Split-Thickness Skin Graft, Permanent Pigment Transfer, and Fractional CO2 Laser Therapy
Main Text
Table of Contents
Pediatric burns are one of the most common forms of injury affecting children worldwide. Of these, hand involvement occurs in 80–90% of such incidents. With the skin in children already diffusely thinner throughout the body than that in adults, this provides a particular challenge for areas that naturally possess thinner skin, such as the dorsal hand. The cutaneous tissue there is the only protection for vital structures in the hand that allow full function, such as extensor tendons, nerves, and vessels. Injury to this area early in life can have a detrimental impact on how the survivor interacts with the physical world, affecting their functional capacity and quality of life. Today we present a case of burn contractures on the right hand of an 8-year-old boy that will be released using a split-thickness graft, along with a pigment transfer graft for his left knee and fractional CO2 laser therapy over areas of hypertrophic scar tissue on his bilateral upper extremities. The split-thickness graft will greatly decrease the tension built up from the burn contracture, while the fractional CO2 laser procedure can soften the surrounding scar, allowing mild remodeling and increased range of motion.
Keywords
Plastic Surgery; Reconstructive Procedures; Scar Remodeling; Hand surgery; Laser therapy
Burns are among the most devastating injuries and are the fourth most common trauma, with 25% occurring in children under the age of 15.1, 2 Children are more vulnerable to burn injuries. A major factor at play involves the discrepancy between body surface area. Children have three times the body surface area to mass ratio than adults.3 Complications of this leftward shift include an increased volume and rate of fluid loss and a higher potential for hypothermia. Skin thickness also contributes. Children’s skin thickness is approximately 70% that of adults, with the dermal layer thickening throughout the aging process from infancy to puberty.3 This demographic, therefore, experiences a greater depth of burn injury than an adult would have experienced at similar temperatures. Therefore children have a greater likelihood of presenting with more severe burns than their adult counterparts, making timely management of both acute and chronic injuries vital to recovery.
After the acute management of burn victims, focusing on electrolyte imbalances, volume depletion, and airway care, the functionality of the affected area then needs to be taken into consideration. Treatment goals revolve around minimizing burn contracture, secondary changes in the surrounding tissue, and preserving neurovascular structures.4 Special considerations need to be taken into account when burns affect the hands, which occurs in 80–90% of incidents.5 This large occurrence of hand burns equally raises the rate of hand deformities. Because hand function is a vital aspect of our ability to interact with the world, full utility after recovery is linked to the patient’s quality of life. Deformities arise depending on multiple factors, one being the type of wound healing process occurring at the site. Burns can heal either by regeneration of skin or repair.6
Regeneration occurs if the burn is superficial or even partial-thickness, sparing the levels containing specialized epithelial cells. If they survive, keratinocytes can migrate from the skin dermal appendages to proliferate and differentiate, healing the defect.7 For deeper insults, healing begins around the edges of the wound, with connective tissue layer deposited to replace lost tissue.7 Contractures occur as part of the normal healing process via stimulation of myofibroblasts to decrease the size of the wound. This reduces the amount of epithelization and collagen deposition needed to fill the defect and is adequate for small areas with loose skin.6 Problems arise when large insults need to be healed in areas of already tight or thin skin. These mechanisms then impair the elasticity of the skin and increase tension, leading to functional loss.
Management, therefore, is complex and tailored to the depth of the burn injury: superficial, deep partial-thickness, and full-thickness. Initial post-burn treatment decisions should be made based on providing the maximum, perceivable benefit for the patient.8 From there, aesthetic, deformities, secondary changes in musculotendon units, and timing of correction must be carefully considered.8 Over time, contractures or edema-induced tension can cause joint stiffening and tendon shortening. If neglected, hand deformities can permanently prevent full function. One of the major treatment options for both acute and chronic treatment of burns is skin grafting: the transfer of cutaneous tissue from one area of the body to the exposed wound.9
Grafting is generally used to cover larger wounds with skin from an area that will easily heal. Early coverage of exposed wounds provides environmental protection, temperature regulation, and decreased water loss. Skin grafts are different from flap techniques in that they do not have their own blood supply. Therefore, the wound bed on which they are placed must be clean and well-vascularized for successful take. The two major types of grafts, split-thickness and full-thickness, are chosen based on the location and size of burn. Skin grafting, along with the use of laser technology to introduce micropores in less-hypertrophic scar sites were the chosen methods of management for our case.
Here we present an 8-year-old child from Honduras who, at the age of 2, incurred a deep scald burn to his right hand, along with small areas of scarring in his right knee and left hand as well. The patient’s chief complaint is increasing tension in the scar tissue in his right hand. The dorsum of the hand contains a burn contracture that is causing deformity of his fingers and inhibiting range of motion. The patient is also concerned about an area of hypopigmentation on his knee.
The use of grafting techniques needs to be considered on a case by case basis. In general, grafting is indicated if simpler methods of closure will not provide adequate healing, the patient has available donor sites, and the recipient site is clean and well-vascularized.9 Specifically, split-thickness grafts can be used in both acute and chronic skin loss for coverage of deep partial-thickness defects, full-thickness defects, and exposed muscle.9 Larger areas are able to be cover with split-thickness grafts as opposed to full-thickness due to the small portion of dermis taken with it and the donor site’s ability to heal by re-epithelialization.
Absolute contraindications include active infections and bleeding at the wound site or exposed structures without an adequate vascular layer.9 Relative contraindications to consider are recipient sites over joints or anatomic landmarks that could potentially limit mobility and aesthetics.9 Tobacco, chronic steroid use, and hematological dysfunctions are risk factors for graft failure and should be taken into account in the treatment plan.
Prior to surgery, the hand was marked; one was through the main contracture, and multiple small ones were in the thumb webspace and ulnar edge. The first cut was made superficially through the scar tissue in the largest of the pre-marked lines. Next a similar cut was made through the web space, releasing the scar into the normal tissue on the palmar side and on the ulnar side of the hand. Undermining completed along all incision lines provided slightly larger skin edges for eventual graft connection. The width of the recipient site was measured in preparation for harvesting the right-sized graft. An epinephrine soaked sponge was placed on the opened wound to decrease bleeding while harvesting the skin graft.
The size necessary for the graft was marked on the right lateral leg. Diluted saline with epinephrine was injected into the donor site, which was then cleaned with Betadine and slickened with mineral oil. An electric dermatome, calibrated to 14-µm thickness and held at a 30–45-degree angle, was used to harvest the graft. Before laying the graft in the recipient site, any bleeders were cauterized. Simple sutures placed initially in the opposite corners held the new graft stable as the rest of the stitches were sewn along the edges in the direction of the skin graft to the hand side. Placement of drain holes decreased potential accumulation of bleeding underneath. After irrigation, a tie-over bolster of Xeroform and cotton was placed on top of the graft, creating the compression and immobilization necessary for graft success while also reducing the potential of hypertrophic scarring.
The second procedure used a dermabrator set at a decreased thickness to obtain a smaller, thinner graft for covering of the patient’s hypopigmented area. After injection of epinephrine, the graft was placed and immobilized with Dermabond. The donor site was then covered with Xeroform followed by Telfa and then wrapped in dry gauze. An anesthetic combination of 0.25% Marcaine and adrenaline anesthetized the site through injection near the lateral femoral cutaneous nerve and smaller nerve branches in the immediate area. Kerlix dressing was wrapped around the graft site. The leftover anesthetic mixture was then used for a dorsal wrist block.
The final procedure involved fractional laser treatment at 25 mJ and 10% density to the patient’s hypertrophic forearm and left hand scarring. Kenalog and betamethasone was rubbed into the micropores created from the treatment, after which the wound was dressed with a vaseline gauze.
Complications can be categorized as short-term or long-term. In the short term, any movement between the graft and skin bed increases the likelihood of graft failure. Therefore, fluid accumulation from infection, hematoma, seroma, or shearing injuries to the area can lead to incomplete take.9 Issues such as wound contractures or pigment inconsistency fall underneath long-term complications.
The patient in our case presented with significant scar contracture following a burn injury he sustained at the age of two. As he grew, tension within the skin continued to increase to the point where his hand functionality became impaired, almost seeming like a tendon abnormality. The first procedure’s focus was to release this built up tension via skin incision through the scar tissue, creating an extensive area of exposure. Given the dimensions of the release, a skin graft was indicated to cover the area. This would increase laxity over the dorsal hand, freeing movement of the appendage. A split-thickness graft, which refers to a skin graft containing the epidermis and a small portion of the dermis, was chosen for treatment.9 Retention of dermis portions within the graft is vital for successful take because it includes the dermal appendages from which epithelialization can occur. This prevents a large percentage of contractions within the donor graft, excluding the small amount taken into account at the edges. The earlier the skin grafts are used post-burn, the more successful they are at controlling the unwanted sequela of wound contraction. Our patient received a skin graft at the time of his burn, helping to hold off shortening of neurovascular and musculotendinous units and joint or bone deformities.
Split-thickness grafts can be harvested via several different methods, including the one used here, an electric-powered dermatome. The benefits of choosing this method come from its ability to harvest the graft at a uniform depth, providing consistency. Also, graft thickness is able to be adjusted, making the electric-powered dermatome ideal in cases like ours, where multiple recipient sites require varying thickness in their split-thickness grafts. Once harvested and placed on the recipient bed, the graft is secured into placed postoperatively for 5–7 days to allow the graft take to progress through three phases: imbibition, inosculation, and revascularization.9 The first involves the graft obtaining oxygen and nutrients via passive absorption from the well-vascularized wound bed.10 During inosculation, a vascular network proliferates between the two surfaces, causing the graft to now have its own supply and pink up.11 Finally during the revascularization phase, new vessel growth occurs into the graft from the wound bed. Once this process is complete, the graft continues to mature into the recipient bed, lasting up to several years. Changes in the maturing skin graft can include pigmentation, flattening, and softening.9
Thinner split-thickness grafts can be used to correct areas of depigmentation. When a burn is deep, it can affect the pigment in the skin for a time period of around six months to a year. However, if pigmentation does not normalize, the burn could be deeper than expected, and interventions for correction can be planned. Hypopigmentation defects require a much thinner graft since only the epidermis is required, containing the basal cell layer composed of the melanocytes that produce skin pigment. The presented case used the same donor site as the hand due to the availability of undamaged skin and to keep the eventual wound-healing process confined to one location. Attachment of the graft was completed with Dermabond since the thinness of it made sewing it into place a more difficult option.
In cases where scarring has undergone mild hypertrophy, laser treatments can be performed. One such treatment is a fractional CO2 laser that treats skin in a pixelated pattern, allowing the intervening skin to remain intact.12 This is better tolerated than previous laser technology that treated the whole skin and was associated with long-term effects of hypo/hyperpigmentation and permanent scarring.12 Since fractional CO2 does not treat the entire surface, it negates or decreases the severity of these adverse effects. Its use has been growing in a variety of treatments, including atrophic acne scars and skin rejuvenation.12 Studies have begun to show efficacy in treating burn scars, reporting improvement regarding pain, itching, and scar tightness.13 We have used it here on the patient’s mildly hypertrophic scars along his forearm and left hand to soften the skin. Topical agents, triamcinolone and betamethasone, were rubbed into the micropores created from the treatment, permitting deep penetration into the skin for the steroid to achieve its goal of breaking bonds between collagen fibers to reduce scar tissue.
Two alternatives to the choice of split-thickness grafting include using a full-thickness graft or a split-thickness meshed graft. A full-thickness graft was passed over in this case on account of the size of graft necessary to close the released area. Full-thickness grafts, while preserving a greater allotment of normal skin characteristics and being more resistant to contraction, have higher chances of failure.6 Their use is best in small defects located in highly visible areas, usually the face. They also leave behind donor sites that are required to heal by primary closure after one use instead of the fast regrowth and reusability seen in split-thickness donor sites.
The addition of mesh to split-thickness grafts is indicated when the available donor site is smaller than the wound size. Meshing allows the skin graft to be expanded through placement of holes throughout the skin in varying ratios, increasing the surface area it can cover. These holes also prevent accumulation of fluid buildup between the layers, decreasing the chance of graft failure.9 In this case, the patient had readily available donor sites that provided a large enough skin graft without necessitating the use of meshing.
Graft stability usually takes three weeks to achieve.6 Within the postoperative period, the use of a combination of splints and daily physical therapy aids in preserving graft take and restoring full range of motion. Physical therapy should be continued until maturation of the graft is complete, as determined by the ability to move and pinch the graft over the recipient area.6
Betamethasone
Kenalog 10 mg/cc
Mineral oil
Kerlix
Stapler
Anesthetic (0.25% marcaine and adrenaline)
Dermabond
Heavy scissors
Webster needle driver
Cotton
Xeroform
Adson tissue forceps
4-0 silk sutures
Electric dermatome
Epinephrine soaked sponge.
There are no disclosures that need to be made at this time.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Institute for Health Metrics and Evaluation. The Global Burden of Disease: 2010 Update. IHME, Seattle, 2012. viz.healthmetricsandevaluation.org/gbd-compare/.
- CDC Injury Prevention; Burns. (n.d.). Retrieved November 22, 2020, from https://www.cdc.gov/masstrauma/factsheets/public/burns.pdf
- Sharma, R. K., & Parashar, A. (2010). Special considerations in paediatric burn patients. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 43(Suppl), S43–S50. https://doi.org/10.4103/0970-0358.70719
- Gupta, R. K., Jindal, N., & Kamboj, K. (2014). Neglected post burns contracture of hand in children: Analysis of contributory socio-cultural factors and the impact of neglect on outcome. Journal of clinical orthopaedics and trauma, 5(4), 215–220. https://doi.org/10.1016/j.jcot.2014.07.011
- Cauley, R., Helliwell, L., Donelan, M., & Eberlin, K. (2017, May). Reconstruction of the Adult and Pediatric Burned Hand. Retrieved November 24, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/28363299
- Goel, A., & Shrivastava, P. (2010). Post-burn scars and scar contractures. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 43(Suppl), S63–S71. https://doi.org/10.4103/0970-0358.70724
- Shpichka, A., Butnaru, D., Bezrukov, E. A., Sukhanov, R. B., Atala, A., Burdukovskii, V., Zhang, Y., & Timashev, P. (2019). Skin tissue regeneration for burn injury. Stem cell research & therapy, 10(1), 94. https://doi.org/10.1186/s13287-019-1203-3
- Sabapathy, S. R., Bajantri, B., & Bharathi, R. R. (2010). Management of post burn hand deformities. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 43(Suppl), S72–S79. https://doi.org/10.4103/0970-0358.70727
- Braza ME, Fahrenkopf MP. Split-Thickness Skin Grafts. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551561/
- Rudolph R, Klein L. Healing processes in skin grafts. Surg Gynecol Obstet. 1973 Apr;136(4):641-54.
- Converse JM, Smahel J, Ballantyne DL, Harper AD. Inosculation of vessels of skin graft and host bed: a fortuitous encounter. Br J Plast Surg. 1975 Oct;28(4):274-82.
- Majid, I., & Imran, S. (2015). Efficacy and Safety of Fractional CO2 Laser Resurfacing in Non-hypertrophic Traumatic and Burn Scars. Journal of cutaneous and aesthetic surgery, 8(3), 159–164. https://doi.org/10.4103/0974-2077.167276
- Fractionated CO2 Laser for Scar Improvement: A Review of Clinical Effectiveness and Cost-Effectiveness; CADTH Rapid Response Report: Summary with Critical Appraisal
Procedure Outline
Table of Contents
- Mark Patient
- Inject Local Anesthetic and Calibrate Electric Dermatome
- Prepare Skin
- Perform Harvest
- Context
- Dermabrasion
- Harvest Skin Graft
- Place Skin Graft
Transcription
CHAPTER 1
Our first case today is a young child, 8 years of age. He is from Honduras originally, and at the age of 2, he was involved in a scald burn injury that was quite deep to his hand, his right hand, small areas of scarring to his right knee and his left hand.
I'm going to be doing some major work because of the burn contracture on his right hand. As he's grown, this has become tighter and tighter and made it look like almost a tendon abnormality, and it has impaired function related to that right hand. So we'll be releasing the scar, and the majority of that - it'll be such a large release, it'll require adding skin. So we'll be using a skin graft, and I believe I'll be using a split thickness skin graft technique where I'll harvest the skin from the thigh with a dermatome and then sew that into position with a graft to immobilize it, and then splint it.
The second part of that procedure - if there's some areas that require Z-plasty, may be accomplished at the same time on that hand, but I think he has a small area that bothers him - it's almost cosmetic, an area of burn dispigmentation, which is an area of hypo - almost vitiligo, it's very hypopigmented and it bothers him when he wear shorts. So we can make that better by permanent pigment transfer with the use of a small split thickness skin graft and dermabrasion. It permanently transfers a little bit of pigment to the area to camouflage the scar.
And finally, the third part of the procedure will be to try to soften the surrounding scar of the right hand and arm and the left hand with the use of a fractional laser. We'll use the laser system to basically create small little holes into the area of the scar where we can then use - rub in steroid into the area and it allows a little bit of remodeling of the scar that'll allow the scar to be a little bit softer.
At the completion of that, he'll have a splint on the right hand and have to be immobilized in that hand for 2 weeks before we take those dressings off. Burns heal by a combination of epithelization and contracture, and as he's continued to grow, he has a bad contracture across the dorsum of his hand. Make a fist? He can make a fist, but he gets a severe band contracture here. It's also hard for him to pull his thumb out all the way, so if we go ahead and release the contracture and add a skin graft, that'll allow him to move better. The tendons - just by having that contracture, makes it look like he has a tendon abnormality, but it's actually just the contracture that causes the abnormality of the motion of the finger. So if we treat the contracture, the motion of the hand will be - allow him to get his hand around a basketball when he's 18 years old, and allow the normal motion of the hand.
So I'll mark some areas where I'm going to make some incisions. So we'll make some incisions along here in the operating room. And that's where we'll be able to release and put in a graft. May also extend along there. He may also require a Z-plasty, so that'll take some of the tension by moving one direction to another. You borrow from one direction, and it lengthens it in the other direction.
So this is the contracture of the hand. It looks like there's a real problem with contracture along the region of the fingers, but in actuality, that skin, when you take the tension off, is normal, pretty much, with very little burn scar. So it's a contracture of the dorsum of the hand causing deformity of the fingers, as noted by the range of motion. It's a very difficult problem for him because of all this - these band contractures. These are skin problems, not tendon problems, so if you just release and treat the skin, it should treat the problem with the range of motion difficulties of the hand.
CHAPTER 2
Previous grafting looks good.
As you go through, you want to try to avoid going too deeply through scar into normal tissue. And fortunately there's a very good fat pad underneath the hand, which allows for a very good slide of tissue. If you're using very hypertrophic, early scar, you don't get this slide and you tend to have a cleavage into the normal tissues underneath the hand, causing a problem.
But already we can see that we have a very large defect. These are the standard veins you see on the dorsum of a normal hand that people can see and put in IVs into, so you can see it's a relatively superficial burn causing this significant contracture. We've gone through an area of previous skin grafting that was accomplished when he was a younger child.
We'll go up here, on top. Let's go through the first web space. Finger down. Thanks.
This is the first web space. There's a contracture in that area, as well. We're kind of just releasing it into the normal tissue on the palmar side, trying not to get into too much of the normal tissue or the palmar tissue, but with trying to fully release the contracture. Hold here, please.
So already we've got the thumb almost in a normal position. Still a little bit of contracture here. Just go another few millimeters into normal, trying not to get too much into the normal tissue but just enough to get the release that you need. There's still the band contracture along the ulnar side. Releasing it here, toward the normal. The more tension on the scar, the thicker that scar's going to be, so it's not surprising that this scar here looks to be 5 to 10 mm thick compared to some of the other scar because it was the one with the most tension on it.
Come on up for a sec.
Looks much better.
Yeah, boy. Could you flex the fingers down like that for me, please, and pull down?
Sometimes when the burn is very deep and has had a previous excision and graft, you're very quickly down to a pair of tenon and tendon, which makes it very difficult to get the slide you need to get a good result. Sometimes those patients require flap reconstruction instead of skin graft reconstruction, which is much more complex and requires a lot more postoperative therapy.
This bluish tinge, that would be the hypothenar musculature. In order to get the skin graft to take, it's going to require a very good hemostasis with very little bleeding underneath the graft and quite a bit of immobilization for about the 2 weeks that the stent that is going to be on there is going to be on. So we'll have to mobilize the fingers because too much motion of the fingers will decrease the ability for the - immobility of the graft that will be required.
Okay, I don't want to undermine too much. Now after all this undermining, you have to say, well, how much of that graft, that undermined skin, is that going to survive? Well, it's pretty close to what's there, so I think it will. Maybe a couple of edges that need to be trimmed back a little bit, but that's basically the release that we need. Some of this may secondarily require Z-plasty in the future. I'd rather not do that today because it may compromise some of the results of the skin graft, but it may require a staged approach of doing further Z-plasties along these abrasions.
I'd rather not get too much into the normal palmar skin because then you'd have a dark patch on his hand and if he raised his hand in school, there would be a dark patch and he'd be very embarrassed. So we'll try to avoid any dark patches on the - on the palmar side of his hand.
Do you have a ruler?
Sometimes in order to keep thing immobilized, we may K-wire the joints. I like to try to avoid K-wiring in children if we don't have to, basically because it can interfere - it can get infected or it can interfere with - growth plates - of the bones, and we want to make sure all those bones get to grow to their normal length.
So we'll go with a 4-inch shim on the dermatome. Epinephrine-soaked sponge. In order to decrease the bleeding postoperatively on the hand area, I'll put in an epinephrine-soaked sponge to decrease the bleeding, wrap that up while we concentrate on harvesting our skin graft.
Are you okay if we take it on the side? I think it'll be easier than -
Yeah, not from the previous side, but if you want to keep it above where his shorts line will be, so he doesn't have any scar problems with that.
Release the tourniquet.
CHAPTER 3
So I'm going to be moving for our skin graft portion of this. The harvest part. The electric dermatome is going to have a different sound than the air-driven one. Right here, if you see the shiny part of the 15 blade, that should just disappear when you check the thickness at 10 μm. It's at 10. It just disappears. It's just a way of helping calibrate what's already been calibrated. If you put it up higher, say at a 16, you'll fall all the way through. So that's how you know your specific calibration's going to work. And him, I think we'll push really hard at a 14 μm thickness to get a nice graft.
To decrease some of the postoperative bleeding and hopefully make the healing a little better, we'll do injection of diluted saline with a little bit of epinephrine in it. It also assists - that clysis assists in - harvesting the graft, especially in areas that are a little uneven, like, say, over the prominence of the hip. Along the area of the lateral thigh is one of the best donor sites, as it traverses along the femur. The long bone of the femur, it's very few irregularities so it's much easier to take a nice graft.
So, wipe off the previous Betadine. I like to use mineral oil to try to make it a little more slippery for the harvest. Oil on the dermatome. It's been measured out and will be the appropriate thickness we need.
I tend to go at about a 30 to 45 degree angle along the region that we need to take, pushing pretty hard along the way. And it always helps to have a great assistant. And then up like an airplane. There. And that's pretty evenly taken.
CHAPTER 4
So as we mentioned before, hemostasis in the region of the - the graft is going to be important in order to make sure the graft takes well. It's a nice vascular bed, so it will bleed a little bit.
Skin, please.
CHAPTER 5
Silks.
The skin graft, harvested at 14 in this young man, you can see it has quite a bit of dermis on it, means it's very white.
4-0 silk, please.
And it'll roll up a little bit. It has a little bit of primary contraction because it's got so much elastin it that it'll curl up a little bit at the edges. So that's about as thick a graft as you can take in a child this size, and the thicker the graft, the less post-secondary contracture that is likely to occur.
Let's start. Two multi-packs, please.
You want the empties here?
Do you have a finer Adson?
Multipack.
Finer Adson.
Thanks.
If you feel it's a little on the oozier side, you can do some pie-crusting to the area. Pie-crusting will allow a little bit of the blood to drain so that you're not going to get bleeding under the graft, which will decrease the chances of it taking postop. The most common places for a little bit of blood pooling would be the corners, so maybe we'll do a little pie-crusting in the corners if we have any issues. Sometimes when you take the tourniquet down, there's a little bit of hyperemia from the previous ischemia to the hand because of the tourniquet, so sometimes you get a little bit more bleeding than you might expect. You just have to be patient and wait for that post-tourniquet hyperemia to kind of abate.
And just put it in as much as you can. Like that.
I just don't want it to roll up.
Yeah, I get that. I'm going to need every bit of it.
It's just curling a little bit.
Yeah, and sometimes if it curls a bit, you can do a half-mattress on the corner to try to suck it right into that edge of the - the suture line that you've got.
Can I have a SNaP, please?
I like to put as much as dermis as I can in there and that helps decrease the secondary contracture. The more - The more you put in, the less stuff contractures. So there will be a sense of - there will be raised edges on either side in the immediate postoperative period. That sometimes alarms the patients a bit, but we do a lot of therapy postoperatively to decrease the secondary contracture where the - where it tries to pull in and get smaller again.
This kid's very compliant, so I don't think I have to do anything with immobilizing the fingers with pinning, with K wires. But that is an option to consider, especially if there's a lot of work that has to be done on the MCP joints, metacarpophalangeal joints.
SNaP will be next.
SNaP.
Any areas where we have excess?
No, there's not a lot of…
You've got the tough corner, don't you?
Yeah, but it looks - I mean, we can put - Do you want more in the web space, maybe? Because it seems - I mean -
No, it looks good. You might need a couple more silks in there, if that's what you mean - maybe 1 or 2 extras.
We're going to irrigate onto the graft at some point, too.
May I have some SNaPs, please?
Another SNaP.
Another silk.
I usually like to sew them in from the skin graft to the hand side, just makes it a little easier to sew in. Trying to sew from the the normal hand side to the skin graft tends to be a little harder to get as much accuracy.
SNaP.
May I have the Stevens scissors, please?
SNaP.
You want a silk?
No, a SNaP.
Drill a couple little drain holes, just in case there's a little bit of bleeding. Hopefully it won't accumulate much and we can get nice healing.
Little irrigation underneath.
Do we have xeroform?
Yes.
CHAPTER 6
So we got a good look, there's no real significant bleeding underneath there. The little compression from the stent itself will be helpful in trying to decrease the - any oozing that tries to happen underneath the graft.
Do we have the cotton?
Heavy scissors, please.
Do you have an empty needle driver?
Some people put mineral oil on this or moisten it. I tend to go with the dry cotton. It's just dealer's choice, doesn't really matter too much, I don't think. I do tend to use a fair amount of cotton, maybe more than most, but - Everybody kind of finds what's perfect for them and what works for them the best.
Okay, sloppiest of sloppy wets, please.
So all these little silks are going to be tied across this dressing, and then - it'll immobilize it and then we'll splint the fingers. I think I'll go with this one. In 2 weeks, this dressing will come down and we'll see how good our graft take is, if there's any problems with fevers or the stent is moving or there's a lot of bleeding, then of course that'd be - we'd take it down early to make sure everything's okay, but in general, when you have a surgically-created wound - a little - try it again, please - surgically-created, um - release, it's relatively a sterile wound, so you don't have to worry about infection as much as you would for, for instance, a - a contaminated open wound, when you're grafting a contaminated open wound.
I'll take those two together and get this funky corner done. Let's see - let's go with one of those. Split the difference.
Let's see what we've got here. I'll have you bring the fingers down just a little bit, like that.
We used a Webster needle driver that has very little tread on it so it's less likely to break the silks as we're tying them down. So if you kind of hold it with a regular needle driver, like that, when you try to release it after the knot, it can sometimes break the stitch.
Heavy scissors.
Could I have a sponge, please? I'm going to want some sponges, unclipped sponges for the fingers, and then we'll wrap with a cling.
Do you want OT?
Yeah, we'll call for them, but then we're going to - we'll just take the small skin graft off on the - for the knee and the dermabrasion, have you seen that procedure yet? I'll show you.
Do you have a cling?
Yes.
Oh, perfect, thank you.
So again, not too tight, but snug. Kind of bend the MCPs a little bit.
Now we're going to take a little bitty piece of skin graft for the knee. So we're doing a dressing where we can see all the fingertips and thumb tip but we'll then splint it with a - a splint decreasing the range of motion of - well, wrist down to MCPs, so - there may be some motion to the PIPs, but the MCPs will be immobilized in that position and the thumb is immobilized, so, the immobilization is greatly helpful. For the graft to take, immobilization is required.
CHAPTER 7
So we can permanently transfer pigment to that dark spot just by the smallest of skin grafts. We just take a little bitty piece next to the one we have already and then add it there, and it'll permanently transfer the pigment so that it'll match a little bit better and he'll be less embarrassed when he's playing soccer.
A little better lighting on that area of dispigmentation.
This usually happens in areas of pretty deep burn where the pigment doesn't recover. Most pigments will recover within 6 months to a year, especially in dark-skinned people, but this one didn't, so it's clearly because it was much deeper burned, more deeply injured.
The dermabrader is the way we kind of take off the top layer of the skin here. So you just put it on the skin and just take the top layer off.
Could we have some gauze, please?
And that's about it. So the dermabrader's nice, all it requires is just taking the top layer off. I'll just take the smallest of small skin grafts here at a much thinner rate, maybe 8 μm instead of the 14. Put it down to 8. Just squeeze like that.
So, push on both sides. I already put it on, thanks. Push on your side with me. I'll push on this side, you put it on that side.
Nice. Do you have an epi-soaked sponge?
So here we have just a very small skin graft that we'll put right on here to transfer that pigment, make it a little darker. This one is much thinner than the last one, it'll have much less white than the last one did, because it's mostly just an epidermal graft with very little dermis. Because you don't need the dermis if you're just transferring pigment.
Will you need silk for that?
No, we're going to use Histoacryl.
Okay.
So it's such a small graft and very thin, it's kind of hard to sew in. We'll have to do a little needle mobilization to make sure the graft takes, but you can take a little bit of cyanoacrylate, or whatever you want to call it, Dermabond or Histoacryl. I'm doing what some of these guys call spot-weld, you kind of fix it in a couple spots, and then you're done.
So you just wrap the knee and immobilize it, and it should take as a graft. If it did take completely, it should heal up very well and eventually that pigment - looks like a little bit of a patch, like a stamp of darker skin in the area, but then that fades and turns into being very similar to the surrounding color and it's much less conspicuous. And since he already has his large donor site to recover from, this little bit extra is pretty minimal.
I'll take a little square of xeroform, please.
For the donor site, we inject a lot of local anesthetic into the donor site because this is what's going to hurt the most. And we can even do a lateral femoral cutaneous nerve block, whether with ultrasound or just by landmarks. And we'll do a xeroform followed by a Telfa followed by a dry gauze wrap, and that'll come down tomorrow.
CHAPTER 8
Do you want chromic?
I think we don't need it because it's going to be pretty immobilized just by the dressings.
So a little bit near the lateral femoral cutaneous nerve as it runs out underneath the inguinal ligament on top of the Sartorius, traversing down toward where this donor site is, and then to get some of the twigs as they get into the area of the donor site. Twigs of nerves. And then anesthetize - the donor site as much as we can for the amount of local we can use. We stop at about a cc per kilo of 0.25 marcaine with adrenaline.
I'm going to take what we have left and give like a dorsal wrist block.
So we're done except for laser, right? So I can start breaking sterility. I'll take a Kerlix, please.
Do you have a stapler? Could I have it, please? Thanks.
In order to tell some people, 'don't take this dressing off,' we'll sometimes put staples across it as a reminder that this isn't the donor site, it's the graft site. But they can take this dressing down tomorrow. We usually keep most of our skin graft patients in the hospital overnight to make sure they have good pain control.
CHAPTER 9
So, dorsal hand release - pretty good-sized graft, need to immobilize kind of the MCPs, that's kind of where it needs to be. The MCPs are about 70°, and thumb. I don't want the wrist or the MCPs to move, I think - the graft's here, so whatever you think is -
I might do Bohler, just because -
Okay.
- it's harder to flex against it when it's…
Sounds good. Bohler splint will be perfect. Yep. Thanks.
And his knee would need an immobilizer, or a knee extensor.
A prefab knee immobilizer will probably work.
Alright.
Thank you. Probably a small adult.
CHAPTER 10
Alright, so, we're going to do a little laser on this burn scar on the back of his hand. It's a little hypertrophic, it's not too bad. And then we're going to work a little bit on his left hand.
I think some of the key things to think about is laser safety. We've got the air handler going, which can be a bit loud, but we've got our stent from our surgery, we want to cover that up because that's flammable. And then behind him, this is a wet drape as well. So these two things will decrease - will help improve laser safety. The laser itself, we're just going to be doing a deep today - sometimes you can do a CPG or superficial treatment - and then - but in this case, I think we just want to do just the one laser for him. It tends to soften up the scar and make it a little better.
We always do a test to see that we have it correctly, everybody around us all has goggles on. And then if you can get a close-up of that, you can see how there's a square pattern, and that pattern - it has bunch of little holes in it. So this is a fraxel laser that treats very deeply, but only a small percentage of the skin is treated at a time. The higher the energy, the deeper it goes, but then you have to decrease the density. In this case, it's quite safe to go ahead on this relatively minor scar, 25 mJ and a 10% density. If it was very hypertrophic, I would consider going up to perhaps a SCAAR FX at 100 mJ, or even more, at about a 3% density.
It's got a foot pedal to help control it.
We use different topical agents after it's done. We've got all these micropores placed into the skin, so we feel that if we then massage in a little bit of Kenalog, triamcinolone steroid, that may help soften up the scar as well. I've been using a little betamethasone for - instead of Aquaphor or Vaseline gauze, but that is a separate choice depending on what you want.
So now we're going to concentrate on his left hand.
Kenalog.
So the next thing we like to do is rub in a little Kenalog into these little pores. So all these multiple little pores, we've got Kenalog, 10 mg per cc. I'll just drip a little bit on there, I've got sterile gloves on. It's a clean procedure, not sterile, but I like to make sure we can minimize any potential postcellulitis, which is pretty uncommon.
Rub a little of that Kenalog in. And then we'll put on the dressings. A little bit up here.
These are not very hypertrophic scars, but they will get a little softer with this. And, um - the children always seem to think that there's an improvement and are very happy to have additional procedures, which is pretty uncommon for kids to want procedures.
I've been just trying a little bit of a betamethasone.
You can just give it to me, thanks. Perfect.
So the betamethasone ointment, just put a little bit of that into the - That's just a personal preference, it's - everybody's got a little bit of different personal preferences. And then we'll put Vaseline gauze dressing on there for 5 days.
And that's it. Great. Thanks, I'll let you work your magic with the dressings.
CHAPTER 11
So in the first case, we were able to harvest a skin - get a tremendous release in the dorsum of the child's hand, on the right hand. The entire contracture causing all that tightness was ameliorated by a release down to the level of the subcutaneous tissue, but not into the fat. It released very quickly. We had an 8 by 8 cm defect without excising any scar or previous skin grafts harvested the skin graft from the thigh, sutured into position with a good immobilization. No Z-plasty seemed to be warranted, or didn't seem to be warranted at this time; secondarily, they may be warranted.
The second part of his procedure was a grafting to a small area of dispigmentation on his knee with a small skin graft and immobilized there, that worked out well. And finally the third procedure, we did some - just as we had intended, some laser to the area of his bilateral upper extremities. And some steroid was rubbed into the area of the wound, so hopefully that'll affect a softer scar for him. He will be immobilized for 2 weeks and we'll get a better idea of how the skin graft has taken and his improvement in function will be after 2 weeks' time.