Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_857_Библиотеки_им_академика_М_И_Перельмана
.pdf
32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
https://t.me/medicina_free
411
Fig. 32.34 Epileptic seizure 4months before admission
Fig. 32.35 Tracheostomy due to microstomia
Fig. 32.36 Excision of all scar tissue
Fig. 32.37 2 large FTSG harvested from left ank and
medial side of right upper arm
412
https://t.me/medicina_free
E. Eriksen
Figs. 32.38 and 32.39 15month follow-up, Left lower eyelid reconstructed 3months later. Bilateral oral commisurotomy due tosecondary microstomia was later required
functioning ulnar artery that needs to be tested
Radial Forearm Pedicle Flap
prior to surgery with a positive Allen test.
This ap can be designed to t the exact size
The pedicle version of the Radial Forearm Flap is
avery good tool to solvehighly challenging and
critical conditions in burns as well as other
trauma, particularly to the face and scalp area.
The fasciocutaneous ap is vascularized by a
pedicle consisting of the radial artery and its 2
vena comitantes that are ligated distal to the
bifurcation of the brachial artery in the elbow
region. When the ap is raised, ow will enter the
ap in a retrograde fashion, based on a normal
of the defect.
As the ap leaves behind a donor defect of the
forearm, donor morbidity is a concern.
The defect may be covered with a STSG,
either a sheet graft or a meshed graft.
As microsurgery may not be readily available,
the pedicle radial forearm ap is indeed a great
tool to solve challenging problems.
The following two clinical conditions will
demonstrate good indications for using this ap.
32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
https://t.me/medicina_free
413
Figs. 32.40–32.43 A 13-year-old boy with a neglected
ame burn to the scalp of 11years duration. The chronic
wound subsequently developed into a squamous cell carcinoma. During excision, it turned out a large part of the
skull bone was eroded by the tumor, exposing the
dura.Following 3–4days with dressing change, the entire
forearm skin was raised as a fasciocutaneous ap based on
retrograde ow through the radial artery. The forearm was
covered with meshed STSGSplit thickness skin grafts
(STSG). Pedicle release on day 16. Good nursing care
made it unnecessary to apply any kind of splint to keep the
position of the hand. This case demonstrates that the
entire scalp may be covered with this ap
414
https://t.me/medicina_free
E. Eriksen
Figs. 32.44–32.46 A 16-year-old girl with a hyena bite.
A huge defect exposing right side of forehead, upper rim
of orbital with the eyeball missing. Repeated theatre visits
Figs. 32.47 and 32.48 Patient was encouraged to move shoulder joint while in bed to prevent shoulder pain and stiffness. Was up walking second post-op day
for debridements. A pedicle radial forearm ap was
designed to t the defect and raised on the left forearm for
better support and position of the arm. No splinting
32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
https://t.me/medicina_free
415
Figs. 32.49 and 32.50 Pedicle released on day 20
Neck Contractures
Anterior and lateral neck contractures are posing
a real challenge to the reconstructive surgeon.
The scar tissue may involve a huge area of the
neck. The chin may be pulled inferiorly towards
the sternum making intubation a real challenge
for the anesthetist. Most hospitals may not have
access to beroptic intubation equipment. If
intubation seems difcult, a preliminary release/
incision of the scar under local anesthesia must
be performed in order to have the patient
intubated.
After intubation, the patient should be positioned with full neck extension in order to have
proper access to the neck. All scar tissue contributing to the contracture needs to be excised. In
severe anterior neck contractures, the resulting wound defect usually appears to be larger
than one would think prior to surgery. The sur-
geon will frequently have to extend incisions into
healthy skin tissue to obtain the best result.
Many surgical techniques have been described
to reconstruct neck contractures:
• Skin graft procedures, STSG and FTSG.
• Local aps and pedicle aps.
• Expander techniques.
• Free aps.
The author recommends reconstructing the
wound defect using FTSG and STSG, frequently
in combination with local advancement aps.
There are good reasons to stick to this method:
• The surgeon will not be sure about the size of
the wound defect until scar release has been
completed.
• Advancement of local cutaneous aps from
the lateral side of the neck will assist the sur-
416
https://t.me/medicina_free
E. Eriksen
geon to make sure to create a V- or Z-shaped
junctions with normal skin, avoiding vertical
scars.
• Once local aps have been advanced and the
actual wound size has been determined, it is
time to plan harvesting the required skin grafts
for resurfacing.
• FTSG is the main choice when resurfacing the
anterior neck. During scar release, the cleavage plane will expose healthy subcutaneous
tissue or platysma, a nice recipient tissue for
FTSG. Once FTSG has been applied to recreate the neck contour, thick STSG may be used
to resurface remaining part of the anterior
neck (submental and sternal areas) in case
there is shortage of FTSG for harvest.
• Meticulous hemostasis is of greatest importance before applying FTSG.
• FTSG may be harvested from the lateral aspect
of the thigh using the Humby knife. Large
FTSG may also be harvested from medial side
of the upper arm or from the abdomen/ank,
using the scalpel, followed by trimming of fat
tissue. The donor areas need to be resurfaced
with 4:1/3:1 meshed STSG(Fig. 32.15).
• A FTSG is elastic due to the dermis
(Fig. 32.51). When applyinginserting the
FTSG Full thickness skin grafts (FTSG) to the
recipient site, make sure to gently stretch the
graft across the wound surface to somehow
match its original size at the donor site.
OverstretchingNeck contractures should be
avoided
• Keep the patient positioned with the neck
extended post-op for 4–5 days with a thick
dressing to support the grafts. A neck collar
should be custom made for the patient to wear
for 5–6weeks post-op.
Fig. 32.51 The FTSG is elastic
32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
https://t.me/medicina_free
417
Figs. 32.52–32.56 A 22years old man with a 5 years
history of ame burn injury to the upper chest, ant neck,
chin and large part of the face incl both eyelids on right
side. A complete scar release was excised, revealing a
huge wound. Reconstruction aimed at bringing the neck
contour back to normal, extending the incisions beyond
the middle of the neck. FTSG on anterior neck, STSG on
upper chest,eyelids, and lower lip
418
https://t.me/medicina_free
E. Eriksen
Figs. 32.57–32.60 A postero-lateral neck contracture in
a small boy lasting from early childhood. The contracture
stretches from the acromion area of left shoulder to the
occipital region. Complete release of the deformity with
scar excision. A FTSG was applied to the concave area of
the neck. The remaining wounds were covered with hand
meshed sheets of STSG
32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
https://t.me/medicina_free
419
Upper Limb
Post burn contractures frequently affect anterior
neck, shoulders, axilla, upper arms, and chest. A
common mechanism is clothes catching re during cooking on ground level kitchen facilities.
Figs. 32.61–32.65 A 15year-old-girl with broad, thick
scar affecting both axillae and the anterior neck, including
scar adhesions between proximal upper arms and the
chest. Three separate surgical procedures. Excision of
scar.FTSG applied to both arm pits and anterior neck.
STSG, meshed and sheets, applied to remaining wounds
420
https://t.me/medicina_free
E. Eriksen
Figs. 32.66–32.70 A14year-old-boy with broad, thick
scar from ame burn injury during early childhood, not
able to elevate his arm above the horizontal line. The best
option was to excise the thick eshy scar to prepare a
U-shaped area for a FTSG as a continuation of the normal
armpit. A 90-degree splint was used for 6weeks post-op.
The U-shaped FTSG enabled the patient to raise the arm
above the horizontal line without any problem. In due
time, the boy should be able to raise the arm into a vertical
position
Соседние файлы в папке Библиотека им академика М.И. Перельмана