Skin grafting surgery after a burn

Almost every one of us at least once in his life burned with boiling water, an iron, hot objects from kitchen utensils, open fire. Someone "was lucky" in everyday life, but someone got his portion of adrenaline in the production. Does it hurt terribly? Of course! Is there a scar? In most cases, yes. But this is with a small size of the wound. And what about the situation if the burn surface has significant dimensions, and skin transplantation after the burn is the most effective or even the only way to solve a difficult physical, cosmetic and psychological problem?

Advantages and disadvantages of skin plasty for burns

Surgery for skin transplantation after a burn or other trauma resulting in a large open wound is called skin plasty. And like any plastic surgery, it can have its advantages and disadvantages.

The main advantage of this treatment of large burn wounds is the protection of the wound surface from damage and infection. Even granulation tissue serves to protect the wound surface, but it is not a full-fledged replacement of mature skin and any decrease in immunity during wound healing can cause serious complications.

An important aspect is that in this way the loss of water and valuable nutrients is prevented through the uncovered surface of the wound. This point is vital when it comes to large wounds.

As for the aesthetic appearance of the injured skin, the wound after the skin transplantation looks much more attractive than the huge frightening scar.

The disadvantage of dermal plasty can be considered as a certain probability of rejection of the graft, which is often the case with allog skin and other materials. If the native skin is transplanted, the risk that it does not take root will decrease significantly.

Very often, after an operation for skin transplantation, during the healing process, skin pruritus appears, which disturbs the patient. But this phenomenon is temporary, which can be prevented by using special creams.

A relative lack of skin transplantation can be considered psychological discomfort from the thought of transplanting someone else's skin with the use of allograft, xenografts or synthetic materials.

[1], [2], [3], [4], [5]

Materials used in skin transplantation

When it comes to skin transplantation, a completely reasonable question arises about the donor material. The material for transplantation can be:

• Auto-skin - own skin from the unfired part of the body, which can be hidden under clothing (most often it is the skin of the inner side of the thigh),
• Allokozha is donor skin taken from a dead person (corpse) and canned for further use.
• Xenot leather is the skin of animals, usually pigs.
• Amnion is the protective shell of the embryo of man and animals belonging to the higher vertebrates.

Currently, there are many other synthetic and natural coatings for burn wounds, but in most cases the above materials are preferable.

When transplanting the skin after a burn, mainly biological grafts are used: auto-skin and allocate. Xenobic, amnion, artificially grown collagen and epidermal cell grafts, as well as various synthetic materials (explants) are used mainly if temporary wound coating is required to prevent infection.

The choice of material often depends on the degree of burn. So, for burns of IIIB and IV degrees, the use of an autograft is recommended, and for a IIIA burn, an allocine is preferable.

For carrying out dermal plastics, 3 types of skin can be used:

• pieces of donor skin completely separated from the body and not communicating with other body tissues (free plastic),
• sites of native skin, which with the help of micro cuts are shifted and stretched over the entire surface of the wound,
• a piece of skin with subcutaneous fat, associated with other tissues of the body in only one place, which is called the feeding leg.

The application of the last two types is called non-free plastic.

Transplants can also differ in thickness and quality:

• thin flap (20-30 microns) include the epidermal and basal layer of the skin. Such a transplant does not have good elasticity, it can wrinkle, and is prone to damage, so it is extremely rare to use burns, except as a temporary protection.
• flaps of medium thickness or intermediate (30-75 microns). They contain epidermal and dermal layers (completely or partially). This material has sufficient elasticity and strength, almost indistinguishable from real leather. It can be used on mobile sites, for example in the joint region, because it does not restrict movement. Ideal for burns.
• A thick flap or flap over the entire thickness of the skin (50-120 microns) is used less often, with very deep wounds or wounds located in the zone of visibility, especially on the face, neck, decollete zone. For his transplant, it is required that the affected area has a sufficient number of blood vessels that connect to the capillaries of the donor flap.
• Composite graft. A flap including, in addition to the skin, a subcutaneous fat layer as well as a cartilaginous tissue. It is used in plastic surgery for facial plastic surgery.

Intermediate skin flaps, also called split, are used for skin transplantation after a burn most often.

Indications for the procedure

In order to understand this issue well, it is necessary to recall the classification of burns by the degree of skin damage. There are 4 degrees of severity of burns:

To burns of the 1st degree are small burn wounds, in which only the upper layer of the skin (epidermis) is damaged. Such a burn is considered light (superficial, shallow) and shows itself painful sensations, a slight swelling and reddening of the skin. Usually does not require special treatment, unless, of course, its area is not too large.

Burns of II degree differ in greater depth. Not only the epidermis is damaged, but also the next layer of the skin - the dermis. The burn manifests itself not only by intense reddening of the affected area of the skin, pronounced edema and strong pain sensations, on the burned skin appear bubbles filled with liquid. If the burn area occupies a site with a diameter less than 7 and a half centimeters, the burn is considered light and often does not require medical attention, otherwise it is better to go to a medical institution.

The majority of household burns is limited to I or II severity, although cases of more severe injuries are also common.

Third degree burns are already considered deep and severe, since severe damage to both layers of the skin (epidermis and dermis) entails the onset of irreversible effects in the form of tissue death. In this case, not only the skin, but also the tissues under it (tendons, muscle tissue, bones) suffer. They differ in significant, sometimes intolerable pains in the affected area.

Burns of the third degree in depth of penetration and severity are divided into 2 types:

• Degree IIIA. When the skin is damaged up to the germ layer, which externally manifests itself in the form of large elastic bubbles with a yellowish liquid and the same bottom. There is a possibility of formation of a scull (color yellow or white). The sensitivity is reduced or absent.
• Degree IIIB. Complete damage to the skin on all its layers, the subcutaneous fat layer is also involved in the process. The same large bubbles, but already with a reddish (bloody) liquid and the same or whitish sensitive to the touch of the bottom. Scabs of brown or gray are located just below the surface of healthy skin.

For a fourth-degree burn, the necrosis (charring) of the tissues of the affected area is characteristic of the bones themselves, with complete loss of sensitivity.

III and IV degrees of burns are considered deep and heavy, regardless of the size of the burn wound. Nevertheless, in the indications for a skin transplant after a burn, only the IV degree and IIIB most often appear, especially if their diameter in diameter exceeds 2 and a half centimeters. This is due to the fact that the lack of coverage of a large and deep wound that can not be dragged on independently, serves as a source of nutrient loss, and can even threaten the patient's death.

Burns of grade IIIA, and also of the 2nd degree are considered borderline. In some cases, doctors may suggest skin transplantation after the burn and in these areas, although there is no special need for accelerating the healing of such burn wounds and preventing their rough scarring.

[6], [7], [8]

Preparation

Skin transplantation after a burn is a surgical operation, and like any surgical intervention it requires certain preparation of the patient and the wound itself to skin plasty. Depending on the stage of the burn and the state of the wound, a certain treatment (mechanical cleansing plus medication) aimed at cleaning the wound from the pus, removing the necrotic areas (dead cells), preventing infection and developing the inflammatory process, and, if necessary, the use of antibiotic therapy for their treatment .

At the same time, measures are being taken to increase the body's defenses (vitamin preparations plus vitamin ointment dressings, restorative products).

Several days before the operation, local agents are appointed from the category of antibiotics and antiseptics: antiseptic baths with "manganese" or other antiseptic solutions, bandages with penicillin or furacilin ointment, and UV irradiation of the wound. The use of ointment dressings is stopped 3-4 days before the expected date of the operation, as the remaining particles of the ointment will interfere with the engraftment of the graft.

The patients are shown high-grade protein food. Sometimes a blood or plasma transfusion is performed. We control the weight of the patient, study the results of laboratory studies, select drugs for anesthesia.

Immediately before the operation, especially if it is carried out under general anesthesia, it is necessary to take measures to cleanse the intestines. At the same time, you will have to abstain from drinking and eating.

If the transplant is performed in the first days after the injury to a clean burn wound, it is called primary and does not require careful measures to prepare for the operation. Secondary transplantation, which follows a 3-4 month course of therapy, requires mandatory preparation for surgery using the above methods and means.

At the preparatory stage, the question of anesthesia is also solved. If a relatively small area of the skin is transplanted or a wound is excised, local anesthesia is sufficient. With extensive and deep wounds, doctors tend to general anesthesia. In addition, doctors should be all ready to receive blood transfusions, if necessary.

[9], [10], [11], [12]

Technique of the transplant skin after a burn

The stages of surgery for skin transplantation after a burn depend on the material used by the plastic surgeon. If you use an auto-skin, the first thing is to take a donor material. And in the case when other types of transplants, including conserved biological ones, are used, this point is omitted.

The fence of autografts (excision of skin flaps of the necessary thickness and size) was previously performed primarily with a scalpel or a special knife for the skin, but now surgeons prefer dermatomes as a convenient and easy-to-use tool that greatly facilitates the work of doctors. Especially it is useful for transplanting large flaps of skin.

Before you start excising the donor skin, you need to determine the size of the flap, which must exactly correspond to the contours of the burn wound, where the skin will be transplanted. To ensure complete coincidence, X-ray or ordinary cellophane film is applied to the wound and wound around the contour, after which the ready-made "stencil" is transferred to the site where it is planned to take donor skin.

Skin for transplant can be taken from any suitable body size, trying to avoid those areas that can not be covered with clothing. Most often, the choice falls on the outer or back of the thighs, the back and buttocks. Take into account also the thickness of the skin.

After the doctor has decided on the donor site, preparation of the skin for excision begins. Skin in this place is washed with a 5% solution of soap (you can use gasoline), and then several times carefully treated with medical alcohol. By "stencil" with a scalpel / knife (for small areas) or dermatome (for large flaps) a suitable flap of the required thickness is cut out, the same across the entire surface.

At the site of the cut, a wound with small bleeding is formed, which is treated with hemostatic and antiseptic agents, after which an aseptic dressing is applied to it. The wounds on the donor site are shallow, so the healing process generally takes place quickly and without complications.

Transplanting the skin after a burn also involves preparing a burn wound. It may be necessary to clean up the wound, remove necrotic tissues, carry out hemostasis, smooth the wound bed, and cut the bruised scars along the edges of the wound.

The excised autograft is immediately placed on the prepared wound surface, gently combining the edges, and evenly pressed down with gauze within a couple of minutes, not allowing the flap to move. Flaps of medium thickness can be fixed with catgut. Above is applied a pressure bandage.

For a good fixation of the skin flap, you can use a mixture of a solution of fibrin (or plasma) with penicillin.

If the skin is transplanted to a small area, skin flaps are taken as a whole, if the wound surface has significant dimensions, several flaps are applied or a special graft with micro cuts is used, which can be significantly stretched and aligned to the size of the wound (perforated graft).

Skin transplantation with dermatome

The surgery for a skin transplantation after a burn begins with the preparation of a dermatome. The lateral surface of the cylinder is covered with a special glue, when it after a couple of minutes slightly dry, the lubricated surface is covered with a gauze napkin. When gauze sticks, excess edges are cut off, after which the dermatome is sterilized.

Approximately half an hour before the operation, the dermatome knives are treated with alcohol and dried. The area of the skin from which the donut flap will be taken is also rubbed with alcohol and waited until it dries. The surface of the dermatome knives (with gauze) and the desired skin area is covered with dermatome glue.

After 3-5 minutes, the glue will dry sufficiently, and you can begin excising the donor skin flap. To do this, the dermatome cylinder is pressed tightly against the skin, and when it sticks, it is slightly lifted by dermatome, starting the cutting of the skin flap. Knives with rhythmic movement cut the flap, which is neatly superimposed on the rotating cylinder. After the required size of the skin flap is reached, it is cut with a scalpel. From the cylinder of the dermatome, the autograft is carefully removed and transferred to the wound surface.

Allograft transplantation

If the skin transplantation after the burn has the goal of closing the wound for a long period, it is advisable to use autografts. If it is necessary to temporarily cover the wound, the best option for this is the transplantation of conserved cadaveric skin.

You can, of course, use the skin of donors, for example, flaps from amputated limbs. But such a coating is quickly rejected, not giving a wound full protection from damage and infections.

Properly preserved canopy is rejected much later. It is an excellent alternative to autografts, if there is no possibility of using them due to a deficiency in the donor skin. But after all, transplanting allodens often gives an opportunity to save a patient's life.

The operation of an allodenos transplantation does not cause any special difficulties. Burning surface is cleaned of pus and necrotic tissues, washed with antiseptic composition and irrigated with antibiotic solution. On the prepared wound, put the allo-skin, first wet it in physiological solution with the addition of penicillin, and fix it with infrequent sutures.

Contraindications to the procedure

Perhaps the operation of skin transplantation after a burn in comparison with other surgical interventions seems harmless and relatively easy, there are situations in which such manipulations are unacceptable. Some of them are associated with insufficient preparedness of the wound for skin transplantation, and others - with pathologies of the patient's health.

Skin transplantation after a burn occurs around 3-4 weeks after injury. This is due to the fact that after 20-25 days the wound is usually covered with a granulation tissue, which looks like a granular surface with a large number of blood vessels of a rich pink color. This is a young connective tissue, which is formed in the second stage of healing of any wound.

Skin transplantation in large areas and deep burns can not be done until the skin is completely cleansed of dead cells and granulation tissue is formed. If the young tissue has a pale color and necrotic areas, skin transplantation will have to be postponed until after the excision of weak tissue in its place does not form a strong new one.

If the wound is rather modest in size and clearly defined, the wounds are cleaned and the skin transplant operation is not forbidden even in the first days after the injury, without waiting for the development of symptoms of secondary inflammation.

It is forbidden to perform skin transplantation if traces of inflammation, wound exudate or purulent discharge are visible in the wound and around it, which is likely to indicate the presence of infection in the wound.

Relative contraindications for skin transplantation are a poor condition of the patient at the time of preparation for surgery, for example, shock, large blood loss, exhaustion, anemia, and unsatisfactory blood test.

Skin transplantation, although not an operation of great complexity, and takes only about 15-60 minutes by time, but when it is performed, it is necessary to take into account the considerable painfulness of such manipulation, as a result of which it is performed under local or general anesthesia. Intolerance to drugs used in anesthesia is also a relative contraindication to a skin transplant surgery after a burn.

[13], [14], [15], [16]

Complications after the procedure

The correct definition of the timing of the operation, careful and effective preparation for skin transplantation after a burn, appropriate care for transplanted skin are the main conditions for a successful operation and help to prevent unpleasant consequences. And yet sometimes the patient's body, for reasons that are understandable only to him, does not want to take even the native skin, considering it to be a foreign substance, and simply melts it.

The same kind of complications can cause incorrect preparation of a wound for surgery if pus and dead skin cells remain in the wound.

Sometimes there is a rejection of the transplanted skin, which is manifested by complete or partial necrosis. In the latter case, a reoperation is shown after removal of the transplanted and non-attached skin flap. If necrosis is partial, only dead cells should be removed, leaving those that have taken root.

Not always the skin gets accustomed quickly, sometimes this process is delayed for a couple of months, although it usually takes 7-10 days. In some cases, postoperative sutures begin to bleed. If there is insufficient sterility during surgery or poor preoperative preparation, additional wound infection may occur.

In some cases, after a successful operation and healing of the transplanted skin, it may cause unexplained ulceration, or there is condensation of the operative scar (the place of connection of the healthy and donor skin), the lack of normal hair growth and a decrease in sensitivity on the wound skin site.

The sad consequences of wrong choice of material for transplantation and untimely operation can be damage (cracking) of the transplanted skin, as well as restriction of movement (contraction) in the joint where the skin was transplanted after a burn.

[17], [18], [19], [20]

Care after the procedure

Restoration of the skin after a skin transplant surgery after a burn occurs in 3 stages. From the moment of the termination of operation of dermal plasty within 2 days there is an adaptation of the combined skin integuments, after which the process of skin regeneration begins, which lasts about 3 months.

During this time, it is necessary to protect the site with transplanted skin from mechanical and thermal damage. The bandage can be removed no earlier than the doctor will allow.

For the first time after removing the bandage, it is recommended to take medications that reduce pain, if necessary, and lubricate the young skin of the transplant with special ointments that prevent it from drying out and peeling off, and also remove skin itching (cold paste, lanolin ointment and other preparations, ensuring the maintenance of sufficient moisture of the tissue).

At the end of the regenerative changes, the stabilization process begins, when no special measures to care for the transplanted skin are required. The beginning of the stabilization process with great confidence indicates that the skin transplantation after the burn was successful.

Rehabilitation period

At the end of the operation for skin transplantation after a burn, it is necessary to ensure a good fit of the graft to the wound bed. To do this, carefully squeeze the remains of blood so that they do not interfere with the adherence of tissues.

Sometimes the graft is secured by stretching sutures (for example, in the case of a perforated flap). If the graft is fixed with threads, then their edges are left uncircumcised. On top of the transplanted skin flap, damp cotton balls are laid, followed by cotton swabs and tightly tied with loose ends of the thread.

To prevent the rejection of transplanted grafts, bandages are irrigated with solutions of glucocorticosteroids.

Usually transplant engraftment occurs within 5-7 days. During this time, the dressing is not removed. After a week, the doctor examines the wound, removing only the upper layers of the bandage. The question of the first dressing is decided individually. Everything depends on the patient's condition after the operation. If the dressing is dry, the patient does not have temperature and swelling, only a wound of the wound is wound.

If the dressing is wet, too, do not worry prematurely. This is due to the accumulation of wound exudate under the graft. Sometimes it's just enough to release it and reinforce the graft with a bandage. If there is blood or pus from under the graft, there is a high probability that it will not take root.

If necessary, the first dressing is prescribed, during which the uninfected tissues are removed. Then they perform a new operation for skin transplantation.

If everything goes smoothly the transplant fuses with the skin for 12-14 days. After removing the bandage, it appears pale and unevenly colored, but after a while it acquires a normal pink shade.

If the bandage is not applied after the operation for some reason, it is necessary to protect the transplanted area from damage (for example, using a wire frame).

[21]