Ann. Medit. Burns Club - vol. VII - n. 3 - September 1994

NATURAL SKIN GRAFT EXPANSION: OUR EXPERIENCE WITH A FOUR-MONTHS PREGNANT BURNED PATIENT

Caleff i E., Bocchi A., Toschi S., Papadia F.

Division of Plastic Surgery, University of Parma, Italy


SUMMARY. Skin has the property of stretchability in natural phenomena such as obesity and pregnancy but it can also be contracted by wound healing or cutaneous grafts. On the basis of these considerations, the case is reported of a four-months pregnant patient with abdominal bums. It is concluded that natural expansion overcomes wound and graft contraction and produces better final results in comparison to unexpanded cutaneous surfaces in the same patient or in another patient in whom natural expansion does not occur.

Introduction

Skin expansion is one of the most important innovations in plastic surgery, making it possible to increase reconstructive possibilities in the event of wide losses of substance.
Our starting point was the observation of the stretching of skin, due to its elastic properties, caused by obesity and pregnancy; while on the other hand we observed skin contraction and reduction after wound heating and skin graft take.
When these two forces conflict, it is of clinical importance to evaluate whether the retractile force overcomes, counterbalances or is inferior to skin expansion.
A clinical example is presented in a pregnant patient with second- and third- degree burns of the trunk and inferior limbs admitted to our hospital and subjected to skin graft to cover the raw areas.

Fig. 1 - Pre-operative aspect (13 days after injury). Fig. 2 - Pre-operative aspect after cleansing (23 days after injury).
Fig. 1 - Pre-operative aspect (13 days after injury). Fig. 2 - Pre-operative aspect after cleansing (23 days after injury).

Case report

C.D.A., 30 years old, presented second- and thirddegree burns in the thorax, left breast, adbomen and left thigh after a car accident, when she was 16 weeks pregnant. She was admitted to our Burns Centre 13 days after injury, coming from another hospital (Fig. 1).
Initially we performed local treatment of the burns with antibiotic products, chemical escharotomy and partial escharectomy.
Twenty-three days after hospitalization (21st week of pregnancy) the patient was submitted to total escharectomy and skin autografting. The grafts were removed from the thigh and meshed 3: 1 (Fig. 2).
The post-operative course was good, with total graft take and rapid healing of donor sites. The patient was discharged 35 days after hospitalization without local systemic or gynaecological complications.
At first, dressings were performed on an out-patient basis once a week, and then every 15 days.

Fig. 3 - Post-operative aspect (4 months). Fig. 4 - Post-operative aspect (1 year after delivery).
Fig. 3 - Post-operative aspect (4 months). Fig. 4 - Post-operative aspect (1 year after delivery).

Abdominal and breast grafts followed the physiological stretching of pregnancy. These were translucent and hyperaemic (Fig. 3).
The patient bore her baby in June 1991 and further controls at our Centre were carried out every two months until one year after delivery, showing a very satisfactory aspect of the abdominal and breast grafted areas, which were soft, elastic and non-painful (Figs. 4, 5). The healing of the left thigh burned areas, even though quite satisfactory, was of worse quality, with hypertrophic blushing and aching tissues (Fig. 6).

Fig. 5 - Post-operative profile aspect showing elasticity of skin and softness of graft (1 year after delivery). Fig. 6 - Post-operative aspect of left thigh (1 year after injury).
Fig. 5 - Post-operative profile aspect showing elasticity of skin and softness of graft (1 year after delivery). Fig. 6 - Post-operative aspect of left thigh (1 year after injury).

Discussion

The.. homogeneous expansion of a skin wound on the one hand allows a complete and more rapid re-epithelialization and on the other leaves a scar of better quality, making an intrinsic compression.
The skin graft site permits the same considerations because its high tendency to retraction shows the effectiveness,of the stretching mechanism even better.

Conclusion

When the natural expansion of raw or healing skin surfaces is performed, the subsequent biological phenoiftena could have a therapeutic significance, allowing a tissue repair of better quality because of the stretching as opposed to wound contraction.
Natural skin expansion improved graft take (through local phlogosis and hyperaernia) and stabilization, substituting post-operative compression and the daily application of zinc oxide products.
The progressive increase of skin tension during natural expansion, as in the case we report, therefore overcomes skin graft and scar retraction due to myofibroblasts.

RESUME. La peau a la propriété de pouvoir s'étendre à cause de certains phénomènes naturels, comme l'obésité et la grossesse. Cependant elle est aussi sujette à la contraction due à la guérison des lésions ou aux greffes cutanées. Sur la base de ces considérations, les auteurs,: après avoir décrit une patiente enceinte de 4 mois atteinte de brûlures abdominales, concluent que l'expansion naturelle surmonte la contraction causée par les lésions ou les greffes et produit des résultats finals supérieurs à ceux que l'on peut obtenir avec les surfaces cutanées non étendues du même patient ou chez un autre patient qui ne présente pas l'expansion naturelle.


BIBLIOGRAPHY

  1. Argenta L.C.: Controlled tissue expansion in reconstructive surgery.Br. J. Plast. Surg., 37: 250,1984.
  2. Davis J.S., Kitlowsky E.A.: The immediate contraction of cutaneous graft and its cause. Arch. Surg., 23: 954, 1931.
  3. Larson D.V., Abston-Willis B., Dobrokosky M., Evans E.B., Lewiss R.: Contracture and scar formation in burn patients. Clin. Plast. Surg., I ~ 653, 1974.
  4. Marks MW., Argenta L.C., Thomton J.: Bum management - the role of tissue expansion. Clin. Plast. Surg., 14: 543, 1987.
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