SURGICAL TREATMENT OF POST-BURN LEUK0DERIVIA

El-Otiefy M.A., EI-Sonbaty M.A.

Plastic Surgery Unit, Department of Surgery Faculty of Medicine, Assiut University, Egypt

SUMMARY. Post-burn leukoderma is one of the common complications of bums which usually lead to social and psychological disturbances. Its treatment can be difficult. 30 patients with post-burn leukoderma have been studied and surgically treated with excision and skin grafting for the last 3 years in our Plastic Surgery Unit. Modifications of the technique were developed during their treatment. The results were encouraging as regards cosmetic appearance.

Pigmentation is not only a protective function of the melanocyte but also plays an important role in cutaneous aesthetics (Fitzpatrick, 1971).
Leuko~erma is the outcome of specific disorders or conditions and ill-defined factors affecting the pigmentary system through either local destruction or absence of melanocytes, and sometimes through inhibition of their function. Although leukoderma is a clinically benign disorder, psychological and social consequences are common (Porter et al., 1979).
Replacement of the affected epidermis with a graft bearing functional melanocytes will improve the cosmetic problems. Such a technique, known as epidermal grafting, was first described by Falabella in 1971.
The aim of this work is to extend experience of repigmentation of post-bum leukoderma by autologous split-thickness skin grafts and to describe a few improvements in the techniques.

This study included 30 patients with post-burn leukoderma who presented to our Plastic Surgery Unit during the last 3 years. 9 were males and 21 were females. Their ages ranged from 7 to 55 years. Most of their leukodermic areas were in the upper and lower limbs and the front of the chest (Table).
Two-thirds of these patients had post-burn contractures in addition to their leukoderma. For these patients correction of their contractures took the first priority, followed by treatment of the leukoderma.
The other one-third of the patients had post-burn leukoderma only, and they presented in order to have their unsightly white areas treated.
Scalped excision of the leukodermic areas was practised in 12 cases (Fig. 1). Tangential skin excision of the leulcodermic areas using a skin graft knife was performed in 13 cases (Fig. 2). Combination of the two methods of skin excision was eftected in 5 cases.
The split-thickness skin grafts used to cover the resultant raw surfaces were taken from normal skin donor sites in 17 cases and from healthy uncomplicated previous donor sites in 13 cases.
The last modification in our work was use of the previously treated leukodermic areas as donor sites of skin graft to show whether it retains or loses its pigmentation (Fig. 3).

Unsightly leukoderma mainly on exposed skin surfaces is a common complication of burns. Patients with burns usually accept hyperpigmentation more than leukoderma.
There are several reports (Falabella, 1978; Kono et al., 1963) that vitiligo vulgaris can be repigmented successfully with multiple minigrafts. Harashina (1985) reported the treatment of leukoderma after bums by a combination of dermabrasion and chip skin grafts.
In the present work, we used the previously reported use of skin graft in the treatment of post-burn leukoderma, but during the period of work there were modifications in this conventional method.
Scalpel excision of the leukodermic areas was usually time-consuming, associated with much bleeding, and resulted in widening of the defects. The skin grafted areas were subject to contractures unless sufficiently splinted. Epidermal excision of the leukodermic areas therefore replaced scalpel excision and it was observed that epidermal excision was a rapid procedure, associated with less bleeding. No widening of the treated areas occurred and after its covering by skin grafts, there was no hazard of contractures, since the dermis remained unharmed.

Fig. 1 Female patient aged 20 years with post-burn leukoderma in front of the knee and leg. a) pre-operative, b) post-operative after scalpel excision and S.S.T.G. Fig. 2 Female patient aged 14 years with post-bum leukoderma of inner side of both thighs. a) pre-operative b) immediate post-operative after tangential skin excision and S.S.T.G.

Fig. 3 Female patient aged 16 years with post-bum leulcoderma a) pre-operative b) post-operative; the treated leukoderma was used again as a donor site in the left thigh c) pre-operative d) post-operative, using the skin taken from the treated leukoderma.

Hyperpigmentation used to be one of the problems afTecting skin grafts (Miry Mir, 196 1), until a method of skin grafting utilizing previous donor areas was reported by Lopez, in 1972. This method seems to produce less pigmentation of the grafts. Using previously healed uncomplicated donor sites as a source of skin graft, the results were cosmetically encouraging as regards the colour of the grafts.
For patients with extensive post-burn leukoderma and limited donor sites, we can harvest the same donor sites more than once. Also the grafted leukodermic areas can be used as an additional donor site with accepted cosmetic appearance.

RÉSUMÉ. La leucodermie est une complication commune des brûlures qui crée très fréquemment des problèmes sociaux et psychologiques. Le traitement peut être difficile. Pendant une période de 3 ans les Auteurs ont étudié chez leur Unité de Chirurgie Plastique 30 patients qui présentaient la leucodermie post-brûlure, soumis à l'excision chirurgicale et à la greffe cutanée. Au cours du traitement certaines modifications de la technique ont été développées. Les résultats ont été encourageants pour ce qui concerne l'aspect cosmétique.

BIBLIOGRAPHY

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