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32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
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Fig. 32.12 FTSG & STSG
Full Thickness Skin Grafts (FTSG)
• A FTSG consists of the whole layer of skin–
epidermis plus the whole dermal layer.
• Full thickness grafts are technically more difcult to harvest and to apply on the wound.Full
Fig. 32.10 STSG meshed 4:1, skin staples applied
Fig. 32.11 Skin graft healed
thickness skin grafts require defatting of the
undersurface of the dermis to enhance graft
take (Fig.32.13).Full thickness grafts are not
meshed by a machine, but are often meshed by
hand with a scalpel (“pie crusting”) to allow
blood and serous uid to escape into the overlying dressing (Fig.32.14).
• Meticulous hemostasis of the recipient wound
is mandatory. Hematoma formation underneath the graft will inhibit graft take.
• FTSGs are preferred to STSGs when reconstructing facial defects and special joint areas:
– Eyelids, lips, and cheek.
– Anterior neck/axilla/elbow.
– Volar aspect of the wrist and hand/ngers.
– Groin/fossa poplitea/ankle.
• Smaller grafts may be harvested from the posterior aspect of the ear, supraclavicular area,
and medial side of the upper arm. These donor
wounds are usually easily closed.
• Hair follicles in grafts harvested from the
groin will lead to hair growth at the recipient
site and should be given concern. Harvesting
from alternative places should be considered.
• When large FTSGs are required, the grafts
may be harvested from the medial side of the
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Fig. 32.13 Fat trimming of FTSG
E. Eriksen
Fig. 32.15 Harvest of FTSG from lateral side of left
thighwith application of STSG to donor site
Fig. 32.14 Hand meshing of FTSG
upper arm, ank, abdomen, or from the
thigh.
• FTSGs from medial aspect of upper arm or
thigh will likely need to be closed with a
meshed STSG (see Figs.32.15 and 32.16).
• When harvesting FTSG from the thigh, the
manual dermatome (Humby knife) can provide a wide graft.
Fig. 32.16 Deep cut covered with 4:1 meshed STSG
from medial side of same thigh
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Harvesting andApplication ofSkin
Grafts
As mentioned above, surgeons should be familiar
with the use of a manual dermatome, the Humby
knife(Fig. 32.7).
The thickness of the graft is determined by
observing the gap between the roller of the dermatome and the blade. When the gap permits a
scalpel or razor blade to gently slide in between
the roller and the blade of the dermatome, a
medium thickness STSG will be harvested –
approximately 0.015 inch in thickness. The gap
needs to be adjusted a bit to widen the space
between the roller and dermatome blade to get a
thicker FTSG graft. The thickness of the graft
may also depend on several factors such as: The
way the handle is used. Angle to the skin, force
applied to the skin, whether the blade is new or
used, from where on the body you harvest and
whether the patient is a child or an adult.
It appears obvious that this procedure needs
experience and practice.
Again, the following points all determine the
thickness of the graft:
a number of small cuts thereby allowing expansion of the graft.
The application of proper bandage and dressing
material is of greatest importance. Properly applied
dressings will prevent hematoma formation and
make sure the graft is not moving. This principle is
applied to grafts wherever they are applied. A shear
injury to the graft from sliding around is one of the
leading causes of graft failure. The surgeon is
responsible for the follow-up of all patients. The
author advises the surgeon to do the rst dressing
change together with the nursing staff, and leave
for the burn nurses to do the follow-up dressings.
However, the surgeon should regularly inspect the
wound in order to determine the appropriate timing
for the skin graft procedure.
The right timing for post-op dressing changes
may vary:
– Elective surgery with skin graft: First dressing
change after 5days.
– Unclean wounds/chronic hyper-trophic granu-
lation wounds with skin graft: rst dressing
change rst orsecond post-op day.
– The patients age– child or older adult?
– Consider that thickness of the skin varies from
one place of the body to another.
– The angle between the dermatome and the
skin surface.
– The pressure applied on the dermatome.
With experience, the surgeon will adjust their
cut to obtain the desired thickness. Practice on
pig skin is appropriate.
The thicker the graft, the deeper the donor
wound, and the more likely the surgeon should
consider re-grafting the donor area with mesh
graft for quick healing. Joint areas should preferably be covered with thick STSG sheet grafts or
FTSGs after hand meshing the graft in a few
areas to permit serous uid and blood to escape
into the overlying dressing.
If a mesh machine is not available, split thickness grafts may still be meshed by hand through
Care forDonor Wounds
Neglecting care for donor wounds may prolong
hospital stay considerably!
Make all efforts to prevent donor wounds from
becoming infected. Infected split thickness donor
wounds may sometimes require a meshed skin
graft for the donor wound to heal properly.
• If possible, avoid harvesting skin grafts from
the posterior aspect of the lower limbs and
trunk. Donor wounds from these areas may
easily become secondarily infected.
• A simple and inexpensive dressing for donor
wounds is Vaseline gauze (non-adherent
gauze) covered with several layers of dry sur-
gical gauze followed with a crepe bandage/
roll gauze bandage.
• Make sure bed clothes and blankets do not
touch the dressing. This is important in order
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to keep the donor wound dressing dry and the
best way of preventing donor site infection.
• Check the donor site dressing every day. If the
dressing becomes wet – a sign of possible
infection– the wet part of the dressing needs
to be changed without delay.
• To prevent donor wound infection, it is advisable to change the outer bandage of the donor
area the rst post-op day. This may be
repeated if dressing again gets soaked. Keep
changing regularly until dressing stays dry.
Chronic Burn Wounds: AChallenge
Many patients present with chronic wounds with
or without a contracture or deformity. Patients
may have waited for months or sometimes even
years before seeking help. Many of these patients,
children as well as adults, show evidence of
malnutrition.
This group of patients are difcult to treat.
Before even considering surgical excision and
grafting procedures, patients may need nutritional support for weeks to come. Measures need
to be taken to address chronic anemia. Blood
transfusions may be necessary but difcult to
obtain in LMICs, unless the family members are
willing to donate.
Sooner or later though, surgery has to be
planned. In the meantime, various routines will
be adhered to, like:
• 24h nutritional support through a NG tube as
necessary
• Routine work-up and treatment (scabies, parasites, HIV, etc.)
• Daily wound care with topical antibiotics.
• Physiotherapy training.
Chronic wounds always consist of a thick
brous tissue that needs to be excised before any
graft is applied. Skin grafts will be rejected in
most instances, partly or in total, if applied to
abrotic tissue oor.
The thickness of this brous tissue may exceed
1cm or more. The only way to secure graft take
is to undertake a complete excision of the brotic
wound. Limb surgery must be performed under
tourniquet control.
Chronic wounds are heavily infected. It is recommended to repeat surgical debridements at
least a few times and obtaining a negative culture
of the base of the woundbefore performing the
nal skin graft procedure.
Daily post-operative dressing changes should
start from day 1, and continue every day until
grafts are healing.
Sub-Acute toChronic Wounds
Many patients present with wounds that are
6–8 weeks old. They are referred when the
wounds do not heal properly. Small blisters may
be a sign of an unstable scar.
When burn wounds do not heal within
3 weeks, they are categorized as third degree.
Some of them may still heal given a little more
time, which often is the right thing to do.
However, when wounds do not heal by
5–6weeks, one should consider surgery, as the following cases underline (Figs.32.17, 32.18, 32.19,
32.20, 32.21, 32.22, 32.23, 32.24, 32.25,32.26, and
32.33):
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Figs. 32.17–32.21 Flame burn injury with unstable scar
7 weeks post injury. Tangential excision with Humby
knife, FTSG across ankle area, meshed STSG on remain-
ing wounds. Total procedure includes application of grafts
under tourniquet
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Figs. 32.22–32.24 12 months bedridden due to
neglected ame burn injury. Severely malnourished. 24/7
NG tube feeding. Daily dressing change. Topical antibiotics. Surgical excisions of infected granulation tissue.
Once debrided wounds appeared clean, meshed STSG
was applied, (Figs.22 and 23). After 4weeks in hospital,
patient was able to stand on 2 legs with good support from
the physio-therapist, (Fig.24). Discharged after 6 weeks
in hospital
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Figs. 32.25 and 32.26 Keep in mind that chronic burn wounds may degenerate into a Spinocellular Carcinoma
(Squamous Cell Carcinoma) if left untreated for many years
Post Burn Contractures
Basic principles in post burn reconstructive
surgery:
Scar formation in neglected burns is the main
reason for the subsequent development of deformities and handicap among burn victims.
Even though burn contractures may affect any
neglected burn victim, the consequences among
children are particularly of great concern. By
• Release of all contracting scar tissue contributing to the deformity.
• Z-plasty.
• Skin graft procedures.
• Transposition/pedicle aps.
nature, scar tissue will contract in order to minimize and close any wound. Contractures and
deformities around joint areas in children will
appear more pronounced as times goes by as a
child is growing. The need for close follow-up
after surgery is therefore of greatest importance
among many pediatric burn victims.
All scar tissue which contributes to the defor-
mity needs to be released. The best cleavage line
for dissection is the level between the scar and
the underlying healthy subcutaneous tissue,
which becomes an excellent recipient bed for a
skin graft. The size of the wound following a
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complete release often appears to be much larger
than the one that would be projected. Harvest of
skin graft should always wait until the size of the
wound has been revealed and accurately measured at its maximum size (e.g., in extension).
Z-plasty is an excellent way of releasing a linear scar in joint areas. The technique is very useful when the adjacent skin structure is normal
without scar formation (see Figs. 32.75 and
32.76).
Sheet grafts, whether STSG or FTSG, are
the main solution for the coverage in the majority
of all post burn contractures(Fig. 32.12).
In joint related areas, a FTSG is usually the
preferred choice. The functional and cosmetic
result using FTSG in head and neck, elbow, hand,
wrist, and ngers is far better than using STSG.
Meticulous hemostasis is of paramount importance when FTSG are applied in order to avoid
“tenting” and graft loss.
Transposition aps are very useful in joint
areas. The donor defect may as well be closed
directly, but often though a skin graft may be
needed.
Distant/pedicle aps are useful under conditions when a skin graft or local transposition ap
may not solve the problem.
Application of the various reconstructive
methods mentioned above will be described
using specic case examples and accompanying
photosthroughout the remainder of this chapter
(Figs. 32.27, 32.28, 32.29, 32.30, 32.31, 32.32,
32.33, 32.34, 32.35, 32.36, 32.37, 32.38, 32.39,
32.40, 32.41, 32.42, 32.43, 32.44, 32.45, 32.46,
32.47, 32.48, 32.49, 32.50, 32.51, 32.52, 32.53,
32.54, 32.55, 32.56, 32.57, 32.58, 32.59, 32.60,
32.61, 32.62, 32.63, 32.64, 32.65, 32.66, 32.67,
32.68, 32.69, 32.70, 32.71, 32.72, 32.73, 32.74,
32.75, 32.76, 32.77, 32.78, 32.79, 32.80, 32.81,
32.82, 32.83, 32.84, 32.85, 32.86, 32.87, 32.88,
32.89, 32.90, 32.91, 32.92, 32.93, 32.94, 32.95,
32.96, 32.97, 32.98, 32.99, 32.100, 32.101,
32.102, 32.103, 32.104, 32.105, 32.106, 32.107,
32.108, 32.109, 32.110, 32.111, 32.12, 32.113,
32.114, 32.115, 32.116, 32.117, and 32.118).
Facial Injuries
Eyelids
1. Thermal injuries to the upper part of the face/
forehead will frequently affect the eyelids.
2. Second degree facial burns usually heal completely within about 2weeks.
3. Wounds of the eyelids that have not healed
properly within 3weeks may easily contract
and retract the eyelids.
4. Early reconstruction of retracted eyelids is of
paramount importance in order to protect the
cornea and restore normal eyelid function.
5. Technique:
(a) General anesthesia is preferred.
Inject lidocaine with adrenaline in the scar
tissue/incision area to minimize bleeding.
Allow 5–7minutes before cutting.
(b) Make an incision about 2–3mm from the
lid margin. Gently dissect the scar tissue
from the underlying normal eyelid tissue.
Bleeding points controlled by cautery.
Make sure a complete release is done.If
both eyelids are involved, release both
together.
(c) FTSG is harvested from behind the auri-
cle, supraclavicular or medial side of
upper arm. Fat tissue needs to be trimmed
off, (Fig.32.13), and the graft needs to be
hand meshed (Fig. 32.14). Secure complete hemostasis. Use 4-0 or 5-0 nylon
stitches.
(d) Tarsorrhaphy is advised before applying
the dressing. Apply ophthalmic ointment.
The dressing should consist of Vaseline
gauze, wet and dry gauze, gentle elastic
bandage.
Remove tarsorrhaphy and stitches within
2–3 weeks. Continue to apply dressing
support to both eyelids for another
2–3 weeks (Figs. 32.27, 32.28, 32.29,
32.30, 32.31, 32.32,and 32.33).
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Figs. 32.27–32.30 Eyelid reconstruction with FTSG harvested from the supraclavicular region
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Fig. 32.31 8 month old girl who fell into the ground
level cooking area with severe facial injury, all 4 eyelids
retracted
Fig. 32.32 Contracture release of all 4 eyelids.
Reconstructed with FTSG harvested from medial side of
upper arm. Tarsorraphy. Bandage support for 3 weeks
before stitch removal
Fig. 32.33 12month follow-up
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