Annals of the M.B.C. - vol. 1° - n° 2 - September 1988

PRIORITIES AND PITFALLS IN TREATMENT OF BURNS

SUMMARY. An analysis of burn work done in I-jubIjana during the last 30 years showed that the most important lesson we learned is to plan an individual strategy of treatment for each severely burned patient. It is an advantage to organize the bum service in the country in erder to have the severely burned patient sent for treatment without delay. If this is done, then we do not miss the best time to perform releasing incisions or excisions of the burn eschar in circumferential bums which compromise the blood circulation causing severe late invalidity.
The early delayed excision of deep dermal burns is the treatment of choice; however it may produce very bad results if not performed properly. A series of patients is shown to illustrate these points.

Introduction

It is very useful to speak openly about our mistakes in early excision of deep dermal and subdermal burns. Sharing the knowledge about pitfalls is often more instructive than the technical details describing how to achieve excellent results.
Burn surgery has made great progress, and the active approach to eliminate the necrotic layers of skin as soon as possible after trauma followed by immediate grafting has won worldwide acceptance.
Even among surgeons convinced of the advantages of this procedure there might be some who are overzealous and do the operation at the wrong time.

I would like to present a number of situations which resulted in unexpected complications because some of the details in the treatment were not respected. The first point 1 would like to present is the time factor in excision.
When Dr. Janzekovic was working and studying the details of early delayed excision she suggested excising the burned layers between the third and the fifth day. There are good reasons for this. As everybody knows a burn will usually be followed by oedema, and the alterations in the circulation make it therefore difficult to differentiate properly the viability of tissue.
As shown in the slides an overzealous surgeon tries to perform the excision of a deep dermal burn of the face during the first twenty-four hours. As seen in the first slide (picture No. 1) there was clearly a great amount of oedema. The excision performed was in many areas too superficial and had a disastrous result as the grafts which were applied immediately did not take. Two years of treatment and more than ten operations were necessary in order to correct the deformity (pictures 2, 3, 4, 5). The conclusion is clear. Never excise before the oedema has subsided.

Picture No. 2 Picture No. 3 Picture No. 4 Picture No. 5 Unsuccessful grafting and end result after additional operation

On the other hand in certain cases there are clear indications for a quick and aggressive surgical approach. If the bum of an extremity is full-thickness and circular causing constrictions, it is necessary to operate. We would prefer to perform not incisions but immediate excision in such situations followed by immediate grafting; provided, of course, that the general condition of the patient permits this procedure, i.e. that the bum of the extremities is not associated with extensive burns elsewhere. In such a situation, we should change our strategy of treatment. As regards priorities we are therefore convinced that immediate excision in constrictive, circular and very deep bums in extremities followed by immediate grafting is the right choice which will give better results in a shorter period of time.
A second consideration concerns mesh grafts; their usefulness is generally well-known. However it is a great mistake to apply mesh grafts to skin defects of the face. The young boy who was admitted rather late presented granulating infected areas of the face (picture No. 6) and because of the infection the surgeon was convinced that it would be safer to cover these areas with mesh grafts and thus obtain a good healing (picture No. 7).

Picture No. 7 Picture No. 6 Picture No. 8: End result unsatisfactory Granulating area of the face - mesh graft applied

This was done, but the aesthetic appearance was never satisfactory, either immediately after the healing or in the years that followed. He underwent several abrasions but from the aesthetical point of view the result, although acceptable, did not completely satisfy the patient (picture No. 8). There is one important observation connected with this case: there seems to be a great reluctance to excise such areas later and replace them by a skin graft of proper thickness.
A third consideration concerns early delayed excision of bum of the hand followed by immediate grafting. In the last twenty years we have performed more than five hundred cases of early excision of burned hands and it was discovered during that period that excision under tourniquet required a great deal of experience. It was found that under inexperienced hands even viable layers of skin were sacrificed unnecessarily. In performing excision under tourniquet, which we prefer, the surgeon is only guided by the pearl white appearance of the dermis and by small unobliterated vessels. Therefore it would be safer for beginners to excise without a tourniquet and be guided by capillary bleeding as regards the viability of the tissue. However we should not forget that there is a valid indication for using the tourniquet in all cases where we must save every drop of blood we can. It is also useful to use magnifying glasses to look at the excised areas in order to differentiate better the thrombosed and non-thrombosed vessels of the dermis.

Conclusion

These considerations, which all relate to the technical procedure in treating deep dermal and subdermal burns, demonstrate that it is not only important to know the method itself, but also all the details and possible errors in performing these procedures.

RÉSUMÉ. Une analyse du travail effectué sur les brûlures à Ljubljana au cours de ces 30 dernières années a montré que la leçon la plus importante à retenir est celle de projeter une stratégie individuelle pour le traitement de chaque patient brûlé.
C'est un avantage que les patients envoyés soient soignés sans retard. Si cela est fait, nous ne perdons pas un temps précieux pour pratiquer une incision ou une excision de la croûte de la brûlure dans le cas de brûlures circonférentielles qui compromettent la circulation du sang et causent des invalidités graves.
La première chose à faire dans le cas de brûlures dermiques profondes est de ne pas retarder l'excision. Cependant cela pourrait avoir des conséquences pénibles si elle n'était pas bien faite. Des exemples illustrent ces points.