Burns : journal of the International Society for Burn Injuries | 2019
Tissue expansion of the lower limb: Retrospective study of 141 procedures in burn sequelae.
Abstract
We would like to thank the authors for their interesting and valuable comments on our recent published article: “Tissue expansion of the lower limb: Retrospective study of 141 procedures in burn sequelae” [1]. Smolle et al. highlighted some very interesting points in their retrospective study “Complications in tissue expansion: A logistic regression analysis for risk factors” [2]. Smolle et al. sorted their indications into three groups: burns sequelae, post-traumatic defects and congenital defects. These represent quite different nosological frameworks. In our study we assessed the complication rate of tissue expansion a very specific population: burn sequelae. Skin expansion in burn sequelae is a risky procedure because the reliability of scar tissue is unpredictable [3]. We would not be able to extrapolate our results to widespread indications, nevertheless we would like to focus on this challenging problem. The authors analyzed more extended sites, such as: scalp, face/neck, trunk and limb. In 1936, Michel Salmon’s “Les artères de la peau” showed in anatomical study the great variability of skin vascularization regarding the location. Thus, we were learned that cutaneous envelope is better supplied but have less elasticity in head and neck zone than in trunk and limbs. Therefore, the justification of our study to focus on lower limb is the difficulty to lead an expansion procedure on this very area. It has low vascularity and some adherent spots (tibial crest and foot plant). Moreover, Pandya have shown that limbs are more correlated to complications than other sites [4]. In their study, Smolle et al. had very innovative data readouts such as the shape of the prosthesis. It would be interesting to assess if a particular shape was correlated to more (or less) complication, and more specifically rectangular ones. In our experience, unfolding rectangular prosthesis, at the beginning of inflating phase, can induce sharpness feeling under the skin. This sometimes led to ischemic spots postponing injection to avoid necrosis and prosthesis exposure. The complications reported in Smolle’s article were comparable to our study. We described some nervous compressions of sensitive superficial fibers that induced resolutive pain, at the end of inflating procedure. Smolle et al. proposed to use Clavien-Dindo classification to manage complications of skin expansion. It retrospectively considers the consequences of these complications [5] and offer the asset of a global care of the patient. In our study we used the Manders classification [6]. It shows a prospective vision in order to give guidelines for the practitioner to cope with a minor or a major complication. To conclude, Smolle et al. have done a great analysis of skin expansion complications in a large nosological framework. Our work aimed to highlight some technical points on a very specific facet of this type of procedure. Once more we would like to congratulate Smolle et al. on their work and hope to hear more from the authors in the future.