Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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The goal of the dressing chosen is to provide a humid environment with elimination of shear forces for 3 to 5 days. During this period, the graft adheres to the bed underneath. Our routine dressing after skin grafting is as follows: fine mesh gauze impregnated with Bacitracin/polymyxin single layer followed by dry bulky gauze dressing secured by Kerlix wrap. Often, a splint to immobilize the joints proximal and distal to the graft is placed followed by an elastic bandage wrap. In areas where an elastic bandage wrap is impractical and shear a realistic concern, a bolster dressing can be placed. The bolster is made of a sheet of impregnated fine mesh gauze with bulky dressing and tie-over silk sutures

(Figure 103-6).

Facial grafts are left open to air with a layer of Bacitracin/polymyxin ointment.

STEP 4: POSTOPERATIVE CARE

The amount of time varies as to when the dressing is removed. Typically in a clean elective case, the dressing can be safely left in place for 4 to 5 days. At this time, the skin should be adherent. If a sheet graft has been placed, often it will be checked on postoperative day 1 or 2 to evaluate for seroma or blood clot. When identified, these are removed by a small hole in the graft created with a no. 11 blade and tip or vacuum extraction using a fine pediatric respiratory suction catheter. If the dressings are removed early, then they are replaced until postoperative day 4 to 5. The donor site treated with Scarlet Red should be dried postoperatively with open air desiccation or, occasionally, careful use of a hair dryer. The donor site should be checked routinely. Healing should be complete in nearly all cases by postoperative day 10. If healing has not occurred, consider removing any remaining donor site coverage material and change to daily care washing with topicals to treat colonization or infection.

Once the skin has taken, application of moisturizer and protection from the sun to both the donor and recipient sites are recommended. The patient should be given exercises to aggressively regain full use of any involved joint. Immobilization beyond what is required for the graft to take promotes contractures and limited return of function. The surgical sites should be monitored closely for evidence of scar hypertrophy and contracture. This typically will present within the first few months postoperatively. The treated areas are monitored until complete healing has taken place, often over a year. A good measure of a mature wound is the absence of hyperemia in the scar. A coordinated effort with a physical therapist with burn experience is highly recommended. It is our practice to fit most grafted areas with custom-made garments for pressure application. Silicone gel pads can be of help with scar hypertrophy in localized areas.

STEP 5: PEARLS AND PITFALLS

FACE GRAFTS

It is recommended when applying skin grafts to the face that aesthetic units are respected. This will achieve the best cosmetic result over time as the face grafts mature

(Figure 103-7).

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ESCHAROTOMIES

STEP 1: SURGICAL ANATOMY

See Figure 103-1 for cross-section of skin.

INDICATIONS

In burn resuscitation, recognition of pathology related to increased tissue pressure is critical to complete care and limiting secondary tissue injury. Skin, particularly skin burned to full thickness, can become a constricting element to tissue swelling and cause a tourniquet-like effect. Key to proper decompression is recognizing the potential, knowing the clinical signs and symptoms, and when necessary, having the ability to test the pressure within the compartment. A circumferential burn that is on an extremity of full thickness is particularly at risk for increased tissue pressure even if the percent of the burn is small, such as an isolated burn to fingers and hand. Clinically, the signs of compartment syndrome are paresthesia, pallor, pulselessness, paralysis, and pain. In the hand, in addition to the usual signs of elevated compartment pressure outlined, delayed or absent capillary refill, resistance to passive stretch, and a claw position at rest are clues to the need for decompression. The large burn may require monitoring of the abdominal compartment pressures and consideration of the fascial compartments in the extremities as possibly in need of decompression. Electrical injury presents one of the most difficult challenges, because there maybe extensive damage within deep muscular compartments with intact overlying skin. The surgical exploration, fascial decompression, and removal of dead muscle should not be delayed, because the resultant myoglobin in the serum is nephrotoxic.

STEP 2: PREOPERATIVE CONSIDERATIONS

Escharotomies are usually completed safely at the bedside with sedation and electrocautery. The possibility of significant blood loss must be considered by the surgeon, and blood should be available if needed. Positioning should be based on exposure of the area to be decompressed, with arms supinated into anatomic position.

STEP 3: OPERATIVE STEPS

Included are diagrams of properly placed incisions for decompressive escharotomies of various body regions (Figure 103-8).

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To obtain an adequate release, the incisions should be mid-axial and completely through the eschar. Avoid deep penetration of the subcutaneous tissue below. Deep penetration can cause excessive bleeding and damage to underlying nerves and blood vessels. However, if there is clinical suspicion of fascial compartment hypertension, an escharotomy can be combined with a fasciotomy for diagnostic and therapeutic purposes. Escharotomy of the upper extremity should begin on the radial side down to the wrist. Details of hand and finger decompressions are represented in Figure 103-9.

A special consideration is the circumferentially deeply burned thorax. Thoracic compartment is manifest by difficulty with ventilation and increased peak airway pressures. Recognition and decompressive escharotomy can be life-saving. Incision lines for thoracic decompression are outlined in Figure 103-8.

A B

FIGURE 103–9

C H A P T E R 103 • Skin Graft—Split Thickness and Full Thickness 1155

STEP 4: POSTOPERATIVE CARE

Wounds that result from decompression should be kept moist and wrapped with the burn. Elevation should be routine to help decrease edema whenever possible.

STEP 5: PEARLS AND PITFALLS

Keep in mind that all circumferential burns do not need to have decompression.

In a moderate burn with an awake patient, you can follow closely with a clinical examination.

SELECTED REFERENCES

1. Herndon DN: Total Burn Care. London, Saunders, 2002.

2. Barret JP, Herndon DN: Color Atlas of Burn Care. London, Saunders, 2001.

3. Sood R, Achauer BM: Achauer and Sood’s Burn Surgery: Reconstruction and Rehabilitation. Philadelphia, Elsevier, 2006.

4. Green DP, Hotchkiss RN, Pederson WC, Wolfe S: Green’s Operative Hand Surgery, 5th ed. Amsterdam, Elsevier, 2005.