P.M. Gilbert

Comparing outcomes of sheet grafting with 1:1 mesh grafting in patients with thermal burns: A randomized trial

BACKGROUND In many units, the standard mesh ratio is 1.5:1, but in our unit we have a 1:1 mesher, which does not expand the skin but provides regular fenestrations. There is some evidence that the unexpanded 1.5:1 meshed graft compares favourably with sheet grafts from a cosmetic perspective whilst reducing the risk of graft failure secondary to a subgraft haematoma, but none comparing the 1:1 meshed graft with the sheet graft. We conducted a randomized trial to compare surgical outcomes in unfenestrated sheet grafts with 1:1 meshed grafts. METHODS All patients aged ≥16 years undergoing skin grafts with either a sheet or a 1:1 mesh for burn reconstruction were included. Patients on steroids, those with conditions that impair healing, and burns >20% were excluded. Patients were randomized into the sheet grafting or mesh graft using a computer-generated allocation system. The mean percentage of graft loss was assessed by a Visitrak overlay system. At 3-4 months, 7-8 months and at 1 year, photos were taken for scar assessment using the Vancouver Scar Score (VSS). RESULTS Out of 72 patients, 48 patients (24 sheet vs. 24 mesh) completed the trial at 12 months. The mean age was 58 years (range 21-90). There was no total loss of graft in either group. The mean percentage of graft loss due to haematoma formation was higher in the sheet graft group (10%) compared to the 1:1 mesh group (6%) (P<0.062). The VSS score was 5 in both groups at 12 months. There was no significant difference in scar quality between the treatment groups. CONCLUSION These results show that the 1:1 mesh graft is superior to the sheet graft with regard to graft loss, although this result is not statistically significant. There are comparable findings in terms of cosmetic perspective at 12 months post-operatively in both arms of the trial.

Should we be using silver based compounds for donor site dressing in thermal burns

f T n burns. We agree with them that a case report can give only imited information on clinical outcomes and that no definitive tatements on efficacy can be made, as we stated in our report. In contrast to some of the single-enzyme digestion ethods previously published, our cell isolation process nvolves two enzymes, dispase and trypsin, plus cell washing y centrifugation. We believe that this approach, with a focus n inclusion of the keratinocyte progenitors from the basal pidermal layer, may enable good results. As we also believe hat this method may be of interest to others in the field, we lected to submit a case report highlighting the two-step, cell ashing process, applied to a deep partial-thickness burn ound, in a clinical ambulatory setting. We consider this echnique an innovative approach to split-thickness skin rafting and only consider it in burn wounds that are deepermal, relatively large, and have not healed in 1–2 weeks. The published case report was the first performed at UPMC ercy Trauma and Burn Center. Since then we have treated 4 more patients with this approach. As we see satisfying linical results, we believe that we may be able to offer the herapy earlier and perhaps even to deeper burns. To this end, e are looking beyond autologous CK15+/alpha-6-integrin+ pidermal progenitors to the mesenchymal stroma cells (MSC) f the dermis. Currently, we have encouraging laboratory esults in the isolation of these cells together with the epidermal rogenitors in an on-site approach of isolation and cell grafting ithin 2 h. We hope to introduce this isolation combination in he near future. Such a combination, using a three-enzyme-step igestion that also involves collagenase, may enable a transiion to cell grafting of large, full-thickness wounds. In our view, his approach would best be tested in a larger, multi-center, ontrolled study and we would be open to any outside interest. gain, we agree with the authors; only such a study would give ufficient information on the effectiveness of such treatments. Jörg Gerlach and Alain Corcos

Mobile telephone induced burn

We wish to highlight an interesting case treated at our Burns Centre recently. A 25-year-old man sustained a rectangular shaped full thickness burn to the lateral aspect of his left thigh whilst inebriated. Upon waking the patient found his mobile telephone damp and functionless in his left trouser pocket. There are many reports of mobile telephone induced injuries in the literature including mobile telephone explosion and acute ear trauma. We purport that although the mobile telephone has become an important means of communication worldwide, care must be taken in its use as there is potential to cause serious injury. Language: en

Correction of postburn superior pole breast deformity and macromastia--a novel approach.

Deep thermal burns to the anterior chest of prepubertal girls although rarely affecting the breast tissue proper [1] can result in unsightly scarring, breast asymmetry [2,3], breast hypoor hyperplasia and challenging nipple displacement and distortion. Various techniques and approaches have been reported in relation to hypoplasia, but macromastia in the presence of burn scarring may also be problematic. The combination of extensive scarring and macromastia has been addressed in different ways in the literature. Despite fears of devascularising the nipple–areolar complex or inducing necrosis in the scarred skin flaps, reduction mammaplasty has been successfully applied in burned breasts [4,5]. We report a case of postburn breast deformity in which unilateral superomedial hypertrophic scarring and tight contractures were treated concomitantly with bilateral macromastia utilising a novel combination of rotational glanduloplasty with nipple transposition and contralateral superior pedicle breast reduction.

Application of Mefix dressing: A technical tip

Mefix (SCA Mölnlycke Ltd) and related adhesive retention dressings have multiple clinical uses, particularly in the management of split skin graft donor sites in burns patient, which is now common practice. They have the benefit of allowing re-epithelisation in a reasonably sterile environment with minimal interference in patients’ daily activities. Methods of adhesive dressing removal have been well described. However, their application is often difficult. These dressings have a tendency to self adhere due to the static effects created from peeling the adhesive tape and from the material’s internal memory. Pinder et al. (2007) reported a method of preventing self-adherence by crumpling the Mefix dressing into a ball and thereby reducing its internal memory. Although effective, this method does not completely remove the static effect. Hence, selfadherence is still a possibility. We would like to report an effective and simpler technique to facilitate its application. Firstly, fold the adhesive dressing in half in the long axis with the matt dressing surface facing outwards once it has been cut to length. Then, peel the adhesive side of the dressing from one corner to the fold and attach it to the desired location. Finally, drag the non-adhesive counterpart along the axis of application whilst applying pressure over the dressing itself (Figures 1 and 2). In our experience, this method gives the user better control and allows for precise application. Further, it improves the overall aesthetic outcome.

Pyoderma gangrenosum: a difficult early diagnosis to make

Pyoderma gangrenosum (PG) is a rare, painful, non-infectious, ulcerative, inflammatory skin condition. It is characterised by ulcers that can spread rapidly showing undermined violaceous borders. It may develop at sites of trauma or in surgical wounds. Early diagnosis is not always easy as there is no single diagnostic test and clinical features are often indistinguishable from other more common ulcerative skin conditions. Diagnosis is made on clinical appearance, patient history and exclusion of other conditions. We describe a case of PG, which proved challenging to diagnose, in a man who presented initially with a non-healing leg ulcer at a site of previous trauma and surgery. He subsequently developed further lesions on the contralateral leg with the classical appearance of PG. PG is a condition, which may be encountered by plastic surgeons and should always be considered in the differential diagnosis of any ulcer.