Andrew Lindford

The dermis graft: another autologous option for acute burn wound coverage.

BACKGROUND Split-thickness skin autografts are the gold-standard in providing permanent acute wound closure in major burns. Split-thickness dermal grafts harvested from the same donor site may provide an additional autologous option for permanent acute coverage and increase the number of potential autologous donor sites. MATERIALS AND METHODS We performed 16 dermis grafts (DG) harvested from the skin of the back in 9 consecutive burn patients. A control donor site consisted of an area of adjacent back skin from which a standard split-thickness skin graft was harvested. The mean age was 63 years (range 23-79 years). The mean initial burn size was 24% TBSA (range 2-40% TBSA). The size of the 16 DG recipient wound beds ranged from 20 to 180 cm2, with mean and median sizes of 62 and 45 cm2, respectively. RESULTS Dermis graft take was complete in 15/16 cases. All grafts recorded >90% epithelialisation by 4 weeks. There was no significant difference in dermis graft and control donor site healing times (p value 0.05). CONCLUSION Dermis grafts can provide an additional autologous option for permanent coverage in acute major burn wounds without increasing donor site size or morbidity.

Comparison of Suprathel® and allograft skin in the treatment of a severe case of toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare potentially lifethreatening drug-induced skin disorder resulting in extensive mucocutaneous exfoliation and systemic involvement. TEN is now generally considered to result from a disregulated immune reaction against epithelial cells. TEN was first described by Alan Lyell [1] and is therefore commonly referred to as Lyell’s disease or syndrome. It is closely related to Stevens–Johnson syndrome (SJS) and both conditions are considered to be caused by the same disease process. SJS is often defined by less than 10% epidermal loss and TEN more than 30% loss with those in between classified as SJS-TEN. Clinically they present with an acute macular erythematous rash with bullae which can rapidly progress to extensive areas of epidermal separation and shedding. A positive Nikolsky’s sign (slight rubbing of the skin resulting in exfoliation of the outermost layer) is characteristic [2]. The SCORTEN severity of illness scoring system helps to predict mortality in TEN patients [3]. Due to often extensive areas of epidermal involvement with resultant water, electrolyte and protein losses it is generally agreed that these patients should be admitted early to a Burn Unit [1]. At present there are no standard management guidelines but treatment should be multidisciplinary with prompt diagnosis, withdrawal of the suspected drug, supportive care and wound management. Many specific pharmacological therapies are cited in the literature but a general consensus and evidence base is lacking. However topical wound care is an integral part of the overall management of this condition. The areas of epidermal loss can be compared to the wound of a partial-thickness burn and thus many different wound dressings are available. At present there is no general agreement as to what is the most efficacious and appropriate wound care material. Suprathel (PMI Polymedics Innovations GmbH, Germany) is a recently introduced epidermal substitute. It is composed of a synthetic co-polymer of polylactide, trimethylene carbonate, and e-caprolactone and has been used in partial-thickness burns as well as in split-thickness skin graft donor sites. It is reported to reduce pain in both burn and donor site wounds and also to reduce exudation of donor sites compared to a conventional open method [4,5]. There are two reports of the use of Suprathel in Staphylococcal scalded skin syndrome [6] and TEN in a young infant [7]. Allograft (cadaveric) skin however is well recognised for its use in TEN as well as its versatility in burn patients in general [8–10]. We report our experience in the use of Suprathel and allograft skin in a severe case of TEN.

Three-dimensional printing for restoration of the donor face: A new digital technique tested and used in the first facial allotransplantation patient in Finland

BACKGROUND AND AIMS Prosthetic mask restoration of the donor face is essential in current facial transplant protocols. The aim was to develop a new three-dimensional (3D) printing (additive manufacturing; AM) process for the production of a donor face mask that fulfilled the requirements for facial restoration after facial harvest. MATERIALS AND METHODS A digital image of a single test persons face was obtained in a standardized setting and subjected to three different image processing techniques. These data were used for the 3D modeling and printing of a donor face mask. The process was also tested in a cadaver setting and ultimately used clinically in a donor patient after facial allograft harvest. RESULTS and Conclusions: All the three developed and tested techniques enabled the 3D printing of a custom-made face mask in a timely manner that is almost an exact replica of the donor patients face. This technique was successfully used in a facial allotransplantation donor patient.

The evolution of the Helsinki frostbite management protocol

BACKGROUND Severe frostbite can result in devastating injuries leading to significant morbidity and loss of function from distal extremity amputation. The modern day management approach to frostbite injuries is evolving from a historically very conservative approach to the increasingly reported use of early interventional angiography and fibrinolysis with tPA. The aim of this study was to evaluate the results of our frostbite treatment protocol introduced 3 years ago. METHODS All frostbite patients underwent first clinical and then Doppler ultrasound examination. Angiography was conducted if certain clinical criteria indicated a severe frostbite injury and if there were no contraindications to fibrinolysis. Intra-arterial tissue plasminogen activator (tPA) was then administered at 0.5-1mg/h proximal to the antecubital fossa (brachial artery) or popliteal fossa (femoral artery) if angiography confirmed thrombosis, as well as unfractionated intravenous heparin at 500 units/h. The vasodilator iloprost was administered intravenously (0.5-2.0ng/kg/min) in selected cases. RESULTS 20 patients with frostbite were diagnosed between 2013-2016. Fourteen patients had a severe injury and angiography was performed in 10 cases. The total number of digits at risk was 111. Nine patients underwent fibrinolytic treatment with tPA (including one patient who received iloprost after initial non response to tPA), 3 patients were treated with iloprost alone and 2 patients received neither treatment modality (due to contraindications). The overall digital salvage rate was 74.8% and the Hennepin tissue salvage rate was 81.1%. One patient developed a catheter-site pseudoaneurysm that resolved after conservative treatment. CONCLUSIONS Prompt referral to a facility where interventional radiology and 24/7 laboratory services are available, and the combined use of tPA and iloprost, may improve outcome after severe frostbite.

Successful Eradication of Multidrug Resistant Acinetobacter in the Helsinki Burn Centre

Multidrug-resistant (MDR) Acinetobacter is an important pathogen implicated in nosocomial infections in healthcare environments. Virulence factors, resistance mechanisms, and limited therapeutic options make this pathogen a major problem currently facing burn intensive care units (ICUs) worldwide. The purpose of this study was to assess the effect of infection control measures taken in Helsinki Burn Centre in 2001 on MDR Acinetobacter prevalence in ICU burn patients. Data were retrospectively collected from patient files from 1998 to 2012. ICU burn patients were defined as those with either over 30% of total body surface area burnt or requiring mechanical ventilation. Inclusion criteria consisted of patients who tested positive for Acinetobacter sp. in routine bacterial cultures or cultures taken because of a clinically suspected infection. Infection control interventions performed in 2001 consisted of various shower room renovations and changes in hospital hygiene and burn treatment regimes. Between 1998 and 2012, 75 patients were diagnosed with Acinetobacter sp. colonization. Following the infection control interventions the incidence of Acinetobacter sp. radically declined. Between 1998 and 2001, there were 31 cases of MDR Acinetobacter colonizations diagnosed, but from 2002 to 2012 no MDR strains were found. Changes to hospital hygiene and wound treatment protocols as well as structural changes to the hospital environment can have a major impact on preventing and treating Acinetobacter outbreaks in burn centers.

Evaluation of HLA sensitization in burn patients after treatment with skin allografts and transfusion of blood products

Treatment for extensive burns may sensitize patients to antibodies specific for human leukocyte antigens (HLA), thus endangering their eligibility for organ and vascularized composite allotransplantation (VCA) recipients. Blood transfusions and allograft skin use are the most common reasons for HLA sensitization in burn patients [1]. The risk of forming alloantibodies against donor red blood cell (RBC) antigens is most likely linked to the number of transfusions [2], genetic predisposition and immune response [3]. This article is protected by copyright. All rights reserved.

Free temporal artery posterior auricular skin (TAPAS) flap: A new option in facial and intra-oral reconstruction

There is a limited availability of suitable microvascular free flap options for the reconstruction of small to medium‐sized facial and intraoral defects. The purpose of this report is to present a new free temporal artery based posterior auricular skin (TAPAS) flap in facial and intraoral reconstruction.

The Helsinki Face Transplantation: Surgical aspects and 1-year outcome

BACKGROUND Since 2005, at least 38 facial transplantations have been performed worldwide. We herein describe the surgical technique and 1-year clinical outcome in Finlands first face transplant case. METHODS A 34-year-old male who had a severe facial deformity following ballistic trauma in 1999 underwent facial transplantation at the Helsinki University Hospital on 8th February 2016. Three-dimensional (3D) technology was used to manufacture donor and recipient patient-specific osteotomy guides and a donor face mask. The facial transplant consisted of a Le Fort II maxilla, central mandible, lower ⅔ of the midface muscles, facial and neck skin, oral mucosa, anterior tongue and floor of mouth muscles, facial nerve (three bilateral branches), and bilateral hypoglossal and buccal nerves. RESULTS At 1-year follow-up, there have thus far been no clinical or histological signs of rejection. The patient has a good aesthetic outcome with symmetrical restoration of the mobile central part of the face, with recovery of pain and light touch sensation to almost the entire facial skin and intraoral mucosa. Electromyography at 1 year has confirmed symmetrical muscle activity in the floor of the mouth and facial musculature, and the patient is able to produce spontaneous smile. Successful social and psychological outcome has also been observed. Postoperative complications requiring intervention included early (nasopalatinal fistula, submandibular sialocele, temporomandibular joint pain and transient type 2 diabetes) and late (intraoral wound and fungal infection, renal impairment and hypertension) complications. CONCLUSION At 1 year, we report an overall good functional outcome in Finlands first face transplant.

Resuscitated unconscious male: Lichtenberg’s sign lighting the way

An intubated unconscious 18-year-old male was admitted to the trauma center with a fern-leaf erythematous pattern on his right chest and flank, a second-degree upper chest burn, and a deep full-thickness occipital scalp burn (Fig. 1a). Earlier in the day his military unit had completed marching and drill exercises in torrential rain. At night in wet tents, his squad suddenly awoke to find him unconscious and in cardiac arrest. After 25 min of cardiopulmonary resuscitation he regained sinus rhythm, but with inadequate breathing had an oxygen saturation of only 52%. Lichtenberg’s figures (keraunographic markings) with their dendritic, arborescent or fern-like branching erythematous skin pattern are pathognomonic for lightning injury (Fig. 1b). Georg Lichtenberg first coined the term in 1777 whilst experimenting with static electricity. The markings’ pathogenesis is unclear, but may result from subcutaneous blood extravasation, appearing within an hour of injury and rapidly fading within a couple of days, much like a wheal and flare (or dermographic) reaction. Lack of histopathological changes on biopsy contradicts Lichtenberg figures being a physical phenomenon. The patient was discharged after 2 weeks and long-term followup revealed mild cognitive impairment. The rest of his squad sustained only minor burn injuries and neuropsychological symptoms.

Paraumbilical perforator flap for reconstruction of the external auditory meatus: A case report

We herein present a technique of using the umbilical stalk for reconstruction of the external auditory meatus. A 49‐year‐old female presented with locally aggressive melanoma affecting her mastoid region. She underwent radical excision including the skin and soft tissues around the external ear with simultaneous lymph node clearance. The resultant defect measured 15 cm × 8 cm in diameter and was 2.5 cm deep. This was reconstructed with a similarly sized microvascular paraumbilical perforator flap that included the umbilical stalk. In the post‐operative course there was complete flap survival but a prolonged wound dehiscence near the auditory meatus that required revision surgery. At 15‐months follow‐up, the patient was melanoma‐free and the auditory meatus was patent. Hearing was also preserved. The umbilical stalk is one of the few skin covered tubed structures in the human body that may be used without major donor morbidity to “replace like with like,” the auditory channel.