|Annals of Burns and Fire Disasters - vol. X
- n. 1 - March 1997
SPEARHEAD PROCEDURE FOR
REPAIR OF WEB SPACE BURN SEQUELAE
Despite early surgery, appropriate physical
therapy and active cooperation on the part of the patient, burns of the web space often
leave aesthetic and functional sequelae. Two types of deformity are involved: interdigital
contracture, which hinders abduction, and webbing, i.e. superfluous interdigital scar
tissue joining adjacent fingers. These deformities may be present in varying degree - the
most extreme clinical and anatomical form is true syndactyly, where separation between the
fingers is nonexistent. A procedure is proposed to obviate these sequelae. This makes use
of a local flap drawn on the dorsal aspect of the hand, the shape of which resembles that
of the blade of a spear - hence the name "spearhead" procedure. The advantages
are that this flap is well vascularized and allows better distribution of the redundant
skin of the web, so that the lateral digital regions can be closed directly. Because of
the broken suture line recurrence is unlikely, and a very natural appearance is achieved.
Roug6 D., Bodnar M., Grolleau LL.,
Braye E, Micheau R, Chavoin LR, Costagliola M.
Eur. J. Plast. Surg., 19: 77-80, 1996.
MANAGEMENT OF BURN INJURIES IN CHILDREN
The importance of the correct management of burn injuries is
evident if it is considered that of the approximately 120,000 burn patients seen annually
in casualty departments throughout the United Kingdom about half are children. This
article presents a treatment protocol for paediatric burns from the first-aid stage
through management in the emergency department until treatment in a burns centre. In order
to obtain the best results from burn injuries in children, it is stressed that a
coordinated team approach is necessary, often over a period of many years. This involves
surgeon, intensivist, physiotherapist, occupational therapist, dietician, social worker,
and clinical psychologist, all of whom must have a particular interest in and specialized
knowledge of burn injuries.
Slator R., Frame J.D.
Eur. J. Plast. Surg., 19: 207-12, 1996.
KERATINOCYTE CELL LYSATES CONTAIN MULTIPLE MITOGENIC ACTIVITIES AND STIMULATE CLOSURE OF
MESHED SKIN AUTOGRAFT-COVERED BURN WOUNDS WITH EFFICIENCY SIMILAR TO THAT OF FRESH
ALLOGENEIC KERATINOCYTE CULTURES
Grafting with allogeneic keratinocyte
cultures has long been used as a wound-healing therapy. Their post-graft survival time is
however limited, and their effect is generally attributed to the production of wound
repair- stimulating factors promoting the proliferation and migration of resident cells.
This study shows that lysates of cultured keratinocytes contain mitogerric activity for
keratinocytes, endothelial cells, and fibroblasts. The lysates also inhibit the
contraction of collagen gels by human skin fibroblasts. In the light of these observations
and in vivo data specifically obtained for this research, the effect was evaluated
of total keratinocyte lysates on the healing of meshed skin autograft-covered burn wounds.
A number of burn wounds (20) were tangentially excised and autografted with meshed
conventional skin grafts. An area treated with a gel containing lysated keratinocyte
cultures was compared in terms of epithelializa-tion on day 5 with an area treated with
placebo-gel. An additional fresh keratinocyte alloculture was used as a positive control
in six patients. It was found that the newly formed epithelium on day 5 was 31.1% in the
treated area compared with 16.5% in the placebo area, a result comparable with that
obtained by treatment with fresh keratinocyte cultures, i.e. 33.8%. These figures indicate
a twofold stimulation of epithelialization.
Dumslaeger L., Verbeken G., Reper R,
Delaey B., Vanhalle S.,
Plast. Reconstr. Surg., 98: 110-7, 1996.
STUDY OF SKIN DONOR SITES AND DEEP PARTIAL-THICKNESS BURNS TREATED WITH CULTURED EPIDERMAL
This report describes the results of banked
cultured human epidermal autografts in two clinical studies in donor sites and in deep
partialthickness burns. Donor split-thickriess skin harvesting was performed in ten burn
patients. Banked cultured epidermal autografts (CEAs) promoted more rapid
epithelialization of the wounds: 6.9 days compared with 11.1 days in controls (healing
reduction time, 37.8%; p < 0.01). Allografted sites were less erythematous than
controls (p < 0.01), with a greater tendency towards normal pigmentation. In the deep
partial-thickness burns study ten patients with 18 wounds were treated. The wounds treated
with cultured allografts presented complete re-epithelialization after 3-6 days. The two
studies indicate that banked CEAs promote significantly faster epithelialization of donor
sites and deep partial-thickness wounds. It is therefore recommended that cultured
allografts should be used routinely in the treatment of burn patients.
Rivas-Torres M.T., Amato D.,
Arámbula-Alvarez H., Kuri-Hareuch W,
Plast. Reconstr. Surg., 98: 279-87, 1996.
FIBROBLASTS USED TO GROW EPIDERMAL AUTOGRAFTS PERSIST IN VIVO AND SENSITIZE THE GRAFT
RECIPIENT FOR ACCELERATED SECONDSET REJECTION
Cultured epidermal autografts (CEAs) are
widely used for wound coverage in severely burned patients. These grafts are particularly
attractive because they permit a 10,000-fold expansion of donor keratinucytes, but they
also have their disadvantages. Apart from the long period required for their growth (3
weeks), the unpredictability of take, the lack of a dermal component, and high costs,
there is also the phenomenon of late graft loss. The purpose of this study was twofold: to
determine whether foreign fibroblasts used to cultivate CEAs persist in vivo after
grafting and whether these fibroblasts sensitize the host to foreign histocompatibility
antigens. Experiments involving mice showed that immunogenic fibroblasts used to grow CEAs
survive in vivo and sensitize the graft recipient for accelerated second-set
rejection. These persistent cells may initiate an inflammatory response capable of leading
to late graft breakdown, thus limiting the utility of CEAs cultivated with a foreign
fibroblast feeder layer.
Scott Hultman C., Brinson G.M., Siltharm S., deSerres S., Cairns
B.A., Peterson H.D., Meyer A.M,
J. Trauma, 41: 51-60, 1996.
CYTOKINES AND PROSTAGLANDIN E2 BY SUBPOPULATIONS OF GUINEA PIG ENTEROCYTES: EFFECT OF
ENDOTOXIN AND THERMAL INJURY
The purpose of this research was to determine
whether distinct subpopulations of enterocytes located in various areas of the intestinal
villi differ from each other in the production of cytokines and other mediators, whether
these cells respond differently to stimulation with lipopolysaccharides, and whether
thermal injury affects the production of the mediators by these cells. The production of
the inflammatory cytokines tumour necrosis factor (TNF), interleukin- I (IL- 1), and
interleukin-6 (IL-6), and the production of prostaglandin E, an immunosuppressive agent
and a regulator of the the production of inflammatory cytokines, were evaluated for
enterocytes from unburned guinea pigs and from guinea pigs 24 hours after thermal injury.
Three subpopulations of enterocytes were obtained by sequential incubations of the small
intestine, from the villus tip towards the crypt, with buffer containing
ethylenediaminetenaacetic acid. The cells were cultured in the presence of endotoxin, and
the supernatants were assayed for the mediators. It was found that thermal injury prompted
all three enterocyte subpopulations to produce larger quantities of TNF and IL-6 compared
with cells from unburned animals, and that enterocytes nearer the crypt produced the
largest quantities of the cytokines. These results are of clinical relevance since gut
integrity is compromised after thermal injury and enterocytes that may previously have
been unexposed or less exposed to endotoxin can become a significant source of
Ogle C.K., Mao J.X.,
Hasselgen P.O., Ogle J.D., Alexander J.W.
J. Trauma, 41: 298-305, 1996.
EARLY USE OF PRESSURE
MASKS TO AVOID FACIAL CONTRACTURE DURING THE PREGRAFTING PERIOD
This paper considers the concept of the use
of pressure therapy on facial burns before definitive debridement and split-thickness skin
grafting are performed, in order to reduce the formation of contracture and deformity in
the healing burn wound. This concept is based on the knowledge that the granulating wound
bed is extremely prone to contraction, with most wound bed contracture occurring within
the first four weeks post-burn as a result of the high myofibroblast content. If
definitive treatment is delayed, considerable wound contraction and deformity will occur
during this pre-graft period and be present at the time of debridement. The application of
pressure masks may prevent these complications. A case history in which good results were
obtained is presented, regarding a 15-year-old patient with 40% BSA flame burns and deep
partial-thickness facial burns. The patient ultimately refused to wear his pressure mask
following discharge and contracture occurred, with reconstruction proving necessary.
Giele H.P., Currie K., Wood F.M.,
J. Burn Care Rehabil., 16: 641-5, 1995.
FREE FLAP DONOR SITES USED IN RECONSTRUCTION AFTER BURN INJURY
It is usually possible to manage burn wounds
without using free tissue transfers. One reason for this is that tissue expansion
techniques for the creation of local flaps are now very versatile and represent a simple
alternative when it is necessary to have vascularized tissues. There are however some
exceptional circumstances when the two concepts can be combined to enhance burn injury
reconstruction even further. Pre-transfer expansion of free flap donor sites also has a
number of advantages compared with post-transfer expansion as it is possible to achieve
immediate primary donor site closure, and the fabrication of flaps of appropriate size and
thickness can be specifically manipulated simultaneously. Three illustrative case
histories are presented.
J. Burn Care Rehabil., 16: 641-5, 1995.