it is a matter not only of compensating for a soft tissue defects, but also of striving to prevent early (infectious) and late (amplitude limitation, pain, loss of function…) complications. Thoroughgoing assessment of the initial injury and associated lesions is conducive to rapid determination of a therapeutic strategy tailored to the relevant functional issues and subsequent rehabilitation. Following a summary of the epidemiological elements and the medical context of management, a review of existing treatments has been drawn up based on the data in the literature and current professional recommendations. Emergency procedures, the different types of excision and the possibilities of autologous covering and skin substitutes are reported. Last but not least, routinely validated indications are synthesized.

[Role of skin substitutes in surgical repair of the sequelae of burn injuries]. / Place des dermes équivalents en chirurgie réparatrice des séquelles de brûlures.

The therapeutic management of the sequelae of deep burns always relies in principle on dermal-epidermal grafts. The latter, the price of which to pay is heavy scarring, cannot always be performed because the surface of skin available may not be sufficient. Research pathways have turned towards the creation of skin substitutes to minimise the scarring and improve the cosmetic quality of the grafts. We review the technical characteristics of collagen matrixes (Intégra(®) - Matriderm(®)) and their method of use.

[Surgical strategy for neck burns and their sequelae]. / Stratégie chirurgicale des brûlures du cou et de leurs séquelles.

Burns of the neck are common and expose them to functional and aesthetic complications which are sometimes very serious. Care in the acute stage and treatment of sequelae contribute to a common goal of restoration: Maintain or recreate a chin-neck angle and get a quality skin as close as possible to the original skin, in terms of flexibility, texture, thickness and color. The wide variety of cases encountered requires knowing the armamentarium available to us today, and the anatomical basis and clinical underlying indications.

Cytomegalovirus infection in severe burn patients monitoring by real-time polymerase chain reaction: A prospective study.

BACKGROUND: Cytomegalovirus (CMV) infection has been shown to occur not rarely in critically ill patients in the past decade. However, little data are available on CMV infection in burn patients whereas their susceptibility to CMV infection has been proved. METHODS: We prospectively assessed CMV viremia by real-time polymerase chain reaction and clinical outcome in immunocompetent burn patients with total burn surface area greater than 15%. RESULTS: Twenty-nine patients were enrolled. The rate of CMV infection was of 71% in CMV seropositive burn patients, and of 12.5% in CMV seronegative burn patients. CMV reactivation was associated with a higher IGS 2 score on admission. High grade CMV viremia was associated with longer mechanical ventilation duration, higher infection number, higher transfused red blood cell number, and longer ICU stays. There were no differences on mortality rate between patients with and without CMV reactivation. CONCLUSION: CMV infection rate is considerable in burn patients with TBSA greater than 15%. This infection seems to be mostly due to reactivation of latently existing virus.

[Necrosis of the glans penis: a complication of an injection of buprenorphin in a opioid abuser]. / Nécrose du gland après injection volontaire de buprénorphine dans un contexte de toxicomanie aux opioïdes.

Necrosis of the penis glans is commonly described after circumcision or strangulation. We report the case of a patient, opioid abuser, who presented an isolated glans necrosis after an injection of buprenorphin. The buprenorphin (Subutex) is a sublingual partial mu-opioid agonist used for the treatment of heroin dependance. Its intravenous or subcutaneous abuse is associated with local infection. The patient require a surgical intervention. After the failure of a mucosal graft, a soft skin graft was done.

A non-surgical device for faecal diversion in the management of perineal burns.

BACKGROUND: Burns to the perineal, buttock and upper thigh areas are frequently exposed to continual faecal contamination which results in sepsis, graft loss, delayed wound healing and shrinkage of scars. A temporary diverting colostomy may be required. Two specifically designed intrarectal catheters were evaluated for their safety and ability to divert faeces away from the burn and allow wound healing. METHODS: A prospective study was conducted involving patients at the burns centre. Either the Zassi Bowel Management System or the Flexi-Seal Fecal Management System were used. These differed only in the presence of a specific intraluminal balloon in the Zassi system to facilitate retention of infused irrigates. Data regarding skin graft success, wound contamination and adverse events were collected. RESULTS: The study included eight participants, five of whom were treated successfully without colostomy. Four participants experienced complications, comprising one bowel occlusion, one anal ulceration and two reversible cases of anal atony. CONCLUSION: A specifically designed intrarectal catheter can divert faeces to allow wound healing, and may avert colostomy. More studies are necessary to evaluate safety.

Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery.

Adequate acute treatment of the deeply burned hand and any subsequent reconstructive procedures may be hampered by the lack of sufficient suitable graft material and the risks of donor site morbidity and scarring. This investigation was designed to determine the feasibility of treating deep hand burns using a dermal regeneration template. Patients with deep hand burns underwent either acute treatment or reconstructive procedures with Integra dermal regeneration template. Wound sites were first grafted with the dermal regeneration template, and then 2-3 weeks later after neodermis formation the silicone layer of the Integra was removed and a very thin split-thickness epidermal autograft placed. Acute grafting was performed on 15 hands in 11 patients and reconstructive surgery on 14 hands in 11 patients. Median follow-up was 12 months. Integra take was 100% on all treated hands. After acute grafting the wound site skin was flexible and supple and did not adhere to the deeper layers, thus permitting free articular and functional movement. Cosmetic results of acute surgery were judged satisfactory by both patients and surgeons. After reconstructive procedures, significant improvements were achieved in cosmetic status, based on Vancouver Scar Scale (p=0.0002), and in three measures of function, namely, thumb opposition score (p=0.0005), fingertip-to-palm distance (p=0.0039) and prehensile score (p=0.0039). Favourable cosmetic and functional outcomes were consistently attained using a synthetic dermal regeneration template for treatment of deep hand burns either by acute grafting or reconstructive surgery.

Reconstructive surgery using an artificial dermis (Integra): results with 39 grafts.

Integra was initially developed for the primary coverage of acute burns. It acts as a network for dermal reconstruction. An epidermal graft overlay is necessary after 3 weeks to achieve the in vivo reconstruction of a full-thickness skin equivalent. The quality of the functional and aesthetic results achieved led us to evaluate the potential of Integra in the treatment of burn scars and for general reconstructive surgery. We present a series of 31 patients who underwent Integra grafting for reconstructive surgery at a total of 39 operational sites. The average area grafted per procedure was 267 cm(2). Complications (silicone detachment, failure of the graft, haematoma) were observed in nine cases. The length of follow-up ranged from 0.5 year to 4 years. Two patients (two sites) were lost to follow-up; the final results in the remaining patients were considered to be good in 28 cases, average in six cases and poor in three cases. The disadvantages of using Integra in reconstructive surgery are the necessity of two operations, the risks of infection under the silicone layer, of the silicone becoming detached and of recurrence of contraction. On the other hand, Integra has many advantages including its immediate availability, the availability of large quantities, the simplicity and reliability of the technique, and the pliability and the cosmetic appearance of the resulting cover. In the light of these preliminary results, Integra appears as a new alternative to full-thickness skin grafting, skin expansion and even skin flaps for reconstructive surgery.

[Integra, a new surgical alternative for the treatment of massive burns. Clinical evaluation of acute and reconstructive surgery: 39 cases]. / Intégra, une nouvelle alternative chirurgicale pour le traitement des grands brûlés. Evaluation clinique en chirurgie aiguë et réparatrice: à propos de 39 cas.

Early excision and prompt coverage in severely burned patients are the best way to lessen morbidity and improve survival. Repair of full-thickness burns requires replacement of both dermal and epidermal components of skin and treatment with split thickness autografts replaces both of them. But healthy skin is not sufficient in extensive burns. Alternative to split thickness skin grafts have been studied by several groups including epidermis, dermis or a complete replacement comprising epidermis and dermis. Because of the difficulties in homografts supplying, a new way was use to replace the dermis. In 1981, Yannas and Burke were the first to develop such a matrix. Intégra is available in France since 1997 and was used in our service for the treatment of both acute and reconstructive surgery for burned patients. Twenty patients were treated for acute surgery. Nineteen patients were treated for reconstructive surgery of burn scar contractures. Fifty-one grafts of Intégra were performed. Long-term final results seem to show that Intégra improve cosmetical and functional results and is a new surgical alternative for the treatment of burns in the acute phase as well as in late surgery of deformities.

[Airbag-caused burns]. / Brûlures par airbags.

BACKGROUND: Injuries by airbags are seen more frequently as more vehicles are equipped. CASE REPORTS: 7 cases of burns by airbags are reported. Most of burns are second degree lesions located on upper extremity and trunk. DISCUSSION: Lots of components are implicated in airbag deployment. So, three types of burn are described: thermal, chemical and friction. The treatment is simple. But, omission could be potentially dangerous, especially alkali chemical keratitis.

[Reconstruction of the nose in deep extensive facial burns]. / La reconstruction du nez dans les brûlures pan-faciales profondes.

The nose is in the medial portion of the face and is frequently injured in trauma of this area. Due to its situation its structure and shape, and its essential function, this organ is particularly exposed in the case of facial burns. These injuries, are usually associated with larger injuries, and frequently with systemic problems, such as respiratory problems. The authors describe nasal burns in the larger context of facial burns, and summarize recent data on this topic. They then recall the fascinating story of rhinopoiesis through the ages. The third part is devoted to their personal approach to reconstruction of the nose in severe panfacial burns, using a forehead flap with one or several tissue expanders.

[Device of the burnt face. Role of compression and splints]. / L'appareillage de la face brûlée. La place des compressions et des conformateurs.

The face is one of the areas of the body most frequently affected by burns. Pressure therapy maintains facial scars until maturation is achieved to present hypertrophic scars or contractures. Elastic pressure garments are usually used, but they do not provide adequate pressure on areas such as naso-labial folds or labio-chin folds. Silicone splints are therefore added under this elastic face mask. A rigid transparent face mask or silicone face mask allows better management of facial scars. A positive plastic mold is obtained from a negative alginate mold of the patient's face. A high temperature plastic is heated and stretched on to the positive mold. The mask is worn continuously excepted when bathing eating and rehabilitation. Follow up is necessary to prevent complications and to revise the mask as the scars change. Nostril and oral commissures are treated with inserts which maintain adequate size or corrected contractures. Satisfactory results can be obtained with cooperative patients.

[Propofol and ketamine for dressing in burnt patients]. / Propofol et kétamine pour la réalisation de pansement de brûlés.

General anaesthesia is often required for burns dressing. Ketamine was the most common agent for carrying out removal of adherent dressings. Disadvantages are delirium on emergence from anaesthesia and prolonged recovery. We have studied an intravenous combination of propofol and ketamine in 29 burned patients for 39 dressings. After induction with 1 mg.kg-1 of propofol and 0.75 mg.kg-1 of ketamine, the maintenance rate was 2.5 mg.kg-1.h-1 of each agent. Satisfactory intraoperative conditions were obtained in all cases. Mean time of recovery was less than 15 min. Unpleasant dreaming occurred in 3 patients only, without agitation. The technique proved to be simple, effective and should revive interest for ketamine in the management of burned patients.

[Development of non-cellular dermis: a step towards a total artificial skin]. / Mise au point d'un derme acellulaire: un pas vers la peau artificielle totale.

In large cutaneous defects due to severe burns, dermal mesenchyme healing has to be controlled in order to avoid granulation tissue that rapidly leads to important contractures and hypertrophic scars. We report a study about the use of an artificial dermis made of human collagen (I and III) and several glycosaminoglycans. This artificial dermis was grafted on Sprague-Dawley rats after a 9 cm2 skin excision on the back. An identical control area was made just under it, on the same animal. The animals were killed on day 2, 7, 14, 21, 30 and different parameters were studied: clinical study, bacteriological study, histopathological appearance, scanning and transmission electron microscopy, immunological study, physical parameters, UV absorption. Direct and indirect cytotoxicity tests, performed on cell cultures showed no change in the morphology and of the growth of the keratinocytes or of the fibroblasts. A biocompatibility study showed on the early days (day 2, 7, 14) that adherence of artificial dermis to the underlying tissue was good. There was virtually no bacterial colonization. Ultrastructural study showed an important cellular colonization, with an inflammatory appearance at the beginning. After a while, fibroblasts appeared, with synthesis of neocollagen fibers as early as the second week. Histological study showed neovessels in the artificial dermis. Later (day 21, 30) the inflammation was less severe and the amount of endogenous collagen increased.(ABSTRACT TRUNCATED AT 250 WORDS)