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CHAPTER42 Frostbite
Treatment
General management
• Patients with signicant frostbite injury should be admitted to a
specialist unit
• Potentially life- threatening conditions, eg. hypothermia (core body
temperature <35°C) and concomitant injuries take priority over
frostbite injuries
• Acore temperature of 34°C should be achieved prior to rewarming of
the aected extremity
• Intravenous uid resuscitation is only indicated if the patient is
dehydrated or has concomitant injuries
Rewarming
• The initial treatment of frostbite should follow the protocol outlined by
McCauley, Heggers, and Robson.
1
• Rewarming should be carried out in a whirlpool bath of recirculating
water containing a mild antiseptic (povo- iodine or chlorhexidine) set at a
temperature of 40– 41°C
• Rewarming should continue for at least 30 minutes or until thawing is
complete and the tissues are pliable and red- purple in colour.
• The treatment is repeated twice daily for 30 minutes until there is clear
demarcation of necrotic tissues or until healing is observed
• The aected area is kept dry and warm in between the treatments
Supportive treatments
• Adequate analgesia with an opiate should be administered; intense pain
is experienced 2– 3days after rewarming and reperfusion, which may
persist for weeks even after demarcation of tissues
• Ibuprofen should be given (400 mg every 12 hours) as it has anti-
prostaglandin eects
• Once the extremity has thawed, clear blisters should be de- roofed while
haemorrhagic blisters should be kept intact
• Avoid massage/ rubbing to the aected area as it can cause
further damage
• Topical aloe vera has been used in North America on wounds after
blister debridement due to its anti- prostaglandin eects
• Aected extremities should be elevated as extracellular crystals melt
with rewarming, causing hyperaemia and oedema
• Broad- spectrum prophylactic antibiotics are indicated if there is a risk of
infection from necrotic tissue
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Treatment offrostbite
• Admit to a specialized unit
• Treat hypothermia or life threatening concomitant injuries rst
• Remove wet or constrictive clothing
• Rewarm with a warm water bath (40– 41°C) for at least 30 minutes or
until thawing
• Repeat treatment twice daily for 30 minutes
• Keep the extremity warm and dry in between rewarming sessions
• After rewarming, debride clear blisters
• Leave haemorrhagic blisters
• Elevate the extremity and splint as necessary
• Avoid smoking
• Administer ibuprofen (400 mg every 12 hours orally)
• Anti- tetanus prophylaxis
• Opiate analgesia
• Broad spectrum antibiotics if there is a risk of infection from necrotic
tissues
• Clear documentation with photos taken every 2– 3days is essential
• Avoid massage/ rubbing or direct heat to the aected area
Surgery
• Tissue may become viable for rewarming despite their initial appearance
and demarcation of non- viable tissues can take weeks
• Early surgical intervention is therefore only indicated for
• Compartment syndrome or vascular impairment requiring a
fasciotomy or escharotomy
• Gross sepsis, liquefaction or gangrene, requiring amputation of the
extremity
• Tissue loss is uncommon in rst- and second- degree frostbite injuries
• In third- and fourth- degree injuries, once the necrotic tissues has
demarcated, mummication and auto- amputation may be allowed to
occur or surgical debridement with amputation or reconstruction can be
performed (Fig. 42.1)
Tissue plasminogen activator
• Tissue plasminogen activator (tPA) can lead to rapid clearance of
vascular thromboses, restore arterial perfusion, and improve tissue
salvage
• Signicant reduction in digital amputation rates have been demonstrated
with tPA
• tPA therapy should be considered in patients with severe extremity
frostbite presenting within 24 hours of the injury
• Diagnostic angiography can used to guide treatment and tPA therapy
should be repeated until reperfusion is conrmed on the angiogram
• Therapy is contraindicated in cases of concomitant trauma, recent
surgery, bleeding diasthesis, pregnancy, repeated freeze– thaw cycles, or
neurological impairment
TREATMENT
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CHAPTER42 Frostbite
(a) (b)
Fig.42.1 Severe frostbite requiring subtotal digital amputation. (A)before and
(B)after amputation.
Vasodilators
• Some benet demonstrated but their role has not been fully
substantiated
• Examples include iloprost (prostacyclin analogue), buomedil
(α- blocker), and pentoxifylline (a methyl- xanthine derived
phosphodiesterase)
Sympathectomy
• May help to reduce oedema, decrease tissue loss, and prevent long-
term sequelae, eg. pain and paraesthesia
• Chemical or surgical sympathectomy, performed 24– 48 hours after
thawing has demonstrated equivocal results
Hyperbaric oxygen
• Safe and inexpensive treatment
• It increases the deformability of erythrocytes, reduces tissue oedema,
and has antioxidant and has antibacterial eects
• Benet of hyperbaric oxygen with large human studies has yet to be
determined
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TREATMENT
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CHAPTER42 Frostbite
Long- term sequelae
• Hypersensitivity to cold
• Sensory decits
• Chronic pain
• Hyperhidrosis
• Heterotropic calcication
• Pigmentary changes
• Osteoporosis
• Subchondral bone loss
• Growth plate abnormalities in children
• Susceptibility to further frostbite injury
Prevention
Prevention is key and a variety of protective measures can help reduced the
occurrence of frostbite injuries.
• Avoid prolonged cold exposure
• Protective clothing worn— multiple loose layers for heat insulation
• Wear insulated or heated insoles, gloves, and hats
• Avoid constrictive or tight clothing that reduce blood ow
• Take protection from the wind
• Keep extremities dry
• Avoid smoking and alcohol
• Maintain nutrition and hydration
• Supplementary oxygen at high altitudes
Further reading
Hallam MJ, Cubison T, Dheansa B, Imray C. Managing frostbite. British Medical Journal
2010;341:1151– 6.
Murphy JV, Banwell PE, Roberts AHN, McGrouther DA. Frostbite: pathogenesis and treatment.
Journal of Trauma 2000;48:171– 8.
References
1. McCauley RL, Heggers JP, Robson MC. Frostbite. Methods to minimize tissue loss. Postgrad Med.
1990;88(8):67–8, 73–7.
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Chapter43
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Hair restoration
Introduction to hair restoration 368
Options for management 370
Conclusion 374
Further reading 374
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CHAPTER43 Hair restoration
Introduction tohair restoration
Scalp and facial hair are essential components of what is perceived to be
normal appearance. Hair regrowth after a burn injury is often as much
a concern for the patient as scar disgurement. Surgical hair restoration
should be delayed until the patient is fully recovered from the acute phase
of the burn injury.
A description of the anatomy and physiology of the hair follicle is beyond
the scope of this chapter but it is important to have an understanding of this
when considering hair restoration surgery.
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INTRODUCTION TOHAIR RESTORATION
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CHAPTER43 Hair restoration
Options formanagement
Not all patients will be suitable for surgery and the burn multi- disciplinary
team should be aware of the non- surgical choices available to the patient.
These include:
• Cosmetic camouage— scalp dyes, microber sprays, eyebrow make- up
• Semi- permanent micro- pigmentation
• Scalp hair restoration systems– partial hair pieces or complete wigs
• Hair- bearing adhesive prostheses— eyebrows, false eyelashes
• Scalp hair bearing prostheses combined with Branemark ear prostheses
The surgical options will depend on the location of the hair bearing area
aected and the size of the defect (Table 43.1). These include:
• Serial excision with or without tissue expansion
• Hair- bearing aps with or without tissue expansion
• Hair- bearing full thickness grafts
• Hair transplantation
In male patients where hair- bearing aps are being considered, it is important to understand the potential for male pattern hair loss in the future and warn the patient that aps taken from areas that are genetically
predetermined to lose hair will do so in their transferred location which
may lead to unnatural patterns of balding. In some cases such loss can be
prevented by using approved medications for androgenetic alopecia such as
oral nasteride or topical minoxidil.
Hair transplantation for scalp scars should be considered as an option
provided that the donor to recipient area ratio is appropriate. Donor hair
harvesting can be maximized using the traditional occipital strip (Fig 43.1)
but in selected cases follicular unit excision may be considered. Both techniques produce grafts (see Fig. 43.1) that are implanted into multiple incisions. Results that can be achieved are shown in Fig. 43.2
Even if aps or serial excisions are utilized, hair transplants can be used
to rene hairlines and sideburns, and ll in non hair- bearing surgical scars
(Fig. 43.3).
Table43.1 Scalp burn scar alopecia classication
Type I Single alopecia segment
Type II Multiple alopecia segments amenable to tissue expansion
Type III Patchy burn alopecia not amenable to tissue expansion
Type IV Total alopecia
Reproduced from McCauley RL etal., Tissue expansion in the correction of burn alopecia:classication and methods of correction. Annals of Plastic Surgery 25(2):103– 15, Copyright © 1990,
with permission from Lippincott Williams & Wilkins.
A Less than 25% of the hair- bearing scalp
B 20– 50% of the hair- bearing scalp
C 50– 75% of the hair- bearing scalp
D 75% of the hair- bearing scalp
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OPTIONS FORMANAGEMENT
Fig.43.1 Donor hair harvesting methods–Strip Follicular Unit Transplantation
(StripFUT) vs Follicular Unit Excision (FUE).
Fig.43.2 Results of hair transplant surger y.
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