Jui-Yung Yang

Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures.

&NA; Free thin anterolateral thigh flaps combined with cervicoplasty were used in a series of seven patients undergoing reconstruction for previous burn injury from September of 2000 to May of 2001 at Chang Gung Memorial Hospital. This method uses a suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures had resulted from flame burns in six patients and from a chemical burn in one patient. The mean age was 32.7 years (range, 22 to 45 years). The size of excised scar ranged from 10 × 2 cm to 26 × 5 cm (mean, 19.7 × 3.3 cm). The size of flaps ranged from 11 × 5 cm to 26 × 8 cm (mean, 21.3 × 6.5 cm). Average operative time was 6 hours. Average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss. The donor site was closed primarily in five cases and by using a split‐thickness skin graft in two cases. At a mean follow‐up time of 5 months, the functional improvement was measured as follows: a mean increase in extension of 30 degrees (preoperatively, 95 degrees; postoperatively, 125 degrees), a mean increase in rotation of 18 degrees (preoperatively, 59 degrees; postoperatively, 77 degrees), and a mean increase in lateral flexion of 12.5 degrees (preoperatively, 26.5 degrees; postoperatively, 39 degrees). The average cervicomandibular angle was improved by 25 degrees (preoperatively, 145 degrees; postoperatively, 120 degrees). This series demonstrates that the use of free thin anterolateral thigh flaps combined with cervicoplasty provides a one‐stage reconstruction with a thin, pliable flap that achieves good cervical contour with low donor‐site morbidity.

Clinical comparison of commercially available Biobrane preparations

This prospective clinical comparison of the three commercially available Biobrane preparations indicated that: (1) All three products of Biobrane are excellent skin substitutes. (2) Regular Biobrane has satisfactory wound adherence, however, its non-porous structure allows limited wound drainage. Because of this, it has the highest incidence of haematoma and fluid accumulation (13.3 per cent) and delayed epithelialization (18.8 per cent) of the three products. (3) Thin Porous Biobrane has poor adherence which limits patient activity and provides poor pain relief. The infection rate of 10 per cent was the highest of the three products. (4) Regular Porous Biobrane demonstrated superiority to the other two Biobrane products in this study. It provided good wound adherence while maintaining wound drainage because of its porous structure. The incidence of blood or fluid accumulation (7.1 per cent) was the lowest in the three products. (5) Most of the complications such as infection, delayed epithelialization, pain and activity impairment were related to fluid or blood accumulation. Adherence was found to be more important and reliable than pore structure. Operative haemostasis thus should be emphasized when using porous Biobrane, as with all skin substitutes.

Symptomatic tracheal stenosis in burns

Tracheal stenosis in burns is rare and usually results from prolonged intubation or tracheostomy. Inhalation injury itself has the potential risk of tracheal stenosis. We reviewed the records of 1878 burn patients during 1987 to 1995 and found seven with tracheal stenosis (0.37%) after an average of 4.4 years follow up. There were 4 males and 3 females with an average age of 27.3 years. The tracheal stenosis developed 1-22 months after burn (average 7 months). Five patients had their inhalation injury confirmed by bronchoscopic examination. The incidence of tracheal stenosis among inhalation injury patients was 5.49% (5/92). Six patients needed intubation in the initial stage either for respiratory distress or prophylaxis, with an average duration of 195.2 h. In addition to prolonged intubation, the presence of inhalation injury, repeated intubations and severe neck scar contractures are also contributors to tracheal stenosis in burns. We favor T-tube insertion as the first treatment choice; permanent tracheostomy was unsatisfactory in our study.

Use of the Scalp as a Donor Site for Large Burn Wound Coverage: Review of 150 Patients

Abstract. The characteristics of rapid wound healing and multiple harvest capacity make the scalp an important donor site when dealing with large and deep burn wounds. This paper reports the results of a retrospective analysis of 150 patients treated for large burn wounds. The findings indicated that bleeding during graft skin harvest could be limited to 50 ml by intradermal injection of epinephrine (1:2,000,000), high-concentration epinephrine-soaked gauze compression (1:20,000), and temporary porcine skin coverage. Use of a scalp graft also carried a low risk of complications, with only four (2.7%) major complications including three cases (2.0%) of visible alopecia and one case (0.7%) of hair transplantation. There were no hypertrophic scars, even in the patient who had the largest number (11) of repeat harvests.

Reverse Dorsometacarpal Flap in Digits and Web-space Reconstruction

Skin defects in some areas of the digits are difficult to reconstruct, such as the ulnar aspect of the little or ring finger, radial aspect of the index, dorsal or volar aspect of fingers with proximal interphalangeal or metacarpophalangeal joint involvement, and proximal phalanx of the thumb. Moderate or severe contracture of the web space and multiple finger injuries without an available cross-finger flap are also a challenge to reconstructive surgeons. The reverse dorsometacarpal flap presents an option for reconstruction because of these difficulties. It is reliable and versatile in design. The donor site can be closed primarily provided the flap is less than 2 cm wide.

Electric water heaters: a new hazard for pediatric burns

The electric water heater has recently become a popular household appliance replacing the hot water dispensing jug. This device provides hot water and potable cool water directly from the faucets thus removing the need to refill the container or boil water separately in a kettle. Along with the convenience of dispensing hot water immediately has come an increased incidence of pediatric burns. This paper presents a 6-year retrospective study of such pediatric scald burns from 1996 to 2001. Computer database records revealed that the incidence of pediatric scald burns caused by the electric water heater during the past 6 years was 6.4% (66/1028). The age of victims ranged 0-6 years (mean 1.5+/-1.1 years), most of the victims were in the 1-2-year-old group. In most common cases burn location was the trunk. The accidents often occurred during the cold months and in the living room of the house. From this retrospective study, it was seen that the etiology and incidence of scald burns among children have changed as people have modified their household practice for obtaining hot water in our country. This study aims to increase public awareness to the problem and suggest some prevention measures to reduce this type of scald injury.

Chemical burn with cresol intoxication and multiple organ failure

In general, immediate water irrigation is recommended for all chemical burns. Very few chemicals cannot be safely washed off the skin with water, however cresol is one of the exceptions. A 40 per cent TBSA cresol chemical burn that subsequently developed systemic intoxication and multiple organ failure is reported. The patient survived after intensive general supportive treatment, repeated haemodialysis and wound care.

Clinical experience of postage stamp autograft with porcine skin onlay dressing in extensive burns

Fifteen patients with extensive burns (deep second-degree burn > 50%, or third-degree burn > 30% of total body surface area) were treated with postage stamp autograft and meshed porcine skin onlay dressing from 1992 to 1996. All patients received the procedure within 10 days of sustaining the burn, with an average of 6.3 days. The areas chosen for postage stamp autograft were the anterior chest, abdomen, back, buttocks and the proximal part of the extremities. The scalp was the donor site of choice when available. The harvested skin was cut into 0.5-1.0 cm postage-stamp-like squares and applied to the recipient sites separated by a distance of 0.5-2.0 cm. The expansion ratio was from 1:4 to 1:9. Meshed porcine skin was then used for onlay dressing. The average graft area was 26% of the total body surface area. The success rate of the skin grafts was nearly 100% in 14 patients. One patient had a 40% loss due to contamination from adjacent wounds. In conclusion, the postage stamp autograft with porcine skin overlay is an effective way to treat extensive burn wounds in the early stages.

Experience of reverse medial arm flaps in the reconstruction of burned elbow scar contractures

There are many methods to correct scar contractures in the elbow region after burn injury, including Z-plasty, Y-V or rectangular flaps, local or distant fasciocutaneous flaps, muscle or myocutaneous flaps, free flaps, tissue expanders and non-surgical orthotics. Among these, the reverse medial arm island flap, based on the recurrent ulnar artery, has proved to be a convenient local fasciocutaneous flap for elbow scar reconstruction. In the past 2 years, 12 reverse medial arm flaps were used in 11 patients. The results are satisfactory. Two complications, one partial flap necrosis, another ulnar nerve compression, were noted. Our clinical experience with this flap encourages us to use it for burn elbow reconstruction in the future. The advantages and disadvantages are discussed.

The role of bone scans in electric burns

From June 1986 to May 1989, 17 patients who sustained high tension electric burns received preoperative 99mTc-MDP bone scan examinations. They were done to detect soft tissue and bone injury and also as a guide for debridement and amputation. From our experience, the correlation between the results of scanning and clinical findings is 88.9 per cent. They are very sensitive and reliable for decision making regarding debridement and limb amputation level when there is coagulation necrosis.