RECONSTRUCTIVE EVALUATIONS ON PLASTIC SURGERY FOR INJURIES AND MASSIVE TISSUE DEFECTS

Belba G., Pepi G.

Clinic of Burns and Plastic Surgery, Hospital N. 2, Tirana, Albania

SUMMARY. The authors present their experience in the plastic surgical treatment of massive tissue injuries in the extremities. After a description of the results of 66 cases, the technical problems of treatment are discussed. Of special interest is the physiopathological division into three entities of the avulsed flap. The practical evaluation of flap vascularization creates premises for a more active surgical attitude, improving the general prognosis.

Introduction
Severe tissue damage usually affects the extremities. This is due to the fact that these body parts are highly mobile and in continuous activity. The causes of the injury are various, but the result is often the same: tissue injury, disorder of anatomic regularity, massive defects combined with bone damage (4, 8). The nature of this shocking trauma requires the formation of complex teams of specialists, who intervene in their various sectors (1, 6). Independently of the surgical stabilization of particular anatomic structures, in the course of the intervention there comes a key moment which decides not only the success of above procedures but also the life of the extremity. At a certain point the plastic surgeon "takes the fl6or"; his task is to defend the reconstructed anatomic formations, to refine the cutaneomuscular system and to secure, through the covering of injured areas, a normal post-operative period, eliminating sepsis with its dangerous surprises. Experience has proved that this is the most difficult period in the treatment of these problematic patients.
In the light of the severe course of the disease and considering the ever wider manipulations by the plastic surgeon, working in this case as a trauma surgeon, surgical opinion gradually displaced these patients towards plastic surgery clinics. The grouping of cases treated during 1990, when the activity of our new bums and plastic surgery opened, is interesting not only because of the high incidence of this polytrauma, but also shows the complex methods of treatment.

Material and method of treatment
During 1990, 66 cases of wounds caused by different mechanical traumas were admitted to our Burns and Plastic Surgery Clinic. This was equivalent to 10.2% of the entire year's hospitalization. Twelve patients were treated in the intensive care unit. Thirty-one cases were urgent, while 35 others presented after time periods of up to 1 or 2 months, on the advice of those who had sent them. The average age of the injured patients was 29 years. 13 were children and 53 adults. 22 were females and 44 males.
The damage was located in the inferior extremities in 41 cases, while in the other cases it was in different body regions. The damage also involved some combined regions, especially femorogluteal and femoroabdominal (Fig. 1, 2).
The patients in reanimation had an average injured tissue surface of about 8.5%, while the average surface for the patients treated in the wards was 1.6%. Besides subcutaneous injuries, the fascia and the respective muscle were generally damaged by the causative agent. In 33 cases (50%) the injury was accompanied by bone fractures, at the level where the main striking force was applied. Consequently, in addition to the 12 patients treated in the intensive care unit, 18 others needed elementary reanimating therapy, because of alterations in the general conditions and as indicated by laboratory analyses.
Before plastic surgery the wounds were explored and debrided. After the orthopaedic or any other intervention the plastic surgeon retreated the wound, refreshed the cutancomuscular tissues, setting them as near as possible to their anatomic position. The defect was permanently covered with skin autografts Of average thickness. In the cases treated conservatively the wounds were gradually treated and plastic surgery was considered only after budding of the granular tissue. We adopted this policy because few of the 40 cases coming from district areas presented in time.

In more extensively injured areas, but also in average or less injured areas, secondary infection developed as a result of unsuitable and delayed treatment. In laboratory analyses, 8 cases of Proteus mirabilis were discovered, which further complicate post-traumatic sepsis. Prognosis was complicated by the coexistence of several micro-organisms. In three cases we observed Proteus and Staphylococcus aureus, and in two cases Staphylococcus with Bacillus coli. Protection from sepsis was achieved through the application of powerful antibiotics like gentamicin, glazidin, amikacin, liquids, electrolytes, tranquillizers, plasma, human albumin, blood'~tc, as required. The main factor in preventi ' rig sepsis is active surgical treatment and intensive local care on the basis of the antibiogram.
In the patients treated in the intensive care unit, we performed on average 2.6 interventions, including two epidermodermic plastic operations and usually one debridement as an intermediate intervention, for the excision of renecrotized tissues.
We performed debridement in only 22.2% of the patients treated in the ward, as a preparatory intervention before plastic surgery. The average number of interventions in this group of patients was 1.5, with an average of 1.3 epidermodermic plastic surgery operations for each case.
Although the damaged surface of the patients treated in reanimation was 5 times as large as that of the patients treated in the ward, the number of plastic surgery interventions was slightly greater. This finding shows once again that delayed wound treatment is made more difficult by the presence of local fibrosis, caused by the deficient initial treatment.

Results
In 52 (78.79%) of the patients the consolidation of the epidermodermic transplants was satisfactory. In 6 cases (9.09%), we observed a total autolysis of the transplant, as a result of infection, with compromising of the general condition in two cases. In these patients we performed more than two plastic interventions per case. In 8 cases (12.12%) we were forced to perform a second plastic operation because of the partial autolysis of the transplant due to different reasons, such as local fibrosis, secretions, and placing of the transplant in regions contused with fractures or bone fragments.
As a result of severe traumatic injuries, in 15 cases (22.7%) amputations were performed at different levels of the inferior extremities (4 in the femoral region, one in the leg, 4 in the foot, and 6 in the fingers). A 70-year-old patient treated for a tissue injury localized in an upper extremity died in the late post-operative period from an acute attack of myocardia. Out of the 66 patients, 65 achieved wound healing. The average length of hospital stay for the patients treated in the ward was 34.1 days, and for those in intensive care 72.1 days.
During hospitalization, in 7 cases various complications were observed such as: pleurisy, bronchopneumonia, pulmonary thromboembolism, osteomyelitis and local fistula. Treatment was given as required. Subsequent medical controls will show how many patients suffer from post-traumatic effects, and how many need reconstructive surgery.

Discussion
A multitude of authors, in anatomic, surgical and laboratory studies, throw light on these problems, with the aim of treating these wounds in the best way possible, fighting the causes of infection, reconstructing injured structures, and covering the defects at the optimal time (3, 4, 5, 9).
Besides the treatment of subcutaneous tissues, aponeurotomy or decompressive fasciotomy (2, 7) are particularly important. This intervention restores life to the extremity, as it frees the tissues from oedema, reduces deep haematomas, makes the circulation less heavy, prevents myoneural deficits from developing and avoids the lodge syndrome.
Our discussion will focus on the treatment of the avulsed flap, a problem which came to light suddenly while we were studying the interventions carried out in patients treated in reanimation. Usually, in each case, the interventions were carried out as follows:

1. debridement of the wound, followed by skin grafts of the defects;
2. debridement of the renecrotized tissues;

3. skin grafts of the defects created by intervention number 2.

As seen from the above list, it is understandable that the carrying out of a complete necrosis of primarily devitalized tissues and of those which devitalize (necrotize) later could cut the number of interventions, reduce the septic condition, and heal the wounds faster. Our opinion is that this does not happen, firstly, because surgeons wish to leave as much cif the avulsed flap as possible, as they are convinced that the epidermodermip transplant can in no way serve as a regional authentic substitute. Secondly, the surgeon is liable to an inevitable feeling of suspicion regarding the quantity of tissues he must excise in the avulsed flap. Amid such complexity of feelings this desire inevitably leads to the conviction that more should be excised. This conviction is however never complete, just as there is no absolute demarcation limit between the part of flap that will survive and the one that will necrotize in a second phase. In order to get nearer to this limit and at the same time to reduce the possibility of error (on either side of the demarcation line), we think it suitable that the avulsed flap be divided into three physiopathological entities (Fig. 3). One author rightly considers the avulsed flap an abnormal one (10). Its division into three specific parts gives us a broader view of the processes going on inside it.

Fig. 3 Avulsed flap in femoral region. 1.necrotic zone   2.ischaernic zone   3.vital zone.

As a result of the direct traumatic injury, the apex of the flap keeps devitalizing. Thus, the first zone for the excision of which there is no surgical dilemma is necrotic. At the base of the flap a second zone is formed, which we would initially call ischaernic, as a consequence of the pulling rather than of the injurious action of the traumatic agent. Because of this action the vascular system of the zone undergoes changes, and ecchymotic islands are created in the flap, even with the formation of thrombi; because of the irregularities of the vessel intima and of local inflammation, the ischaemic zone becomes fully necrotized. The main pathognomonic sign of the necrotizing process is the appearance of epidermal blisters. The third zone, the vital one, is the zone at the base of the flap, on which the pulling action is tense but not injurious.
The surgeon must be guided by his ability and experience to excise as many tissues as possible near the demarcation line between the ischaernic zone and the vital zone. This demarcation line is very difficult to define at first and becomes easily discernible at a second critical moment. Its existence at the late post-operative period shows that we have not avoided intervention N' 2, and that we should defend the patient from probable infection. When technical equipment is perfected and we can define the demarcation line from the very beginning, new horizons will open up for the microcirculation of the avulsed flap.

RESUME. Les auteurs pr6sentent leur exp6rience du traitement, moyermant la chirurgie plastique, des 16sions massives tissulaires des extr6mit6s. Apr&s avoir d6crit les r6sultats de 66 cas, ils consi&rent les probl&mes techniques du traitement. La division physiopathologique du lambeau retranch6 en trois entit&s revet un int6ret particulier. L'&valuation pratique de la vascularisation du lambeau cr6e la base pour une attitude chirurgicale plus active, cc qui am6liore le pronostic g6n6ral.

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