Adult burn patients with more than 60% TBSA involved-Meek and other techniques to overcome restricted skin harvest availability--the Viennese Concept

Bacterial fluorescence imaging as a predictor of skin graft integration in burn wounds

BACKGROUND

Split-thickness skin graft (STSG)1 integration rates are susceptible to improvement. Infection and/or biofilm should be appropriately addressed prior to grafting to improve the likelihood of graft-take. Incorporating technological aids such as fluorescence (FL)2 imaging (MolecuLight®), which accurately locates areas of bacterial loads above 104 CFU/gr, for graft site assessment and preparation could yield better outcomes.

METHODS

This single-center, prospective observational study included adult burn patients with previously infected wounds that had been deemed clinically and microbiologically clean and were therefore candidates for grafting. Prior to grafting, a FL imaging assessment (blinded to the surgical team) localized areas positive for moderate-high bacterial loads (>104 CFU/gr). Intra-operatively, a standard swab sample from the recipient site was collected by the surgical team. Postoperatively, areas positive/negative for FL and areas of graft take and failure were overlapped and measured (cm2) over a 2D schematic. The performance and accuracy of FL imaging and swab sampling in relation to graft outcomes were assessed.

RESULTS

38 patients were enrolled in the study. The mean total body surface area (TBSA)3 involvement was 14.5 ± 12.4 % [range 0.8 - 40.2 %]. 25/38 of the subjects enrolled had complete graft take while 13 had partial graft losses. There were no total losses. FL-imaging was positive in 100 % of losses versus 31 % (4/13) of the swab microbiology. FL-imaging was found to have a sensitivity of 86 %, specificity of 98 %, PPV of 72 %, NPV of 99 %, and an accuracy of 94 % for predicting any type or range of graft loss in the entire cohort. Meanwhile, the sensitivity of microbiology from swab samples was 30 %, with a specificity of 76 %.

CONCLUSIONS

FL imaging is an accurate method for assessing recipient sites and predicting the outcome of a skin graft among burn patients. These findings suggest that FL imaging can inform better decision-making surrounding grafts that may lead to better outcomes.

LEVEL OF EVIDENCE

Level IIA, Therapeutic study.

Challenges in the Management of Large Burns

Large burns provoke profound pathophysiological changes. Survival rates of patients with large burns have improved significantly with the advancement of critical care and adaptation of early excision protocols. Nevertheless, care of large burn wounds remains challenging secondary to limited donor sites, prolonged time to wound closure, and immunosuppression. The development of skin substitutes and new grafting techniques decreased time to wound closure. Individually, these methods have limited success, but a combination of them may yield more successful outcomes. Early identification of patients with likely poor prognosis should prompt goals of care discussion and involvement of a palliative care team when possible.

Expansion of fibroblast cell sheets using a modified MEEK micrografting technique for wound healing applications

Cell sheet engineering, a scaffold-free approach to fabricate functional tissue constructs from several cell monolayers, has shown promise in tissue regeneration and wound healing. Unfortunately, these cell sheets are often too small to provide sufficient wound area coverage. In this study, we describe a process to enlarge cell sheets using MEEK micrografting, a technique extensively used to expand skin autografts for large burn treatments. Human dermal fibroblast cell sheets were placed on MEEK's prefolded gauze without any use of adhesive, cut along the premarked lines and stretched out at various expansion ratios (1:3, 1:6 and 1:9), resulting in regular distribution of many square islands of fibroblasts at a much larger surface area. The cellular processes essential for wound healing, including reattachment, proliferation, and migration, of the fibroblasts on expanded MEEK gauze were superior to those on nylon dressing which served as a control. The optimal expansion ratio with the highest migration rate was 1:6, possibly due to the activation of chemical signals caused by mechanical stretching and an effective intercellular communication distance. Therefore, the combination of cell sheet engineering with the MEEK micrografting technique could provide high quality cells with a large coverage area, which would be particularly beneficial in wound care applications.

Skin regeneration, repair, and reconstruction: present and future

Background

Large skin defects caused by trauma (e.g., burns) or due to other reasons (e.g., tumor-related skin resections) require sufficient skin replacement. The constant improvement of innovative methods of skin replacement and skin expansion mean that even burn victims with more than 80% body surface burned have a realistic chance of survival. Due to these new developments, not only has survival rate increased, but also quality of life has increased tremendously over the past decades.

Methods

The aim of this review is to present an overview of current standards and future trends concerning the treatment of skin defects. The main focus is placed on the most important technologies and future trends.

Results

Autologous skin grafting was developed more than 3500 years ago. Several approaches and techniques have been discovered and established in burn care and plastic surgery since then. Great achievements were made during the 19th and 20th centuries. Many of these old and new techniques are still part of modern burn and plastic surgery. Today, autologous skin grafting is still considered to be the gold standard for many wounds, but new technologies have been developed, ranging from biological to synthetic skin replacement materials.

Conclusion

Today, old and new technologies are available which allow us new treatment concepts. All this has led to the reconstructive clockwork for reconstructive surgery of the 21st century.

Use of a biosynthetic wound dressing to treat burns: a systematic review

OBJECTIVE

Accelerating the process of wound healing, reducing infection risks, and decreasing pain and discomfort in the burn area are important goals of burn treatment. To achieve these goals, the use of biosynthetic wound dressings has increased in recent years. Suprathel (PolyMedics Innovations, Germany) is a biosynthetic wound dressing used to treat both partial-thickness burns and split-thickness skin graft (STSG) donor sites, full-thickness wounds, large-scale abrasions, and scar revisions.

METHOD

This study is a systematic review of empirical evidence reported on the application of the biosynthetic wound dressing in burns up to 2017. Keywords such as 'Suprathel', 'effectiveness', 'safety', and 'cost' were searched in PubMed, Cochrane, Scopus and Embase databases.

RESULTS

A total of 14 publications were identified, based on the inclusion and exclusion criteria. The findings reported in the literature reviewed were classified in terms of safety, effectiveness and cost-effectiveness of use of the biosynthetic wound dressing. Regarding safety and effectiveness, the dressing was found to yield desirable results, particularly for partial thickness burns and STSG donor sites. As of 2017 no health economics assessments have been carried out.

CONCLUSION

Despite the desirable advantages of the biosynthetic wound dressing with respect to its effectiveness, safety and ease of use, its major limitation was found to be its cost. However, in the absence of comprehensive studies on the quantification of all factors, there is scant scientific evidence for making reliable conclusions from this systematic review.

Combined Complex Skin Repair in Patient With Extensive Burns: A Case Report

Auto-skin grafting is the current treatment of choice for extensive burns. Nevertheless, the lack of donor sites for skin grafting remains one of the greatest limiting factors for the treatment of extensively burned patients. We present the case of a 53-year-old male patient with deep and full thickness burns on 91% of the total body surface area. We used the Meek technique for split-thickness skin graft expansion to treat this patient. In order to obtain sufficient skin for grafting, we repeatedly harvested the same anatomical areas. Acceleration of burn wounds, recipient, and donor site healing was achieved by systemic treatment with recombinant human growth hormone and topical recombinant human epidermal growth factors. This combined, complex treatment modality contributed to the successful skin repair in this patient.

Historical Evolution of Skin Grafting-A Journey through Time

Autologous skin grafting was developed more than 3500 years ago. Several approaches and techniques have been discovered and established in burn care since then. Great achievements were made during the 19th and 20th century. Many of these techniques are still part of the surgical burn care. Today, autologous skin grafting is still considered to be the gold standard for burn wound coverage. The present paper gives an overview about the evolution of skin grafting and its usage in burn care nowadays.

Using Various Skin Graft Techniques in Major Burn Reconstruction: A Lesson Learned From a Taiwanese Cornstarch Explosion

PURPOSE

Four hundred and ninety-nine patients had burn injuries in an explosion in Taiwan on June 27, 2015, 24 were admitted to the intensive care units of Taipei Veterans General Hospital. This study details our experience with surgical management of these patients, focusing primarily on various skin graft techniques.

MATERIALS AND METHODS

This single-center retrospective study included patients who underwent at least one of the previously mentioned skin graft techniques because of extensive skin defects. The demography, burn diagram, treatment modalities, postoperative outcome, and costs were all analyzed, and a comparison with traditional mesh skin grafts was performed. The literature was also reviewed.

RESULTS

Fourteen patients underwent the Meek skin graft technique. Only 3 received ReCell and 1 cultured epithelial autograft (CEA) at separate time point. Overall, the autologous skin grafts, including Meek/ReCell/CEA were completed within 6 months. The average skin graft success rate was approximately 72.9%, 79.2%, and 38% in Meek, ReCell, and CEA, respectively. The infection rate was approximately 35.7%, 25%, and 100% in Meek, ReCell, and CEA, respectively. The average surgical cost and total medical cost were significantly higher in patients who underwent Meek/ReCell/CEA treatments.

CONCLUSIONS

In our experience, Meek and ReCell treatments had acceptable success rates, but CEA treatment not. ReCell and CEA treatments are useful in the event of extremely limited donor sites, and they are fragile, easily infected, and technically challenging. These techniques also require longer hospitalization and tend to be more expensive, all factors that should be considered when assessing treatment options.

Air-fluidized therapy in the treatment of severe burns: A retrospective study from a burn intensive care unit in Austria

INTRODUCTION

Air-fluidized therapy (AFT) has long been used in the treatment of severe burns. In patients with extensive burns involving the posterior trunk, we aim to keep affected posterior areas dry and to postpone their treatment, initially applying available split-thickness skin grafts in functionally more important regions. We retrospectively assessed the impact of AFT on the survival of patients treated in the burn intensive care unit (ICU) of the Medical University of Vienna, Austria, between 2003 and 2016.

METHODS

This retrospective single-center study included patients aged ≥18 years with burned total body surface area (TBSA) ≥20% and IIb-III° thermal injuries on the posterior trunk who received AFT. Survival rates were compared with those predicted by the abbreviated burn severity index (ABSI). Demographic, clinical, and surgical data were analyzed.

RESULTS

Seventy-five of 110 patients with posterior trunk burns received AFT. Their survival rate exceeded that predicted by the ABSI score (mean ABSI, 10.0 ± 2.0; 73.3% (95% CI: 62-83%) survival rate vs. 20-40% predicted; p <  0.0001); no such difference was observed in the non-AFT group (mean, 8.8 ± 1.9; 65.7% (95% CI: 48-81%) survival rate vs. 50-70% predicted). Patients receiving AFT had significantly greater TBSA (median, 50% (35-60) vs. 30% (25-45) and longer ICU stays (median, 63 (36-92) vs. 18 (9-52) days; both p <  0.0001). Fifty-one (68.0%) patients in the AFT group and 26 (74.3%) patients in the non-AFT group underwent posterior trunk surgery (p =  0.66) a median of 16 (10-26) and 5 (2.5-9.5) days, respectively, after admission (p <  0.0001).

CONCLUSIONS

Patients receiving AFT had significantly better survival than predicted by ABSI score in contrast to patients not receiving AFT although burn injuries in this group were more severe (greater TBSA, higher ABSI). As intensive care was similar in these groups aside from AFT, the better survival could be attributed to this additional therapy.

Managing Wounds with Exposed Bone and Tendon with an Esterified Hyaluronic Acid Matrix (eHAM): A Literature Review and Personal Experience

The loss of extracellular matrix in combination with the exposure of structures such as bone and tendon pose a major challenge; the development of granulation tissue and subsequent reepithelialization over these structures is extremely slow and often may not happen at all. Replacement of the matrix has been shown to significantly increase the chances of healing since, with revascularization of the matrix, a wound bed is created that may either heal by secondary intention or via the application of a skin graft. A literature search on an esterified hyaluronic acid-based matrix (eHAM) returned five articles on the treatment of wounds with tendon and bone loss in which the eHAM was used. The etiologies of the wounds described varied among the articles, as did treatment modalities. However, all of them received proper debridement of necrosis with subsequent (although not always immediately) application of the eHAM. A very high percentage of all wounds reached the different primary endpoints in the studies, which were complete reepithelialization, complete coverage with granulation tissue and/or 10% coverage of the original wound size with epithelium, the latter being a strong indicator of the wound continuing to heal. The individual authors concluded that the esterified hyaluronic acid matrix (eHAM) is a valuable tool to assist in the complete healing of difficult to heal wounds.

Repair of soft tissue defects in finger, thumb and forearm: less invasive methods with similar outcomes

We review recent developments in using occlusive dressings, dermal templates, and venous flaps for less invasive approaches to treat soft tissue defects of the forearm and fingers. Occlusive dressings can be used for thumb tip or fingertip trauma with soft tissue defects of small or moderate sizes. They permit skin regeneration without use of skin graft or a flap transfer. This is currently a popular way to treat tip soft tissue defects in European countries. Extensive soft tissue defects in the thumb, fingers, hand and forearm require flap transfers traditionally, but in recent years, surgeons use dermal templates to cover the defect site to allow regeneration of subcutaneous tissues, over which a skin graft is used in lieu of a flap. Transfer of a venous flap is currently a reliable procedure and is less invasive compared with conventional flaps, which usually damage a named artery in the donor. We advocate that less invasive methods should be considered for soft tissue defects in the hand and forearm.

Five Years Experience With Meek Grafting in the Management of Extensive Burns in an Adult Burn Center

Background

In extensive burn injuries with lack of donor sites for skin grafting, the Meek technique of skin expansion can be an efficient and effective method in covering extensive wounds. The aim of this retrospective study was to present our experience with the Meek technique of grafting.

Methods

We performed a retrospective analysis of patients from our burn center who underwent Meek grafting between 2012 and 2016. Demographics, burn details, clinical course, operative management, and outcomes were collected and analyzed from patient records and operative notes. Outcome measures, including graft take rate, complications and need for further surgery, were recorded.

Results

Twelve patients had Meek grafting. The average age was 38 years (range: 15-66). The average percent total body surface area burned was 54.3% (range: 31%-77%). Eighty-three percent of grafted areas healed well, and no regrafting was necessary. In the remaining 17%, infection and hematoma were the leading cause of graft failure.

Conclusions

Meek grafting constitutes a rapid and efficient surgical approach for the skin coverage of extensive full-thickness burn injuries with limited autograft donor sites.

Necrotizing Fasciitis: An Overview and 2 Illustrative Cases

Necrotizing fasciitis is the generic term for a series of progressive gangrenous infections of the skin and subcutaneous tissues. Typically, necrotizing fasciitis start with an, often small, infected lesion with atypical symptoms, which then quickly develops into a rapidly spreading, massive infection. The primary therapy is excision of all necrotic tissue in combination with treatment of systemic symptoms such as shock. The defects resulting from rigorous excision are often very large. Once they are clean, they require closure with an autograft. This article reviews the symptoms and treatment of necrotizing fasciitis. In addition, it illustrates, with 2 cases, how a hyaluronic-based extracellular matrix can be used to "fill in" with neodermis for the lost dermis and can create a wound bed most suitable for grafting.

Scalp as a donor site in children: Is it really the best option?

BACKGROUND

Since 2003 we have used the scalp as a donor site for split skin grafts (SSGs) in major burns when there was a shortage of conventional donor areas. However, we seen a high incidence of complications, contrary to international experience.

OBJECTIVE

The aim of this study was to analyze the results and complications related to the scalp as a donor site and to determine whether there is an association between our specific patient population and the complications encountered.

METHODS

A retrospective review of our scalp donor site outcomes over a 12-year period was conducted. The cohort included 25 patients, 15 of black African descent, nine of mixed race and one Caucasian. The various hair types were identified based on ethnicity and classified into eight types. Most of our patients had hair types VI-VIII. None of these patients had scalp burns and all received standard burn treatment. The SSGs were taken with an electric dermatome with a standard micrometric setting of 0.2mm. Complications were categorized into short- or long-term, with a mean follow-up time of 1.59years.

RESULTS

The mean age of the 25 children was 5.7years. Nineteen sustained flame burns and 6 sustained hot water burns, with a mean total body surface area of 44.9%. A total of 43 scalp procurements were performed in the 25 patients studied. The group of 15 black African patients (hair types VI-VIII) had a total of 22 procurements, the nine patients of mixed race (hair types III-V) had 18 procurements and the single Caucasian patient (hair types II-III) had two procurements. The median healing time was 15days, 11.8days and 8.5days, respectively, per group. Significant complications were encountered, including folliculitis 44%, non-healing wounds 52%, alopecia 16% and visible, hypopigmented scars 3%. One patient had a hypertrophic scar and no hair transfers to the recipient areas were observed. The various hair types correlated with the complications encountered. Five children, with an average burn size of 65.2% (range: 40-85%) died of sepsis. Due to the small sample size, the only statistically significant findings were related to the total body surface area of the burn and the number of times skin was harvested from the scalp, with a p-value of 0.005. The p-values for the healing times related to the first, second and third croppings, were p=0.022, p=0.00032 and p<0.001 respectively.

CONCLUSION

Our study suggests that in pediatric patients of black African descent (hair types VI-VIII) the scalp is not an ideal donor area, due to the unacceptably high incidence of complications. Hence, every precaution should be taken when it becomes necessary to harvest donor skin from the scalp.

Modified Meek Micrografting Technique for Wound Coverage in Extensive Burn Injuries

The modified Meek micrografting technique constitutes a rapid and efficient surgical approach for the skin coverage of extensive full-thickness burn injuries. A total of 10 burn patients (mean 68 ± 9.2% TBSA) admitted to our burn unit required one or more Meek micrografting procedures (mean 2.2 ± 0.5) to cover in average 43.4 ± 11.6% TBSA (range between 10 and 75% TBSA). This goal was achieved using a donor site area ranging between 2.5 and 18% TBSA. All patients developed local infection to Pseudomona aeruginosa (75%), Stenotrophomona maltophilia (25%), methicillin-resistant Staphylococcus aureus (12.5%), and Acinetobacter baumannii (12.5%). Thus, the average of Meek regrafting after graft-take failure was 13.1 ± 6.4% TBSA (median: 9%; range from 0 to 36%). The period to obtain stable definitive wound closure was in average of 67.2 ± 21 days post injury. The modified Meek micrografting provides a reliable and versatile method for the coverage of large burn wounds with limited autograft donor sites and is now routinely used in our institution. Its systematic use improves operating times and overall outcomes reducing the number of surgeries, increasing the percentage of graft take, and decreasing the length of stay.

Development of a Conceptual Framework to Measure the Social Impact of Burns

Measuring community reintegration following burn injury is important to assess the efficacy of therapies designed to optimize recovery. This project aims to develop and validate a conceptual framework for understanding the social impact of burn injuries in adults. The framework is critical for developing the item banks used for a computerized adaptive test. We performed a comprehensive literature review and consulted with clinical experts and burn survivors about social life areas impacted by burn injury. Focus groups with burn survivors and clinicians were conducted to inform and validate the framework. Transcripts were coded using grounded theory methodology. The World Health Organization's International Classification of Functioning, Disability and Health, was chosen to ground the content model. The primary construct identified was social participation, which contains two concepts: societal role and personal relationships. The subdomains chosen for item development were work, recreation and leisure, relating with strangers, and romantic, sexual, family, and informal relationships. Qualitative results strongly suggest that the conceptual model fits the constructs for societal role and personal relationships with the respective subdomains. This conceptual framework has guided the implementation of a large-scale calibration study currently underway which will lead to a computerized adaptive test for monitoring the social impacts of burn injuries during recovery.

Measuring the Social Impact of Burns on Survivors

Many burn survivors experience social challenges throughout their recovery. Measuring the social impact of a burn injury is important to identify opportunities for interventions. The aim of this study is to develop a pool of items addressing the social impact of burn injuries in adults to create a self-reported computerized adaptive test based on item response theory. The authors conducted a comprehensive literature review to identify preexisting items in other self-reported measures and used data from focus groups to create new items. The authors classified items using a guiding conceptual framework on social participation. The authors conducted cognitive interviews with burn survivors to assess clarity and interpretation of each item. The authors evaluated an initial pool of 276 items with burn survivors and reduced this to 192 items after cognitive evaluation by experts and burn survivors. The items represent seven domains from the guiding conceptual model: work, recreation and leisure, relating to strangers, romantic, sexual, family, and informal relationships. Additional item content that crossed domains included using self-comfort and others' comfort with clothing, telling one's story, and sense of purpose. This study was designed to develop a large item pool based on a strong conceptual framework using grounded theory analysis with focus groups of burn survivors and their caregivers. The 192 items represent 7 domains and reflect the unique experience of burn survivors within these important areas of social participation. This work will lead to developing the Life Impact Burn Recovery Evaluation profile, a self-reported outcome measure.

The MEEK technique: 10-year experience at a tertiary burn centre

Extensive full-thickness burns pose a great challenge to the burn surgeon. Lack of autograft donor sites is an important limiting factor to achieving wound closure. To overcome this problem, various methods of treatment have been suggested in the past, including the MEEK technique. This study was carried out at the Bogenhausen Hospital Burn Unit, Munich, Germany from 2006 to 2015. There were a total of 148 skin grafting operations. The modified MEEK technique was performed on 67 patients. Patients included 34 males and 33 females, with an average age of 39·6 years. The mean percentage body surface burned was 65%, and full-thickness injury occurred in 52%. The mean area graft per procedure was 20%. The viability of the graft as assessed between the 7th and 10th day was generally in the range of 60-90%. The average number of operations required was 2·21. The mean length of stay was 27 days. Infection was documented in five patients, and seven deaths occurred. The mean follow-up was 3·2 years. When faced with large surface area burns and limited donor sites, the MEEK technique is a satisfactory method for coverage.

Important Developments in Burn Care

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the epidemiology of severe burn injury in the context of socioeconomic status, gender, age, and burn cause. 2. Describe challenges with burn depth evaluation and novel methods of adjunctive assessment. 3. Summarize the survival and functional outcomes of severe burn injury. 4. State strategies of fluid resuscitation, endpoints to guide fluid titration, and sequelae of overresuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraoperative strategies to improve patient outcomes, including hemostasis, restrictive transfusion, temperature regulation, skin substitutes, and Meek skin grafting. 7. Translate updates in the pathophysiology of hypertrophic scarring into novel methods of clinical management. 8. Discuss the potential role of free tissue transfer in primary and secondary burn reconstruction.

SUMMARY

Management of burn-injured patients is a challenging and unique field for plastic surgeons. Significant advances over the past decade have occurred in resuscitation, burn wound management, sepsis, and reconstruction that have improved outcomes and quality of life after thermal injury. However, as patients with larger burns are resuscitated, an increased risk of nosocomial infections, sepsis, compartment syndromes, and venous thromboembolic phenomena have required adjustments in care to maintain quality of life after injury. This article outlines a number of recent developments in burn care that illustrate the evolution of the field to assist plastic surgeons involved in burn care.

Comparing the Curative Efficacy of Different Skin Grafting Methods for Third-Degree Burn Wounds

Background

Our research purpose was to compare the curative efficacy of different skin grafting methods for treating third-degree burn wounds.

Material/Methods

A total of 105 patients with third-degree burns were involved in this study. The burn wounds of these patients were treated using three different methods: Meek skin grafting, Stamp skin grafting, and Microskin grafting. Patients treated with different methods were placed in different groups. The skin graft survival rate, skin graft fusion time, wound healing time, total time of surgery, and 1% total body surface area (TBSA) treatment costs in each group were evaluated during and after the grafting procedures. After the operations, patients were followed up for 3 to 18 months in order to evaluate the postoperative outcomes.

Results

The skin graft survival rate was significantly higher in the Meek group compared to the rates in the Stamp and Microskin groups (both P<0.01). In addition, the skin graft fusion time, wound healing time, and 1% TBSA treatment costs were significantly lower in the Meek group compared to those in the Stamp and Microskin groups (both P<0.01). Furthermore, the Meek group exhibited better results with respect to curative efficacy, scarring status, and joint activity in comparison to the other two groups (both P<0.05).

Conclusions

The Meek skin grafting method showed better clinical efficacy for treating large wound areas in third-degree burn patients compared to the Stamp and Microskin skin grafting methods.

Use of negative pressure wound therapy in burn patients

According to previous research, adjunctive negative pressure wound therapy (NPWT) can help manage infected wounds when applied along with appropriate debridement and antibiotic therapy as deemed clinically relevant. NPWT not only removes fluid, and reduces oedema, but also promotes perfusion around the wounds. In addition, NPWT may lead to improved graft fixation when used as a bolster, especially in patients who are less compliant or have poor graft fixation that result from using traditional methods. NPWT is a good choice to bolster skin grafts in young, active and less-compliant patients. We propose an enhanced segmental compartment-covered technique, which uses NPWT adjunctively as first-line wound treatment to help manage postoperative infection. Moreover, NPWT promotes granulation tissue formation to prepare the wound bed for subsequent skin graft and may be used as a bolster over the graft, which helps to attain skin graft viability.

Surgical treatment and management of the severely burn patient: Review and update

Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns. Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients.

Experience and outcomes of micrografting for major paediatric burns

BACKGROUND

The deficit of donor sites in major burns over 50% of the total body surface area has necessitated the application of methods besides traditional meshed autografting to achieve definitive skin cover. The Meek micrografting technique was introduced at this hospital in 2011, especially in the absence of a reliable source of deceased donor allograft skin. The purpose of this study was to evaluate this strategy with reference to its technical execution, efficacy and indications in the context of major paediatric burn surgery.

METHODS

A cohort study was performed of all paediatric patients with major burn who underwent Meek micrografting at a dedicated paediatric burn centre in a developing country over a five year period. Demographics, details of their burns, operative management and clinical course and outcomes were collected from patient records and operative notes and analysed.

RESULTS

Thirty-five patients were managed using the micrografting technique during the study period. The mean patient age was 4.1 years (range 3 months-11 years) and their mean total body surface area (TBSA) burn was 49.7% (range 15-86%). Eleven patients sustained inhalation injuries and five developed a re-feeding syndrome on account of delayed referral. The mean abbreviated burn severity index (ABSI) was 8.5 (range 2-13). The hospital length of stay in the 27 survivors was a mean of 75.5 days, equating to 1.4 days per percentage burn. Eight patients died during the course of treatment, with a mean TBSA burn of 67.75% (range 38-86%). Graft take one month after surgery was documented to be more than 90% in 24 patients, of whom 3 subsequently died. Eleven patients had less than 90% graft take at this time, of whom 5 died.

CONCLUSION

There is a considerable 'learning curve' associated with this technique. In order to achieve success one must ensure a completely viable, non-infected bed, obtained by tangential or fascial excision, followed by allografting as temporary coverage and to 'test the wound bed' for definitive coverage. Infection resulted in the majority of autograft loss in this series, and in addition to risk factors like burn size and inhalation injury, accounted for many of the deaths in this series. Meek micrografting offers high expansion ratios, thereby facilitating durable wound cover in the presence of limited donor sites. It is unlikely that a lethal dose, 50% (LD₅₀) of almost 70% TBSA would have been possible in this context without the regular application of this technique. This study advocates for the widespread availability of Meek micrografting and deceased donor allograft skin in developing countries.

Paracrine Factors from Irradiated Peripheral Blood Mononuclear Cells Improve Skin Regeneration and Angiogenesis in a Porcine Burn Model

Burn wounds pose a serious threat to patients and often require surgical treatment. Skin grafting aims to achieve wound closure but requires a well-vascularized wound bed. The secretome of peripheral blood mononuclear cells (PBMCs) has been shown to improve wound healing and angiogenesis. We hypothesized that topical application of the PBMC secretome would improve the quality of regenerating skin, increase angiogenesis, and reduce scar formation after burn injury and skin grafting in a porcine model. Full-thickness burn injuries were created on the back of female pigs. Necrotic areas were excised and the wounds were covered with split-thickness mesh skin grafts. Wounds were treated repeatedly with either the secretome of cultured PBMCs (Sec(PBMC)), apoptotic PBMCs (Apo-Sec(PBMC)), or controls. The wounds treated with Apo-Sec(PBMC) had an increased epidermal thickness, higher number of rete ridges, and more advanced epidermal differentiation than controls. The samples treated with Apo-Sec(PBMC) had a two-fold increase in CD31+ cells, indicating more angiogenesis. These data suggest that the repeated application of Apo-Sec(PBMC) significantly improves epidermal thickness, angiogenesis, and skin quality in a porcine model of burn injury and skin grafting.

Retrospective review of a tertiary adult burn centre's experience with modified Meek grafting

Background

Autologous split skin grafting is the gold standard in treating patients with massive burns. However, the limited availability of donor sites remains a problem. The aim of this study is to present our experience with the modified Meek technique of grafting, outcomes achieved and recommendations for optimized outcomes.

Methods

We retrospectively reviewed patient records from our tertiary referral burn centre and the Bi-National Burns Registry to identify all patients who had modified Meek grafting between 2010 and 2013. Patient records were reviewed individually and information regarding patient demographics, mechanism of injury and surgical management was recorded. Outcome measures including graft take rate, requirement for further surgery and complications were also recorded.

Results

Eleven patients had modified Meek grafting procedures. The average age of patients was 46 years old (range 23 – 64). The average total body surface area (TBSA) burnt was 56.75 % (range 20–80 %). On average, 87 % of the grafted areas healed well and did not require regrafting. In the regrafted areas, infection was the leading cause of graft failure.

Conclusions

Modified Meek grafting is a useful method of skin expansion. Similar to any other grafting technique, infection needs to be sought and treated promptly. It is recommended for larger burns where donor sites are not adequate or where it is desirable to limit their extent.

Skin tissue engineering advances in severe burns: review and therapeutic applications

Current advances in basic stem cell research and tissue engineering augur well for the development of improved cultured skin tissue substitutes: a class of products that is still fraught with limitations for clinical use. Although the ability to grow autologous keratinocytes in-vitro from a small skin biopsy into sheets of stratified epithelium (within 3 to 4 weeks) helped alleviate the problem of insufficient donor site for extensive burn, many burn units still have to grapple with insufficient skin allografts which are used as intermediate wound coverage after burn excision. Alternatives offered by tissue-engineered skin dermal replacements to meet emergency demand have been used fairly successfully. Despite the availability of these commercial products, they all suffer from the same problems of extremely high cost, sub-normal skin microstructure and inconsistent engraftment, especially in full thickness burns. Clinical practice for severe burn treatment has since evolved to incorporate these tissue-engineered skin substitutes, usually as an adjunct to speed up epithelization for wound closure and/or to improve quality of life by improving the functional and cosmetic results long-term. This review seeks to bring the reader through the beginnings of skin tissue engineering, the utilization of some of the key products developed for the treatment of severe burns and the hope of harnessing stem cells to improve on current practice.

Epidermal healing in burns: autologous keratinocyte transplantation as a standard procedure: update and perspective

Background:

Treatment of burned patients is a tricky clinical problem not only because of the extent of the physiologic abnormalities but also because of the limited area of normal skin available.

Methods:

Literature indexed in the National Center (PubMed) has been reviewed using combinations of key words (burns, children, skin graft, tissue engineering, and keratinocyte grafts). Articles investigating the association between burns and graft therapeutic modalities have been considered. Further literature has been obtained by analysis of references listed in reviewed articles.

Results:

Severe burns are conventionally treated with split-thickness skin autografts. However, there are usually not enough skin donor sites. For years, the question of how covering the wound surface became one of the major challenges in clinical research area and several procedures were proposed. The microskin graft is one of the oldest methods to cover extensive burns. This technique of skin expansion is efficient, but results remain inconsistent. An alternative is to graft cultured human epidermal keratinocytes. However, because of several complications and labor-intensive process of preparing grafts, the initial optimism for cultured epithelial autograft has gradually declined. In an effort to solve these drawbacks, isolated epithelial cells from selecting donor site were introduced in skin transplantation.

Conclusions:

Cell suspensions transplanted directly to the wound is an attractive process, removing the need for attachment to a membrane before transfer and avoiding one potential source of inefficiency. Choosing an optimal donor site containing cells with high proliferative capacity is essential for graft success in burns.

Sandwich-type fiber scaffolds with square arrayed microwells and nanostructured cues as microskin grafts for skin regeneration

The paper reports the fabrication of sandwich-type scaffolds consisting of radially-aligned nanofibers at the bottom, nanofiber membranes with square arrayed microwells and nanostructured cues at the top, and microskin tissues in between as microskin grafts for use in skin regeneration. This class of nanofiber scaffolds was able to confine the microskin tissues in the square arrayed wells and simultaneously present nanotopographic cues to the cultured NIH 3T3 fibroblasts and primary rat skin cells, guiding and facilitating their migration in vitro. More importantly, we demonstrated that the sandwich-type transplants exhibited an even distribution of microskin grafts, greatly improved the 'take' rate of microskin tissues, and promoted re-epithelialization on wound in vivo. In addition, the void area in the scaffolds was well suitable for exudate drainage in wound. The sandwich-type scaffolds show great potential as microskin grafts for repairing extensive burn injuries and may provide a good solution for the treatment of acute skin defects and chronic wounds including diabetic ulcer, pressure ulcer, and venous stasis ulcer.

The use of the Meek technique in conjunction with cultured epithelial autograft in the management of major paediatric burns

BACKGROUND

The management of major paediatric burns remains challenging, in part due to limited donor sites. Skin graft expansion facilitates rapid closure of the burn wound, reducing the risk of sepsis. We reviewed our unit's experience with a combined modified Meek technique and cultured epithelial autograft (CEA).

METHODS

A retrospective chart review over a seven year period from April 2004 to April 2011 was conducted of patients whose burns were treated with Meek and CEA.

RESULTS

The Meek technique was combined with meshed split skin grafts and CEA to either donor, graft site or both in 7 cases. One case had Meek skin grafts alone with cultured cells applied to both donor and graft sites. There were two scald burns and five flame burns, with total body surface area ranging from 30% to 70%. Mean length of stay was 51 days (range 41-74 days). The average number of surgical procedures undergone to obtain good coverage was 3.3. There were small (1-3%) areas of breakdown in six cases which received regrafting. Two of these patients had confirmed wound infections. All patients had varying degrees of hypertrophic scarring (HTS) but remained well at follow up.

CONCLUSIONS

The Meek technique facilitates high expansion ratios, allowing for a greater area of skin coverage. Epithelialisation in the burn wound appeared to be enhanced by the application of CEA. The Meek technique in combination with CEA would appear a useful additional option in achieving wound closure in the severely burned paediatric patient.

Harborview burns--1974 to 2009

BACKGROUND

Burn demographics, prevention and care have changed considerably since the 1970s. The objectives were to 1) identify new and confirm previously described changes, 2) make comparisons to the American Burn Association National Burn Repository, 3) determine when the administration of fluids in excess of the Baxter formula began and to identify potential causes, and 4) model mortality over time, during a 36-year period (1974-2009) at the Harborview Burn Center in Seattle, WA, USA.

METHODS AND FINDINGS

14,266 consecutive admissions were analyzed in five-year periods and many parameters compared to the National Burn Repository. Fluid resuscitation was compared in five-year periods from 1974 to 2009. Mortality was modeled with the rBaux model. Many changes are highlighted at the end of the manuscript including 1) the large increase in numbers of total and short-stay admissions, 2) the decline in numbers of large burn injuries, 3) that unadjusted case fatality declined to the mid-1980s but has changed little during the past two decades, 4) that race/ethnicity and payer status disparity exists, and 5) that the trajectory to death changed with fewer deaths occurring after seven days post-injury. Administration of fluids in excess of the Baxter formula during resuscitation of uncomplicated injuries was evident at least by the early 1990s and has continued to the present; the cause is likely multifactorial but pre-hospital fluids, prophylactic tracheal intubation and opioids may be involved.

CONCLUSIONS

1) The dramatic changes include the rise in short-stay admissions; as a result, the model of burn care practiced since the 1970s is still required but is no longer sufficient. 2) Fluid administration in excess of the Baxter formula with uncomplicated injuries began at least two decades ago. 3) Unadjusted case fatality declined to ∼6% in the mid-1980s and changed little since then. The rBaux mortality model is quite accurate.

Comparison of healing parameters in porcine full-thickness wounds transplanted with skin micrografts, split-thickness skin grafts, and cultured keratinocytes

BACKGROUND

Transplantation of skin micrografts (MGs), split-thickness skin grafts (STSGs), or cultured autologous keratinocytes (CKs) enhances the healing of large full-thickness wounds. This study compares these methods in a porcine wound model, investigating the utility of micrograft transplantation in skin restoration.

STUDY DESIGN

Full-thickness wounds were created on Yorkshire pigs and assigned to one of the following treatment groups: MGs, STSGs, CKs, wet nontransplanted, or dry nontransplanted. Dry wounds were covered with gauze and the other groups' wounds were enclosed in a polyurethane chamber containing saline. Biopsies were collected 6, 12, and 18 days after wounding. Quantitative and qualitative wound healing parameters including macroscopic scar appearance, wound contraction, neoepidermal maturation, rete ridge formation, granulation tissue thickness and width, and scar tissue formation were studied.

RESULTS

Transplanted wounds scored lower on the Vancouver Scar Scale compared with nontransplanted wounds, indicating a better healing outcome. All transplanted wounds exhibited significantly lower contraction compared with nontransplanted wounds. Wounds transplanted with either MGs, STSGs, or CKs showed a significant increase in re-epithelialization compared with nontransplanted wounds. Wounds transplanted with MGs or STSGs exhibited improved epidermal healing compared with nongrafted wounds. Furthermore, transplantation with STSGs or MGs led to less scar tissue formation compared with the nontransplanted wounds. No significant impact on scar formation was observed after transplantation of CKs.

CONCLUSIONS

Qualitative and quantitative measurements collected from full-thickness porcine wounds show that transplantation of MGs improve wound healing parameters and is comparable to treatment with STSGs.

A clinical review of infected wound treatment with Vacuum Assisted Closure (V.A.C.) therapy: experience and case series

Over the last decade Vacuum Assisted Closure((R)) (KCI Licensing, Inc., San Antonio, TX) has been established as an effective wound care modality for managing complex acute and chronic wounds. The therapy has been widely adopted by many institutions to treat a variety of wound types. Increasingly, the therapy is being used to manage infected and critically colonized, difficult-to-treat wounds. This growing interest coupled with practitioner uncertainty in using the therapy in the presence of infection prompted the convening of an interprofessional expert advisory panel to determine appropriate use of the different modalities of negative pressure wound therapy (NPWT) as delivered by V.A.C.((R)) Therapy and V.A.C. Instill((R)) with either GranuFoam() or GranuFoam Silver() Dressings. The panel reviewed infected wound treatment methods within the context of evidence-based medicine coupled with experiential insight using V.A.C.((R)) Therapy Systems to manage a variety of infected wounds. The primary objectives of the panel were 1) to exchange state-of-practice evidence, 2) to review and evaluate the strength of existing data, and 3) to develop practice recommendations based on published evidence and clinical experience regarding use of the V.A.C.((R)) Therapy Systems in infected wounds. These recommendations are meant to identify which infected wounds will benefit from the most appropriate V.A.C.((R)) Therapy System modality and provide an infected wound treatment algorithm that may lead to a better understanding of optimal treatment strategies.

Train surfing and other high voltage trauma: differences in injury-related mechanisms and operative outcomes after fasciotomy, amputation and soft-tissue coverage

BACKGROUND

In the context of scarce reports on train surfers among high voltage electric injuries, we conducted a retrospective review between January 1994 and December 2008.

METHODS

After matching for inclusion criteria we reviewed patient records of 37 true high voltage injuries (12 train surfers [TS] and 25 other high voltage injuries [HV]).

RESULTS

TS were significantly younger (TS 15.8 years vs. HV 33.3 years, p<0.0001), and had a greater %TBSA (TS 49.7%TBSA vs. HV 21.5%TBSA, p=0.0003) without affecting the median length-of-stay (TS 52 days vs. HV 49 days) or number of operations (TS 4 vs. HV 3). TS had different injury patterns, with a higher percentage of affected extremities (TS 72.9% vs. HV 52.0%, p=0.0468) and associated injuries (TS 58% vs. HV 20%, n.s.) than HV. Both groups demonstrated comparable fasciotomy (TS 71.4% vs. HV 55.8%) and amputation rates (TS 17.1% vs. HV 15.4%). While TS required less flaps (TS 3/12 vs. HV 18/25; p=0.0153), soft-tissue reconstruction revealed an overall low incidence of complication rates (one partial pedicled flap loss and two total free flap losses).

CONCLUSIONS

Train surfers have proven to be a distinct group of patients among high-voltage injuries notably as a result of a younger age, a shorter electric contact duration and higher velocity-induced trauma. With a possibly declining trend of train surfing-related accidents in an aging society, it will be interesting to see if emerging economies will face comparable phenomena, for which prevention strategies remain key.

Aesthetic improvements of skin grafts in nasal tip reconstruction

Defect closure on the nasal tip subunit still remains challenging. Full-thickness skin transplantation still is used despite its poor outcome in terms of the nasal tip contour caused by lack of dermal tissue. To avoid subsidence deformities associated with nasal tip reconstruction with skin transplants, this study analyzed methods using combined epidermal and dermal replacement. For 30 consecutive patients with a nasal tip defect, a retrospective comparison was made between conventional full-thickness skin transplantation, retroauricular perichondrodermal composite grafts, and skin transplantation supplemented with the collagen-elastin matrix, Matriderm, used as a dermal substitute (n = 10 per study group).The postoperative results were evaluated in a randomized and blind manner by external facial surgeons using the Manchester Scar Scale. The findings showed a marked improvement in nasal tip contour with combined epidermal/dermal replacement without any deterioration in other graft qualities, justifying the additional effort involved in this procedure. Two patients developed fistulae after Matriderm-aided skin transplantation. Therefore, the authors do not consider this a suitable method for nasal tip reconstruction.

Use of a collagen-elastin matrix for hard to treat soft tissue defects

As deep soft tissue defects with exposed bone, cartilage or tendons are not suitable for wound closure with skin mesh grafts, other techniques are needed. We report on six patients, one female and five males, aged between 32 and 89 years, and deep soft tissue defects with exposed tendons, cartilage or bone. The aetiology of these defects was vascular (n = 3), tumour surgery (2), and post-traumatic (1). Wounds were treated with a collagen-elastin matrix applied above the exposed structures. In five patients, the procedure was combined with mesh graft transplantation in the same setting. Follow-up varied between 12 and 40 weeks. Wound healing was uncomplicated in all transplanted patients until first dressing change after 7 days. All but one transplant showed a 100% take rate and the transplant was stable within 10-14 days. A complete wound closure was also achieved without transplantation, but this took 8 weeks. No adverse effects were noted. There was no skin contracture of the skin grafts. Collagen-elastin matrix with split-thickness skin grafts is a useful tool in deep soft tissue. The time to heal can be reduced.

Review of burn injury research for the year 2009

Research in burn care for the calendar year 2009 was robust and diverse with >1400 research articles published on a wide range of topics. In this review, the authors highlight some innovative and potentially impactful research related to the overall care of burn- injured patients. The authors grouped articles according to the following categories: critical care, infection, inhalation injury, epidemiology, psychology, wound characterization and treatment, nutrition and metabolism, pain and itch management, burn reconstruction, and rehabilitation. They found that the holistic nature of burn care is reflected in the diverse research performed in 2009 throughout the world and that this research has provided important evidence that has improved or will improve burn care overall.