Burns: Management of Burns- Rehabilitation phase, Grafts, Flaps

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3. Rehabilitation phase
Goals
  • Prevention of scars and contractures
  • Physical, occupational, and vocational rehabilitation
  • Functional and cosmetic reconstruction
  • Psychosocial counseling
Surgical management
  • Natural debridement: With natural dEbridement, the dead tissue separates from the underlying viable tissue spontaneously

MECHANICAL DEBRIDEMENT
1.Tangential Excision
  • A special blade is used to slice off-thin layers of damaged skin: until livE tissue is evidenced by Capillary bleeding.
  • Commonly used with deep partial-thickness burns and followed with immediate coverage with a biosynthetic or biologic dressing or an autograft.
2. Fascial (Primary) Excisioncm
  • The skin, lymphatics, and subcutaneous tissue are removed down to fascia, with either immediate autografting or temporary coverage with biologic or biosynthetic dressings.
  • This is repeated until all deep burn areas are removed.

BURN WOUND COVERNGS
  • @ Skin graft
  • @ Allograft/Homograft:
  • @ sheet graft
  • @ Meshed graft
  • @ Cultured epithelial auto grafting
  • @ Xenograft Heterograft


Reconstructive surgeries
Types of plastic surgeries
  • Aesthetic (cosmetic)
  • Reconstructive
  • Reconstructive surgeries
  • Attempts to restore a more normal appearance
  • Function in a person who has an abnormal body part
  • In whom a body part is missing
  • Graft: A skin graft is a tissue of epidermis and varying amounts of dermis that is detached from  its own blood supply and placed in a new area with a new blood supply. Does not maintain original blood supply.
  • Flap: Any tissue used for reconstruction or wound closure that retains all or part of its original blood supply after the tissue has been moved to the recipient location. Maintains original blood supply
Indications for Grafts
  • Extensive wounds
  • Burns
  • Specific surgeries that may require skin grafts for healing to occur.
  • Areas of prior infection with extensive skin loss.
  • Cosmetic reasons in reconstructive surgeries

Classification of Grafts based on source
  • 1.Autografts - A tissue transferred from one part of the body to another. Coverage is permanent
  • 2.Homografts/Allograft - tissue transferred from a genetically different individual of the same  species. Coverage is temporary (3 days to 2 wk) Eg. Cadaveric skin
  • 3.Xenografts/ Heterograft - a graft transferred from an individual of one species to an indiyidual of another species.. Coverage is.temporary (3 days to 2 wk) Eg. Porcine skin
4. Cultured epithelia autograft(CEA)
  • Is a method of obtaining permanent skin from a person with limited available skin for harvesting
  • Here biopsied keratinicytes are grown in culture medium containing epidermal growth factor
  • Approximately 18 to 25 days, the cells expand 10,000 times and form confluent sheets that can be used as a skin grafts
5. Artificial skin:
  • BioBrane - Porcine collagen bounded to silicone membrane, coverage is temporary (10-21 days)
  • TransCyte- Human, dermal fibroblast- derived matrix with growth factors, coverage is temporary (10-21 days)
  • Integra- Bovine collagen and glycosaminoglycan bonded to silicone membrane, coverage is permanent
  • AlloDerm- Acelluar dermal matrix derived from donated human skin, coverage is permanent
BURN WOUND COVERINGS
  • @ Allograft/Homograft:
  • Human cadaver skin, about 0.015-inch thick
  • SOURCE: Fresh, cryo preserved homo grafts available from tissue banks
INDICATIONS
  • @ To debride untidy wounds
  • @ To protect granulation tissue after escharotomy
  • @ To cover excised wound immediately
  • @ To serve as test graft before autograft
Types of Grafts
  • Grafts are typically described in terms of thickness or depth
  • Split Thickness: Contains 100% of the epidermis and a portion of the dermis.
  • Split thickness grafts are further classified as thin or thick.
Full Thickness: Contains 100% of the epidermis and dermis.
Split Thickness: Used when cosmetic appearance is not a primary issue when the size of the wound is too large to use a full thickness graft.
  • 1.Chronic Ulcers
  • 2.Temporary coverage
  • 3.Correction of pigmentation disorders
  • 4.Burns
Thickness
  • Thin STSG: 0.008-0.012 inches mostly epithelium, thin reticular (elastin)
  • Medium STSG: 0.012-0.018 in most commonly used
  • Thick STSG: 0.018-0.030 in almost like full thickness, used in certain application like face, flexion surfaces where contraction is minimal
Full thickness
Indications
  • 1.if adjacent tissue has premalignant or malignant lesions
  • 2. Specific locations that themselves well to FTSGs - the nasal tip, forehead, eyelids, medial canthus,concha and digits.
The Process of Take
  • Phase 1 (0-48h) - Plasmatic Imbibition
Diffusion of nutrition from the recipient bed.
  • Phase 2 - Inosculation
Vessels in graft connect with those in recipient bed.
  • Phase 3 (day 3-5) - Neovascular Ingrowth
Graft revascularized by ingrowth of new vessels into bed.
Requirements for Survival
  • Bed must be well vascularized.
  • The contact between graft and recipient must be fully immobile.
  • Low bacterial count at the site.
Factors determining the degree of primary contraction-
  • The amount of primary contraction is directly related to the thickness of dermis in the graft.
  • Unsuitable sites for grafting: Bone, Tendon, Infected Wound, Highly irradiated
  • Donor Sites: The ideal donor site would provide skin that is identical to the skin surrounding the recipient area.- Colour - Thickness - Hair - Texture

Factors Affecting Wound Healing:
Age: affects wound repair. The rate of healing appears to slow with increasing age.
Infection: infection lead to healing failures.
  • Nutritional factors: nutrition is of extreme important factor for wound healing.
  • Vitamins: vitamins are important for normal tissue repair as vitamin C, A, E, B, (Thiamine) and B2 (pantothenic acid).
  • Trace elements are metals: that are needed for enzyme function.
  • As iron zinc, copper, manganese calcium, and magnesium.
  • Shortages of trace elements may contribute to impair healing. Oxygen:
  • Adequate blood supply is essential for healing.
  • Oxygen is required to supply the energy for high metabolic needs healing wound.  
Poor vascularity essentially translates into hypoxia.
  • Diseases causing impaired wound healing:
  • Diabetes altered healing.
  • Chronic renal failure and liver failure lead to impaired healing   Malignancy lead to healing abnormalities.

  • Other causes of impaired healing :
steroids drugs alter healing
Chemotherapy agents lead to impair healing
Radiations
Drugs that alter immune system
Complications of skin grafts:
  • 1.Wound problems due to grafting on an inadequately prepared or unsuitable bed.
  • 2.Avascularity.
  • 3.Infection.
  • Graft problems:
  • Early:
  • Failure of take due to inadequate contact between graft bed.
Inadequate fixation (shearing)
  • Haematoma
  • Failure of take/graft lysis due to infection
Late:
  • Avoidable scarring/contracture
  • Excessively expanded mesh graft
  • Graft margins crossing anatomical segment & trophic
  • ulceration/trauma
Graft insensate
Graft too thin for permanent cover
  • Donor Site Problems:
  • Failure to heal
  • Infection


FLAPS
  • Flaps are areas of tissue raised from one area of the body without being completely detached, so that blood supply is intact
  • Indication-
  • amputation stump
Pedicle-flap
  • This full-thickness graft includes not only skin and subcutaneous tissue, but also subcutaneous blood vessels to ensure a continued blood supply to the graft.
  • Pedicle-flap grafts may be used during reconstructive surgery to cover previous defects.
Musculocutaneous flaps
  • Flap comprising both muscles and skin
  • Used to heal osteo myelitis
Free flaps
  • Free flaps are harvested from one area of the body to reconstruct a defect in a distant area
Advantages
  • Only a single operation is needed
  • Few problems with mobility
  • New vascularization is provided to the area to aid healing
  • Mobilization of tissue is minimized
Disadvantages
  • Prolonged surgery 6-24 hrs
  • 2 separate incision required
  • Necessity of immediate re-exploration of muscle
  • Need for sophisticated monitor devices
Skin expansion
  • Technique used to increase the amount of local tissue available to reconstruct a defect.  
  • An inflatable silicon balloon is placed under the skin or muscle flap adjacent to a defect  
  • Expander is inflated sequentially over several weeks or months to stretch the overlying tissue  
  • Tissue is sufficient to resurface the defect then balloon is removed and flap is contoured.

Contracture
  • Primary contraction due to elastin fibers in dermis.
  • More seen in FTSG.
  • Corrected by stretching the graft
  • Secondary contracture
  • More severe in thinner STSG, more severe if meshed.  
  • May reach 40% of surface.
  • Correction: Prolonged splinting

Contracture ----Z-PLASTY
  • The old scar is removed and new incisions are made on each side, creating small triangular flaps of skin.
Keioids
  • Thick, puckered, itchy clusters of scar tissue that grow beyond the edges of the wound or incision.
  • They are often red or darker in color than the surrounding skin.
Treatment:
  • By injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning.
  • To shrink the scar.
  • Repeated several times with intervals of 4 weeks in between treatments
  • Hypertrophic Scars
  • Thick, red, and raised.
  • Remain within the boundaries of the original incision or wound.
  • They often improve on their own-though it may take a year or more-or with the help of  steroid applications or injections.
  • If fails surgical excision and grafting can be done
Hair transplant

  • Reconstruction of the scalp following burns to be replaced by hair bearing tissue.

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notes.nursium.com: Burns: Management of Burns- Rehabilitation phase, Grafts, Flaps
Burns: Management of Burns- Rehabilitation phase, Grafts, Flaps
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