Azzam Farroha

Use of biobrane® to dress split-thickness skin graft adjacent to skin graft donor sites or partial-thickness burns.

Biobrane® (Smith & Nephew Wound Management, Hull, United Kingdom) is a flexible biosynthetic wound dressing that has been widely used to dress partial-thickness burns and donor sites of split-thickness skin grafts (SSG).1–3 We reported 11 cases from March 2008 to March 2012 in which Biobrane was used to dress SSG, where the grafted areas were adjacent to donor sites or partial-thickness burns. Biobrane was used to dress SSG and their adjacent donor sites in five cases. In the other six described cases, we used Biobrane in mixed-depth burns. After tangential excision and skin grafting the deep burns, Biobrane was used to dress the SSG and adjacent superficial partial-thickness burns. Nine of the 11 cases were children. Biobrane was used to cover SSG over scalp, forehead, arms, legs, dorsum of foot, and abdomen. It was fixed with staples. An outer absorbent dressing was applied for 2 days, then Biobrane was left exposed (Figure 1). After removal of staples, Biobrane came off the sheet grafts on day 5 and it peeled off the meshed grafts, superficial burnt areas, and donor sites on days 10 to 14. In all reported cases, SSG fully took without complications, and patients were comfortable. Biobrane applied over SSG on flat and convex body surfaces promoted adherence of the SSG to the wound, prevented shearing, and allowed fluid drainage. Its transparency allowed regular checking without disrupting the graft, and at the same time facilitated healing of the adjacent donor sites or partial-thickness burns. In all cases, Biobrane was our first choice to dress the partial-thickness burns or SSG donor sites. By using the same dressing to cover the adjacent SSG, we negated the extra theater time needed when using different dressings; therefore, this method is cost-effective.

The use of Emla® cream to remove staples from skin-grafted areas.

Emla® cream 5% (AstraZenica UK Limited, Luton, United Kingdom) is a topical anesthetic agent containing 2.5% lidocaine and 2.5% prilocaine. In addition to its anesthetic effect, Emla® cream produces a biphasic vascular response with initial vasoconstriction, which reaches its maximum level after 90 minutes of application. After prolonged application (of more than 3 hours), vasodilatation occurs.1 Doses of up to 10 g of Emla® cream applied on leg ulcers result in plasma levels of lidocaine and prilocaine well below toxic levels.2 Emla® cream is used safely on open wounds.2,3 Staple fixation of split skin grafts is commonly used in plastic surgery due to the ease of use and the short time taken to secure the grafts. Removal of staples is often associated with discomfort and pain, and on occasion, removal is not tolerated well and becomes a prolonged process. Bleeding at the time of removal can obscure staples, which can result in the staples remaining in and becoming buried. We present the use of Emla® cream for the removal of staples from split-thickness skin-grafted areas in a patient who was on anticoagulant therapy. A 71-year-old man on warfarin sustained 6% TBSA to his right leg. Warfarin was stopped, and a therapeutic dose of Clexane® (Sanofi-Aventis, Surrey, United Kingdom) was given. Tangential excision and meshed split-thickness skin grafting were performed. After the surgery, warfarin was restarted in addition to Clexane®. On the sixth postoperative day, a wound check indicated that the graft had taken well. We applied a small amount of Emla® cream (a total of 5 g) over each of the staples. Then the wound was covered with cling film for 30 minutes. The patient was comfortable and reported no pain during removal of staples; no bleeding occurred (Figure 1). We believe that a topical application of Emla® cream to staples is simple, effective, offers good pain relief, and creates an environment that is pain-free and less stressful for the patient and the care team. The dual benefits of this cream, pain relief and vasoconstriction, facilitate the removal of all staples in one session in a timely manner.

Improving and Maintaining Conformity of Acticoat® Dressings with Shear Reducing Transfixion Suture.

Acticoat® (Smith & Nephew plc, 5 Adam Street, London, WC2N 6LA, UK) is an antimicrobial barrier dressing with an absorbent inner core. It is widely used in the treatment of burns, because it is effective and convenient.1,2 We present our experience in a regional burn service of using Acticoat® in injured patients with the addition of transfixion sutures, silk suture size 0 or 2-0, to stabilize the dressing in situ. We found this technique useful in dressing convex areas, such as scalp, shoulders, buttocks, and trunk. Acticoat® is transfixed on one side then pulled across to ensure it conforms snugly to the contour of the wound bed and/or graft, followed by transfixion of the other sides. Few quilting sutures are also applied to secure the dressing. For circumferential areas on limbs, Acticoat® is transfixed proximally to prevent slipping during movement. The transfixed Acticoat® is covered with outer dressing layers. The main advantage of this technique is transfixion suture secures the inner dressing layer to prevent shearing of the skin graft with early mobilization of patients. Another advantage is removal of the outer gauze dressings and replace daily or once it becomes wet without disturbing the inner Acticoat® dressing protecting the skin grafts for 3 to 7 days. We found this method very useful when grafting the buttocks and back. An additional advantage of transfixed Acticoat®, when patients with extensive burns became febrile, it was easy to remove the outer gauze dressing to cool the patient and keeping Acticoat® to protect the wounds (Figure 1). Acticoat® had been fixed to the body by staples in our burn service, but we found the use of sutures more convenient to patient, safer to staff and provide better stabilization of the dressings. Also, Acticoat® has been fixed to body as part of tie over dressing, but the outer dressing usually becomes wet within 1 to 2 days and then all dressing is removed by removing the tie-over. However, we still use tie-over dressing for concave areas as axilla.

A method of limb elevation during burn surgery

Elevation of limbs during burns surgery to access the posterior aspect is routinely required. We describe a method of limb holding during burns surgery using sharp towel clips fixed to the distal phalanges of a patients hands or feet. The limb is held in elevation using a sterile crepe bandage from the towel clips to a hook hung on a rail fixed to the theatre ceiling. We have used this technique for patients with extensive severe burns for many years with no significant damage to the nail beds or the tips of fingers and toes. This technique is convenient for surgeons as it allows easy access to hands and feet and the posterior aspects of arms and thighs. It is cost effective and safe as it spares an assistant and decreases the risk of potential occupational injury.Level of Evidence: Level V, therapeutic study.

The Use of Povidone Iodine Antiseptic Solution Can Also Help in Distinction Between Superficial and Deep Burns

Povidone iodine is an effective antiseptic solution. Skin prepping with VideneR-antiseptic solution contains 10% w/w cutaneous solution Iodinated Povidone (Ecolab Ltd., Lotherton Way, Leeds, United Kingdom) preoperatively is routinely performed at our regional burn service. Povidone iodine stains the normal skin and the deep burns whereas it does not stain the superficial burns. The full thickness and deep dermal burns are dry, therefore the betadine sticks to the surface whereas on the contrary the superficial burns exudate. This helps in mapping deep dermal and full thickness burns before performing early tangential excision.

Chemical burns in children caused by wipes

Chemical burns are rare in children and usually secondary to accidents caused by tasting common household products.1 Burns to the perineum are rarely seen as an isolated injury; mostly they have been reported in the context of extensive scald or flame burns.2 Early recognition of nonaccidental injuries is very important. Doctors used to consider the possibility of child abuse in every injured child presented to emergency departments. Intentional injuries constituted 1 to 3% of all burnt children admitted to hospitals.3 It is reported that 9.3% of 440 pediatric burns patients were hospitalized during 2000 to 2002 because of neglect.4 We present here the cases of two brothers with chemical burns involving the perineum and medial aspects of buttocks, presented on the same day. The older child was 30 months old (Figure 1) and the younger one was 14 months old (Figure 1). Their father noticed blisters when he changed their nappies in the morning and he took them to a local hospital. Because nonaccidental injuries were suspected, social services were involved and child protection issues were raised and the children were admitted to the hospital. The father was denied access to the children, and taken into police custody until the social concerns were cleared. Three days later, the two children were referred to our regional pediatric burns center. Full assessment showed no other injuries and no further medical problems. The children had no known allergies; however, the father reported using a new brand of baby wipes several hours before, which he had not used before. He did not change the brand of nappies or soap that did not cause irritation in the past. The history and clinical examination were consistent with pattern of burns caused by chemical irritation of using the wipes. The burns were superficial, of partial thickness, and treated conservatively. The burns fully healed in 7 days and the children were discharged home. Further investigation did not reveal other similar cases. These two cases highlight the importance of early discussion and referral to the regional pediatric burns service to avoid unnecessary stress to children and their families.

Tattooed skin grafting in burns surgery.

colostomies in paediatric peri-anal burns. Burns 1999;25(November (7)):645–50. [3] Bordes J, Goutorbe P, Asencio Y, Meaudre E, Dantzer E. A non-surgical device for faecal diversion in the management of perineal burns. Burns 2008;34(September (6)):840–4. [4] Keshava A, Renwick A, Stewart P, Pilley A. A nonsurgical means of fecal diversion: the Zassi Bowel Management System. Dis Colon Rectum 2007;50(July (7)):1017–22.

Custom-made standardised over-dressings for torso burns; economical and efficient

Introduction: Torso burns following debridement and skin grafting usually require fairly complex dressings. The dressing consists of an interface layer, an absorbent layer and a retaining layer. Although numerous inner dressings are now available from multiple manufacturers, Gamgee dressing (pad of cotton and gauze) is often used as an outer absorbent dressing. Dressing the torso is usually a challenge, and the purpose of this paper is to present a custom-made over-dressing for torso burns, which reflects the current practice at our centre. Materials and Methods: A U-shape cut is made at one end of the Gamgee to design the shoulder straps. This custom-made dressing is held in place by a custom-designed netted vest. Results: This custom-made over-dressing for the torso was found to be comfortable for patients, easily made from locally available materials, easy to apply, absorbent and not restrictive of movement. The shoulder straps prevent sliding of the Gamgee, and in a nonrestrictive way. The netted vest provides the required compression to keep the Gamgee in firm contact with the inner layers of the dressing without compromising respiration. Conclusion: In this report, we present our practice of a custom-made dressing that is very efficient and economical. We hope that this information will be of practical use to other centres managing burns.

Is it safe to combine abdominoplasty and posterior vaginal repair in one surgical session

Many multiparous women complain of protruded and pendulous abdomens and vaginal outlet relaxation which affect their sexual relationships with their male partners. This study included 47 patients who had these complaints. Some of these patients were working outside the homes and all were mothers of 2–5 children. Due of their home and job responsibilities, they did not have enough time or money for multiple surgeries in more than one session. Material and Methods: The age of these patients was 26–54 years and all patients had poor skin elasticity, pendulous excess subcutaneous fat and skin below the level of the anterior vulvar commissure, and a lax musculoaponeurotic anterior abdominal wall. Also, all patients had a relaxed vaginal outlet and 32 patients had rectocele. Careful perioperative assessment and management was done for each patient to ensure fitness for the long operation and to avoid complications. The combined surgical session consisted of two steps: abdominoplasty and posterior vaginal repair. All the patients were kept in the hospital for two days and they returned to their usual routines in the third week after surgery, and they resumed their sexual relationships with their male partners in the sixth week after surgery. Results: There were no serious complications and this approach was convenient for the patients and their families. The recovery time of the combined surgical session was the same as that of just abdominoplasty, and significantly less than the sum of the recovery periods if the two surgeries had been performed in two sessions. The cost of the combined surgical session was significantly less than doing the surgeries in two sessions. All the patients had significant improvement in their sexual relationships.