Surgical management of post-burn skin dyspigmentation of the upper limb

The use of 4% hydroquinone, 0.1% tretinoin, and 0.1% betamethasone creams to prevent hyperpigmentation of split-thickness skin grafts in Long-Evans rats

BACKGROUND

The increase in the pigmentation of skin grafts during the healing process is a cosmetic problem. There are a variety of medical and surgical treatment options for skin graft darkening.

AIMS

The aim of this study was to investigate the effects of topical hydroquinone, tretinoin, and betamethasone application on hyperpigmentation of skin grafts.

METHODS

A skin defect was created on the backs of 17 Long-Evans rats, and a 2 × 2 cm split-thickness skin graft was sutured. After 15 days, eight rats in the treatment group were treated with application of hydroquinone, tretinoin, and betamethasone cream, while nine rats in the control group were not treated. Visual evaluation was performed on days 45 and 75 using the Melasma Severity Scale (MSS), and histological evaluation was performed on day 75 using S100 and Masson Fontana (MF) staining. The Mann-Whitney U test was used for statistical analysis.

RESULTS

Mean MSS values of the treatment group on days 45 were significantly lower compared to the control group (P = .036). On day 75, the mean MSS score of the treatment group was also lower; however, the difference was not statistically significant (P = .302). Histological evaluation of S100 and MF staining scores of the treatment group showed fewer melanocytes and fewer pigments in epidermis (P = .009 and P = .002, respectively).

CONCLUSIONS

This study showed that topical application of hydroquinone, tretinoin, and betamethasone reduced the hyperpigmentation, number of melanocytes, and melanin pigment intensity that developed on the rat skin graft models. Clinical studies are needed to assess whether a similar effect could be observed with human skin grafts.

Surgical management of leukoderma after burn: A review

Burns are a common and sometimes devastating injury causing a significant amount of pain, disability, and occasionally death. Burns can have serious aesthetic and functional consequences such as pigmentary changes and formation of scar tissue. Hypopigmentation or depigmentation is often a result of partial- or full-thickness burns, which is referred to as leukoderma after burn. Thus, this study is aimed at systematically reviewing the surgical options for treating leukoderma after burn in order to gain insight into the advantages, disadvantages, and future implications of each surgical technique. The surgical procedures reviewed include dermabrasion with thin split thickness grafting, epidermal cell suspension spray, suction blister epidermal minigrafting, minigrafting, cultured epithelium, noncultured keratinocyte suspension, and chip skin grafting.

Physical and psychiatric recovery from burns

Burn injuries pose complex biopsychosocial challenges to recovery and improved comprehensive care. The physical and emotional sequelae of burns differ, depending on burn severity, individual resilience, and stage of development when they occur. Most burn survivors are resilient and recover, whereas some are more vulnerable and have complicated outcomes. Physical rehabilitation is affected by orthopedic, neurologic, and metabolic complications and disabilities. Psychiatric recovery is affected by pain, mental disorders, substance abuse, and burn stigmatization. Individual resilience, social supports, and educational or occupational achievements affect outcomes.

Physical and psychiatric recovery from burns

Burn injuries pose complex biopsychosocial challenges to recovery and improved comprehensive care. The physical and emotional sequelae of burns differ, depending on burn severity, individual resilience, and stage of development when they occur. Most burn survivors are resilient and recover, whereas some are more vulnerable and have complicated outcomes. Physical rehabilitation is affected by orthopedic, neurologic, and metabolic complications and disabilities. Psychiatric recovery is affected by pain, mental disorders, substance abuse, and burn stigmatization. Individual resilience, social supports, and educational or occupational achievements affect outcomes.

Abnormal pigmentation within cutaneous scars: A complication of wound healing

Abnormally pigmented scars are an undesirable consequence of cutaneous wound healing and are a complication every single individual worldwide is at risk of. They present a challenge for clinicians, as there are currently no definitive treatment options available, and render scars much more noticeable making them highly distressing for patients. Despite extensive research into both wound healing and the pigment cell, there remains a scarcity of knowledge surrounding the repigmentation of cutaneous scars. Pigment production is complex and under the control of many extrinsic and intrinsic factors and patterns of scar repigmentation are unpredictable. This article gives an overview of human skin pigmentation, repigmentation following wounding and current treatment options.

Super-thin abdominal skin pedicle flap for the reconstruction of hypertrophic and contracted dorsal hand burn scars

Dorsal contracture is one of the most common complications of burned hand and can result in a spectrum of deformities and functional disabilities. The injury usually necessitates surgical reconstruction and to the majority of patients, cosmetic end result is a very important issue. In this retrospective study, the authors present the technique of super-thin skin abdominal pedicle flap for the treatment of dorsal hand hypertrophic burn contracture, and review the results. Overall 42 medium or large hypertrophic and contracted scars of the dorsal hand in 34 patients were treated using this procedure. Generally, the functional and aesthetic outcomes were evaluated as good. The functional results were comparable to employment of other types of flap with no relapse of contracture. From the aesthetic point of view, the reconstructed skin was similar to the skin of the rest of the extremity, with good color match, bulkiness, laxity, and suppleness. The scar of the donor region was comparable to the scar of abdominoplasty procedures on the ipsi-lateral side of the lower abdomen. Therefore, this procedure can be considered a reliable and technically simple modality in the treatment of dorsal hand burn contractures.

Can aesthetic facial reconstruction be judged in black and white?

Aesthetic considerations of the face need to be evaluated in real-life full color. Staged contouring and insetting of a transferred free flap is sometimes required. This consists of debulking, thinning, and reshaping the flap. If the facial area is involved, however, color mismatch of a free flap represents an aesthetic challenge for the reconstructive surgeon, and often is missed with black and white photos. This article reports on a patient in whom a first dorsal metatarsal cutaneous free flap was used to reconstruct a full-thickness defect in the lateral orbit including upper and lower eyelids and outer canthus. The flap resulted in an unacceptable aesthetic outcome consisting of a bulky, hypopigmented deformity. Revisional surgery consisted of debulking the free flap and resurfacing it with a full-thickness skin graft taken from the postauricular area. This resulted in a pleasant, thin, and better color match reconstruction. The advantages of the first web space of foot free flap to the eyelid are well described. The authors are of the opinion that the flap does not match the color of the eyelid region, and therefore suggest that if used, prefabrication or a second procedure is needed. Evaluation of the postoperative results needs to be in color because black and white can mask the final aesthetic result.

Delayed primary excision and grafting of full thickness alkali burns of the hand and forearm

In a prospective study, 15 cases of domestic alkali drain cleaner burns involving the dorsal aspect of the hand and forearm were included. There were ten males and five females. The average age was 27 years and the mean total body surface area burnt was 2%. All patients failed to do immediate water lavage at home and hence all wounds ultimately required excision and grafting. Patients were initially treated with daily silver sulfadiazine dressing on an out-patient basis. Seven to 9 days after injury, patients were admitted to hospital and underwent excision and grafting. On final follow-up, there was excellent return of function, which was assessed using the grip strength of the hand and the range of motion of the wrist and fingers. Cosmetic appearance and texture of the graft were assessed according to a proposed grading system. The cosmetic result was considered satisfactory in 12 patients and poor in three patients. There were no excellent cosmetic results, because of hyperpigmentation of the healed graft. Advantages of delayed primary excision and grafting of full thickness alkali burns of the hand and forearm are discussed.

The use of split thickness skin grafts in the correction of Apert's syndactyly

Stiffness of the interphalangeal joints of the fingers is a constant feature of Apert's syndrome. Because of this stiffness, the author has used split-thickness skin grafts when correcting Apert's syndactyly, thinking that contraction of such grafts post-operatively would not cause any joint contracture or finger deviation. This paper reports the results of eight patients whose average age at first surgery was 6 months. Separation of all digits was accomplished before the age of 2 years. A dorsal rectangular flap and interposing triangular digital flaps were utilised to create the web space and partially cover the skin defects in the fingers. The remaining digital defects were covered with thin split-thickness skin grafts which took fully in all cases. At final follow-up (1-6 years), the areas covered by skin grafts have reduced in size significantly because of skin graft contraction. However, this did not result joint contracture or digital deviation.

Pediatric burns induced by psoralens in Saudi Arabia

Over a 5-year period, three children with psoralen-induced burns were seen. All children were on treatment for vitiligo with a psoralen oil and burns were sustained from unsupervised sun exposure while playing outdoors. The burn wound was partial thickness and involved 6-40% of the total body surface area. All wounds healed without infection or contracture with topical silver sulfadiazine. However, the previously normal skin in phototoxic areas became significantly hyperpigmented while the areas with vitiligo remained hypopigmented. Differences between psoralen-induced burns and other second degree sunburns unrelated to psoralens are discussed.