The use of allogeneic cultivated keratinocytes for the early coverage of deep dermal burns – indications, results and problems

Since 1995, keratinocytes are grown into cultures and used as allografts for the coverage of deep dermal defects in our burn unit. Donor skin samples are mostly acquired from other burn patients. In addition, special methods of skin preservation allow us the use of skin, which has been taken in redundancy for split thickness skin grafting from nonburned patients.Thirty five patients with deep partial thickness burns in the face were treated since 1996 according to the following concept: Dermabrasion or tangential excision was performed before the 5(th) day following trauma. If viable dermis was present, the wounds were covered with sheets of allogeneic cultivated keratinocytes. In cases of deeper defects, autologous skin grafts were applied. In 23 cases, epithelialisation was achieved within 10 days, in 8 patients, a prolonged duration until complete healing was observed. In 5 faces, coverage of residual defects with skin grafts was necessary. The mentioned problems of wound healing occurred from infection, incomplete excision of burn eschar and a depth of the wound which was retrospectively seen too deep for the treatment with keratinocytes. At follow up, patients were examined clinically and functionally with Frey's faciometer(R), which is an instrument for quantification of mimic movements. In cases of uncomplicated healing, a nearly complete restitution was found.Other indications include deep dermal burns in children and the coverage of early excised wounds in adults, with a reasonable amount of viable dermis remaining, both resulting in a significant reduction of donor-site morbidity. In severely burned adults with limited donor sites, it offers the possibility of immediate definite coverage of large areas.     

Full-thickness grafting of acute eyelid burns should not be considered taboo.

Split-thickness skin grafts are commonly used for the treatment of acute eyelid burns; in fact, this is dogma for the upper lid. Ectropion, corneal exposure, and repeated grafting are common sequelae, almost the rule. It was hypothesized that for acute eyelid burns, the use of full-thickness skin grafts, which contract less than split-thickness skin grafts, would result in a lower incidence of ectropion with less corneal exposure and fewer recurrences. The records of all patients (n = 18) who underwent primary skin grafting of acutely burned eyelids (n = 50) between 1985 and 1995 were analyzed retrospectively. There were 10 patients who received full-thickness skin grafts (12 upper lids, 8 lower lids) and 8 patients who received split-thickness skin grafts (15 upper lids, 15 lower lids). Three of 10 patients (30 percent) who received full-thickness skin grafts and 7 of 8 patients (88 percent) who received split-thickness skin grafts developed ectropion and required reconstruction of the lids (p = 0.02). No articles were found substantiating the concept that only split-thickness grafts be used for acute eyelid burns. The treatment of acute eyelid burns with full-thickness rather than split-thickness skin grafts results in less ectropion and fewer reconstructive procedures. It should no longer be considered taboo and should be carried out whenever possible and appropriate.     

Excision of burns of the face

Sequential excision of burns is now a common technique. Nevertheless, standard texts, when describing the treatment of facial burns, recommend allowing spontaneous separation of the eschar and then grafting on granulation tissue if healing does not occur. This method yielded disappointing results for us and the reconstructive procedures required were of great magnitude. Therefore, in January of 1979, we began primary excision and grafting of those face burns not essentially healed at 10 days. We have now treated 16 consecutive patients (approximately 5 percent of all face burns) in this manner who are at least 12 months postinjury. Three were lost to follow-up, leaving 13 for evaluation. This method yields better appearance and function than that obtained by allowing spontaneous healing over more than 3 weeks or grafting on granulation tissue and decreases the magnitude of subsequent reconstruction.     

Towards quantitative assessment of burn based on photoacoustic and optical coherence tomography

Accurate and timely assessment of the severity of burn is essential for the treatment of burns. Currently, although most first‐degree and third‐degree burns are easily diagnosed through visual inspection or auxiliary diagnostic methods, the second‐degree burn is still difficult to distinguish due to the ambiguity boundaries of second‐degree with first‐degree and third‐degree burns. In this study, we proposed a non‐invasive technique by combing photoacoustic imaging (PAI) and optical coherence tomography (OCT) to multi‐parameter quantitatively assess the burns. The feasibility and capacity of the dual‐mode PAT/OCT for assessing the burns was first testified by tissue‐mimicking phantom and burn wounds in mouse pinna in vivo. The further experiments conducted on the back of rats showed that the changes in skin scattering structure, vascular morphology and blood flow provided by the dual‐mode PAI/OCT system can determine distinct boundaries and depth of the burns. The experimental results prove that combined PAI/OCT as a novel method can be used to assess the severity of burn, which has the potential to diagnose the burns in clinic.     

Occlusion following laser resurfacing promotes reepithelialization and wound healing

One of the critical parameters that has not been examined carefully following laser skin resurfacing is the effect of eschar on the wound healing process. Because occlusive dressings minimize the occurrence of eschar, the present study was undertaken to evaluate the effect of occlusion following laser resurfacing. It is clear that CO2 lasers promote epidermal cell loss and variable amounts of dermal injury. To characterize the wound repair process after laser treatment, biopsy specimens were obtained 2 to 4 days after treatment. Specimens from 15 patients were examined; the preauricular biopsy specimens were paired such that one specimen was from skin that had been occluded and the other specimen (from the same patient) was from skin treated without occlusion. Skin specimens were examined by indirect immunofluorescence using antibodies to specific epidermal and dermal antigens. The results indicate that the keratinocytes that repopulate the epidermis migrate from the hair follicles and express keratin 17, an intermediate filament protein expressed in keratinocytes during the early stages of wound healing. The migration of keratin 17-expressing cells begins 48 hours following laser resurfacing in skin treated with occlusion, whereas cell migration from the follicles of skin treated without occlusion is delayed. In summary, occlusion promotes enhanced cell migration and diminished eschar formation, resulting in more rapid healing.     

Evaluation of Lyophilised, Gamma-Irradiated Amnion as a Biological Dressing

Burns, non-healing wounds and pressure sores cause extensive damage to the skin leading to infection and loss of precious body fluids. Despite advances in burn management the mortality rate continues to be high and the search for an economical and easily available dressing to control burn wound infection continues. Autologous skin has limited availability and is associated with additional scarring. Conventional dressings require frequent changes which can be painful and may even require anaesthesia.Amnion is an excellent biological dressing and its use in the treatment of burns has special appeal in India as there are religious barriers to the acceptance of bovine and porcine skin.Lyophilised, irradiated amnion provided for the first time in the country by the Tata Memorial Hospital Tissue Bank was evaluated as a temporary biological dressing. It was used to treat 35 patients with burns, 21 patients with bedsores and non-healing ulcers and the skin graft donor sites of 11 patients.The amnion was easy to handle and stuck well to the raw wound bed. An open dressing was used in most of the second degree burns which healed with hyperemia and early pigmentation. In patients with third degree burns, ulcers or skin graft donor sites, closed dressings were used. The exudate and induration were reduced and patients were more comfortable and experienced less pain. There was healthy granulation with good re-epithelialisation. Amnion was not used in patients with infected third degree burns.     

Rice cooker steam hand burn in the pediatric patient

Burn injuries often lead to significant cosmetic and functional deformity. In the Orient, household electric rice cookers have caused a significant number of steam burns to infant hands. The clinical course and treatment outcome of these burns have been studied retrospectively in a review of the medical records of 79 pediatric patients treated for acute hand steam burns and of 38 other patients who underwent correction for postburn contracture. Electric rice cookers caused all of the acute pediatric steam burns treated at our institute. Of the 81 hands treated between 1995 and 1998, 38.3 percent healed with conservative treatment and 61.7 percent required skin grafting. The volar aspects of the index and middle fingers were those most frequently involved. Eighteen of 36 hands (50 percent) grafted with split-thickness skin developed late contractures requiring additional procedures. Among the 38 patients who underwent correction for postburn deformity, initial treatment was split-thickness grafting for 60.5 percent, full-thickness skin grafting for 7.9 percent, and spontaneous healing for 31.6 percent. Awareness among medical personnel and continued public education should be promoted to help prevent this unique type of pediatric steam burn from occurring.     

Early release of third-degree eyelid burns prevents eye injury

Burns to the eyelids occur in more than 20 percent of flame injuries and can lead to ocular damage and even blindness. Burn wound contracture can cause ectropion of the eyelid, resulting in exposure keratitis, corneal ulcers, and conjunctivitis. At our hospital, early eyelid release and grafting has made a significant difference in the long-term outcomes of third-degree eyelid burns; however, the question of just how early eyelid release and grafting should take place is an unresolved issue. Fifty-seven children with third-degree eyelid burns were reviewed; 17 had eyelid release within 7 days of receiving eyelid burns and 40 had a delay in eyelid release of more than 7 days after injury. Analysis was by chi-square with the Yates continuity correction or Fisher's exact test when appropriate. Corneal ulcers developed in 2 of 17 of the early eyelid release of third-degree burns, compared with 25 of 40 delayed releases (p = 0.001), exposure keratitis in 3 of 17 early releases, and 30 of 40 in delayed release (p = 0.000); conjunctivitis was identified in 1 of 17 early releases and 14 of 40 delayed eyelid releases (p = 0.025). Release of eyelid burns within 7 days of injury can prevent the development of exposure keratitis, progressive conjunctivitis, corneal ulceration, and the need for corneal surgery. We suggest that early release and grafting should be the treatment of choice for children and young adults with third-degree burns to the eyelids.     

Our Clinical Experience using Cryopreserved Cadaveric Allograft for the Management of Severe Burns

Human cadaveric allograft is the most commonly used alternative wound closure material for excised burn wounds when limited donor sites or the overall patient condition does not permit immediate grafting with autologous skin. The Skin Bank in Singapore has supplied a total of 33,000 cm² of cryopreserved cadaveric allograft to the Burns Centre in Singapore for the early post-burn treatment of 17 severely burned patients with body surface area (BSA) burn wounds averaging 58% (range 33–90). An average of 13% (range 3–30%) cadaveric allograft was transplanted on 17 patients. Seven patients had recovered from their burn injuries and ten patients died of multiple complications related to their burn injuries. Our clinical observation has shown good adherence of cadaveric allograft when applied on clean and debrided wound bed after 4–7 days of post-operation. The availability of cadaveric allograft permits early excision and wound coverage before the patients' condition is further compromised. Our clinical experience using cryopreserved cadaveric allograft is proving to be indispensable in the management of patients with severe burns. This revised version was published online in July 2006 with corrections to the Cover Date.     

通便化痔颗粒对痔疮模型大鼠的疗效

目的对酸灼伤大鼠皮肤能否行成痔疮模型进行方法学研究及通便化痔颗粒对此模型的药理作用。方法采用10 mol/L盐酸灼伤人工划伤的大鼠肛门周围皮肤及肛门内侧的黏膜,连续灌胃给予通便化痔颗粒10 d后,进行肉眼观察及光镜观察评分。通便化痔颗粒能使被盐酸灼伤并发生病理性改变的皮肤得到有效地恢复。结果病理结果显示痔疮模型成功;通便化痔颗粒在大、中剂量下能使大鼠被盐酸灼伤发生病理性改变的皮肤得到有效地恢复。结论酸灼伤大鼠皮肤模拟痔疮模型成立;通便化痔颗粒能够有效恢复大鼠痔疮模型皮肤组织。     

Calcium carbonate gel therapy for hydrofluoric acid burns of the hand

Hydrofluoric acid is used extensively as an industrial cleaning agent for metals and glass. Many workers are injured by cutaneous contact of the acid with exposed skin surfaces, particularly hands. Hydrofluoric acid burns are characterized by delayed onset of symptomatology with skin ulceration, and severe pain may be of extended duration. Treatment of hydrofluoric acid burns traditionally has consisted of local infiltration or intraarterial injections of calcium solutions. These injections are painful and frequently require retreatment. A new treatment utilizing a topical gel of calcium carbonate is described. Nine patients have been treated for hydrofluoric acid burns of the hand with calcium carbonate gel applied topically and covered with occlusive glove dressings. A gel slurry is compounded from calcium carbonate tablets and K-Y Jelly. Fingernails of the affected fingers are removed if a subungual burn is obvious. The gel is put into a surgeon's glove and placed over the burned hand. The patient replaces the glove and slurry every 4 hours for 24 hours. After the first day, the glove is discontinued unless there is resumption of painful symptoms. Full range of motion is encouraged during this interval. The calcium carbonate gel technique was successfully utilized in nine patients with no further need for injection therapy. In these patients, pain relief was obtained within 4 hours of treatment, with no further progression of skin ulceration. No reconstructive procedures were required in any patient, and only one patient did not return to full-duty work within 1 week. There were no long-term sequelae from burns treated with this topical therapy, except one patient, who presenting 24 hours after the burn, developed a digital tip neuroma that was excised.     

Fist position for skin grafting on the dorsal hand: II. Clinical use in deep burns and burn scar contractures

The fundamental problem in all types of hand burns is a loss of skin and subsequent deformities. The goal of skin grafting on the dorsal hand is to graft a sufficient amount of skin, as much as the original amount, and to restore normal hand function without secondary deformities. The safe, or Michigan, position commonly has been used for immobilizing the hand. However, this position is to protect hand function rather than to provide for adequate skin grafting. This institution has developed a new hand position (the fist position) for grafting the greatest amount of skin on the dorsal side of the hand. In the fist position, the hand is positioned flexing all joints of the wrist and the fingers and maximally stretching the dorsal surface of the hand before skin grafting. Ten hands with deep second- or third-degree burn (n = 6) and burn scar contracture (n = 4) of the dorsal hand in eight patients were treated with split-thickness skin grafting after immobilizing in the fist position. The burns and contractures involved nearly the total area of the dorsal hand. The hand was kept in the fist position for 7 to 9 days after skin grafting. Excellent functional and cosmetic results were observed in all cases during the follow-up period of 6 months to 2 years. Complications resulting from hand immobilization for a short period did not occur. The fist position may be a proper hand position for skin grafting to reconstruct the dorsal hand.     

Early excision and skin grafting of selected burns of the face and neck

Since 1979, 16 patients with facial and neck burns have been treated with excision and skin grafting within the first 4 days of injury. The injuries were tangentially excised and immediately covered with split-thickness skin grafts. Detailed consecutive results are presented. The patients can be divided into three groups. Group 1 consisted of small subdermal or circumscribed deep dermal burns of the face (n = 8). Healing was quick. Some patients developed signs of overgrafting. As a late result, unevenness and discoloration were seen. Group 2 consisted of mixed deep dermal and subdermal burns of the face and neck (n = 5). Usually, minor areas had to be regrafted. Some patients developed hypertrophic scars at border areas. In the completely excised and grafted area, the skin was smooth, pliable, and discolored. Group 3 consisted mostly of subdermal burns of the face and neck (n = 3). The surgical trauma was significant. Small areas had to be regrafted. Ectropion and microstomia developed. It is concluded that in selected cases of deep dermal and subdermal burns, early excision and skin grafting will result in faster healing and less scarring than expectant treatment.     

Characterization of Staphylococcus aureus in a Pediatric Burn Unit

A one-year study on an endemic strain of Staphylococcus aureus phage type 84/85 in a children's burn unit is described. The endemic strain rapidly colonized the burns and nares of acute patients after admission but was not isolated from a patient on admission. Nonendemic strains of S. aureus found on some new patients were mostly non-phage typable and did not prevail in burns. The endemic strain was rarely isolated from the nares and skin of reconstructive patients or from the nares of hospital personnel. The endemic strain did colonize the oral cavity, normal skin, and intestinal tract of some acute patients. Endemic and nonendemic strains of S. aureus from the burned children were compared in their biochemical activities and antibiotic sensitivities to two groups of S. aureus from one other local and one Danish burns unit. The latter groups of strains represented different combinations of staphylococcal phage group III strains. Each of the four groups of strains differed in production of hemolysins, Tween 80 hydrolysis, egg yolk reaction, and proteolysis of casein and gelatin. All of the strains were uniformly sensitive to gentamicin, oxacillin, and cephalothin. Only 4 of 162 strains tested were methicillin resistant. The endemic S. aureus strains of phage type 84/85 were uniformly resistant to eight other antibiotics including lincomycin and clindamycin. The endemic strain was not the known cause of a clinically documented infection in a group of 82 acute patients studied. The possible role of S. aureus strains of phage group III in burn grafting problems is discussed.     

Use of Banked Tissue in Plastic Surgery

The availability of safe and reliable, banked tissues in India has enabled the use of human bone allografts as a viable alternative to autografts in reconstructive surgery. Lyophilised, irradiated bone grafts were used in 2 cases of rhinoplasty, a case of hemifacial atrophy, and as a chin implant.In the patient with revision rhinoplasty the rib graft was resorbed. The patient with hemifacial atrophy developed seroma and infection in the zygomatic and infraorbital area and the rib graft had to be removed. The graft from the same rib that was placed over the mandible was retained well and incorporated completely. The iliac crest cortico-cancellous grafts did well in the second case of augmentation rhinoplasty and in the augmentation of chin.The primary objective of reconstructive surgery in the treatment of burns, non-healing wounds and pressure sores is to remove the dead tissue and restore the continuity of the skin without delay. Lyophilised, irradiated, human amnion is a temporary biological dressing conveniently available off-the-shelf. It was used in twenty four patients with burns, eight patients with bedsores and six patients with non-healing ulcers mainly on the foot. The total surface areas of burns sustained were from 2% to 40%. The burns ranged from second degree to deep third degree burns. Amnion was not used in patients with infected third degree burns.The amnion provided good biological cover in all the patients. It was easy to handle and apply, and provided pain relief. The duration of healing varied depending on the extent and depth of the wound and the amount of exudate. The superficial bedsores healed with a single application of amnion. Reduced exudate, healthy granulation tissue and enhanced epithelisation were observed following application of amnion.     

Morphological characteristics of the healing of burn wounds covered by an activated-charcoal tissue dressing

Activated-charcoal cloth and dressings product based upon this material were applied for covering burn wounds. As a control served a gauze dressings with greases and solution topical drugs. The healing of deep thermal burns of 3rd degree on rabbits studied by a histological method was differed by a rapid decreasing of inflammation reaction, active epithelialization and soft scar formation. A clinical use in 15 burned patients was shown that in combination with enzymatic and antimicrobial drug solutions these materials accelerate healing and epithelialization of superficial burn wounds and improve treatment of deep burn wounds before autodermoplasty.     

Reduction mammaplasty in postburn breasts.

Thermal injury to the anterior chest in the adolescent girl can lead to severe disfigurement of the breasts. Just as in certain non-burn female patients, mammary hyperplasia can occur in patients with previous full-thickness burns of their breasts. Most plastic surgeons have been reluctant to perform reduction mammaplasty in these patients for fear of devascularizing the skin graft or the nipple-areola complex. A series of six patients with full-thickness burns of the breasts and subsequent skin graft coverage before reduction mammaplasty is reported. Four patients had bilaterally burned breasts requiring reduction. Two patients had one burned breast reduced, and one required a balancing procedure on the unburned side. Reduction mammaplasty was performed using the inferior-pedicle technique. The mean amount of tissue removed for the left and right breasts was 454 and 395 g, respectively. There was no nipple loss, hematoma, infection, or major loss of skin flaps. Reduction mammaplasty in this group of patients is safe and carries minimal risk if certain key concepts are followed carefully.     

磺胺嘧啶银混悬液联合银锌霜分阶段疗法在大面积烧伤中的应用

目的：观察2008年1月至2010年12月期间98例TBSA大于35%的烧伤病人创面联合应用磺胺嘧啶银混悬液联合银锌霜的疗效。方法：以同期76例应用碘伏的病人作为对照,两组病人的平均年龄、烧伤面积、Ⅲ度面积无显著差别,用药方式均以半暴露为主。结果：磺胺嘧啶银混悬液联合银锌霜组能显著增加细菌转阴率,减少抗生素应用时间及植皮手术次数,缩短愈合时间。结论：磺胺嘧啶银混悬液联合银锌霜较碘伏能显著增加抗感染能力,有利于肉芽创面形成,为自行愈合或再次手术打下良好基础,值得应用。     

TIMP-1, MMP-2, MMP-9, and PIIINP as serum markers for skin fibrosis in patients following severe burn trauma

The wound-healing process of patients with severe burns often leads to the formation of extensive fibrotic scars. In this study, serum concentrations of tissue inhibitors of metalloproteinase-1 (TIMP-1), matrix metalloproteinase-2 (MMP-2), matrix metalloproteinase-9 (MMP-9), and amino-terminal propeptide of procollagen type III (PIIINP) were measured by enzyme-linked immunosorbent assay as markers for excessive cicatrization in 22 patients with acute burn injuries. All patients were followed up for 6 months to determine a fibrotic reaction during the wound-healing process after operative treatment using the Burn Scar Index. Blood samples were drawn immediately before the operation; at postoperative days 1, 3, 7, and 14; and 1, 3, and 6 months after the operation. Twenty patients who underwent elective plastic surgical operations served as the control group. There was a significant increase (p < 0.05) of TIMP-1 in the burned patients by the third postoperative day. Later in the follow-up period, the serum concentrations remained at a significantly elevated level (p < 0.05) compared with preoperative values. In comparison with the control group, the postoperative serum concentrations of TIMP-1 of the burned patients were significantly higher (p < 0.05) at any time and correlated with the total body surface area burned at the third and seventh postoperative days (p < 0.05; r2 = 0.46 versus r2 = 0.53) and the Burn Scar Index after 6 months (p < 0.05; r2 = 0.65). Serum levels of MMP-2 and MMP-9 showed a significant elevation (p < 0.05) only between postoperative days 3 and 14 in patients with burn wounds. PIIINP increased significantly (p < 0.05) in the sera of the burned patients at postoperative day 3 and remained significantly elevated up to 6 months after injury. At any time after trauma, PIIINP serum levels were significantly higher (p < 0.05) in the burned patients than in the control group and correlated with the total body surface area burned at postoperative days 3 and 7 (p < 0.05; r2 = 0.41 versus r2 = 0.44) and the Burn Scar Index after 6 months (p < 0.05; r2 = 0.5). Obviously, the physiological balance between matrix metalloproteinases and their endogenous inhibitors is disturbed after burn trauma. The elevated systemic TIMP-1 concentration might contribute to tissue fibrosis, leading to pathological scar formation. The increase of PIIINP after thermal trauma indicates a fibrogenic component of wound healing.