Medicine

“ We restore, repair and make whole those parts … which nature has given but which fortune has taken away, not so much that they may delight the eye but that they may buoy up the spirit and help the mind of the afflicted.”

Plastic reconstructive surgery. History of it’s development. Classiffication of transplantation. Types of tissue transference. Particularities of patient’s care after plastic surgery.

Gaspar Tagliacozzi 1597

Plastic surgery is the restoring of normal appearance and function of the body parts. The task of plastic surgery is to treat congenital and acquired defects that can appear after traumas, diseases, tumors or operations ( so called reconstructive surgery) and also to improve some particularities of the patient’s body which he or she wants to ( cosmetic surgery). Reconstructive surgery is restoring the patient back to normalcy, and cosmetic surgery is superseding the normal.

History

Operations similar to modern plastic ones were held 600 years before Christ , when in India injured noses were restored. Later there are no any dates about plastic operations till XV century. In that time Sicilian man – Anthony Branka used the tissue from hand for restoring injured ears and lips. The Italian man Gaspar Tagliacozzi (1545-1599) is known as founder of plastic surgery. In 1597 he published the work of all his life – he was restoring injured noses by tissues from hand. But his work was judged by people. He was buried on not saint land. But later townsmen of Bolonya made monument in his honor. It looks like a man holding nose in his hand.

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In XVII-XVIII centuries there were no moves in plastic surgery, cause in that times people thought that tissues of slaves could be used for transplantation. Now we know about reaction of immune system and so on. The progress in this field started in 1814 year, when the surgeon Josef Carpu from London made the operation on the nose using tissue from forehead. He’s read in the English journal about such operation that was done in the Indian colony (the patient took rise alcohol drink for anesthesia). So, to the end of XIX century there were published 100 of issues about different methods of plastic surgery.

Then the Great War I was started and that was the great impulse for the development of plastic surgery, because the need for treating wounds especially of face appeared and specific surgical centers were organized.

The founder of modern plastic surgery is English surgeon Harold Delf Gillis that worked as a plastic surgeon in the Queen Mary’s hospital in England.

In 1917 Filatov provided the method of skin plastic with help of a round migrated stalk.

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Pedzet in 1939 proposed for a taking of autodermografts a dermatome. In 1946 Colocolov also designed in Leningrad dermatome, which was successfully used for a long time in Ukraine. Now there are different electric and hand dermatomes, that give the possibility to get skin graft of different thickness.

“Gold years “of plastic surgery are 60-s, 70-s, 80-s years. Cosmetic surgery appeared as independent field on those years. Tord Skoog was founded the International Association Of Plastic Surgeons , which first session was on 1955y. in Stockholm . Now this organization has 10600 people from 77 countries.

Basic techniques of plastic surgery

Excision of skin lesions

Factors in obtaining a fine line scar:

1. a traumatic technique

2. placement of the scar in the same direction as skin lines

3. the age of the patient

4. the region of the body

5. the type of skin

6. complicating factors – skin disorders, infection

1. Careful handling of tissues is essential if one is to obtain a fine linear scar and maintain function. Skin and the subcutaneous tissues that have been crushed, dried by exposure to the air, damaged with hot sponges, or strangled by a suture under too much tension will undergo some degree of necrosis. The necrotic cells may serve as a culture medium for infection and at least will be replaced by scar. Sharp knives, scissors, needles, and skin hooks, as well as sutures of the proper size, swaged to a needle, are all important to minimizing this trauma. By the way, it is better to use surgical pincers only for fixation of those areas of skin, that will be removed during the operation.

2. Scars are at least conspicuous when they follow the wrinkle lines, contour lines, lines of dependency, or are concealed by the hair of the scalp or eyebrow.

The wrinkle lines of the skin generally lie perpendicular to the long axis of the underlying muscles and are caused by the wrinkling that accompanies muscular contraction . Wrinkle lines of the face, known as the lines of expression. This lines are accentuated with smiling, grimacing, frowning, pursing the lips, and closing the eyes tightly.

Contour lines are the lines of division at the juncture of body planes. Examples are found at the juncture of the cheek with the nose, the cheek with the ear, the scalp with the ear, the cheek and neck skin in the submundibular region.

The lines of dependency occur in older people due to the effect of gravity on loose skin and fatty tissue. The “turkey gobbler fold” in the submental region and the more laterally located jowl lines of the submundibular region are typical lines of dependency.

3. Children’s scars can remain erythematous and hypertrophy for prolonged periods of time, and the final result may be less satisfactory under these circumstances. In general, such scars have a less desirable final appearance than scars of person of middle age and older.

4. Scars resulting from excisions or incisions in the eyelids, palms, soles, and in the vermilion or mucous membranes are usually finer and less conspicuous than those seen elsewhere.

5. Some patients have thick, oily skin which contains hypertrophied and overactive sebaceous glands. Wounds in this type of skin may heal with a very noticeable depressed scar skin with these characteristics may be present over the distal half of the nose, the middle portion of cheeks, and the forehead.

6. Patients who have abnormalities in their fibrous and elastic tissues often develop wide scars.

Operative technique of suturing skin wounds

Methods of wound suture

Buried sutures aid in closing a wound in layers. The periosteum or perichondrium, the muscular fascia, and the subcutaneous tissue layer should each be closed by suture. It is wise in the subcutaneous layer to insert the suture so that the knot is tied deeply, away from the skin surface.

Another method sometimes used for closing the subcutaneous tissue is the continuous alternating suture. The ends of this suture can be left permanently in the subcutaneous tissue or passed to the surface so that the suture can be removed after 2 or 3 weeks.

Skin suture can be of several types

1. The simple interrupted suture should be inserted so that the needle enters the skin of the first side at an angle of 90 degrees or greater. As the needle passes through a comparable amount of subcutaneous tissue on the second side, it begins to angle back toward the wound edge. Ideally, the angle of exit for the needle is the as its angle of entrance.

2. The vertical mattress suture is used principally to assure aversion of skin edges and is unsurpassed for this purpose.

3. The horizontal mattress suture provides close approximation of the skin edges with some aversion. This can be helpful in closing skin wounds in the hand that are under tension.

4. The half-buried horizontal mattress suture is very effective for closing the point of V-shaped wound. The use of this suture often prevents necrosis of the tip of the V, which may follow the use of a simple interrupted suture. This suture is also advantageous for suturing a skin flap into place. The buried portion of the suture lies within the flap so that it effectively holds the flap in place, and yet the danger of damaging the skin by inserting sutures through it is avoided.

5. The subcuticular (continuous intradermal) suture is very practical and useful. The needle passes horizontally through the dermis. This suture can usually be left in place for 2 to 3 weeks.

The classification of transplantation according to the sourсe

- Autoplastic(iso) – from the same organism

- Alloplastic(homo)- from the human to human

- Xenoplastic(hetero)- from animal to human

Check internet page: www.kombustiolog.com.ua

The classification of plastic operations

1. Main groups of plastic operations:

a) plastic by local tissues

b) plastic by far located tissues

c) free transplantation of skin

2. Transplantation of different tissues

a) tendons, bones, fascias

b) cartilages, cornea, vessels

c) fat, nerves

3. Transplantation of organs

a) kidneys, liver, heart

b) pancreas, lungs, fingers

SURGICAL MANAGEMENT. Surgical management is restorative rather than preventive. Surgical techniques for contracture release are most commonly performed in the neck, axilla, elbow flexion areas, and hand. Specific surgical procedures to improve movement vary for each client. Reconstructive and cosmetic surgery can be performed for many years after the burn injury. Restoration of function and improvement of physical appearance through surgical techniques often increase the client's feelings of self-worth and promote a positive body image. Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state.

Types of tissues transference

It is very important to choose the method which will give us the best functional and esthetic effect. Firstly, you should try to close the defect with the help of neighboring tissues (plastic by local tissues, flap on the peduncle from the tissues that are situated near – Indian method of plastic). These methods give the best functional and aesthetic result, because skin of nearly located areas is used. Such skin has similar properties to the skin of defected area.

If there is no such possibility the question about closing the defect by usage of Italian plastic, or migrated flap.

Types of methods of local plastic

1) The V-Y advancement technique has numerous applications. Rather a V-shaped incision is made in the skin, after which the skin on each side of the V is advanced and the incision closed as a Y. This V-Y technique can be used to lengthen such structures as the nasal columella, in certain instances, close the donor site of a skin flap.

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2) Z-plastic – is simply a technique by which two triangular flaps are interchanged, one by another. It has three major uses: to increase the length of the skin in a desired direction, to change the direction of a scar so that it will lie in the same direction as the skin lines, and to rotate the axis of the tissue included in the Z-plastic flaps. It is often used in case of after burn deformations of different localizations.

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Joint contracture

Z-plastic

Contracture

Z-plastic

3) Indian plastic – is the closing of defects by skin flap. It consists of skin and subcutaneous tissue that is moved from one part of the body to another with a vascular pedicle or attachment to the body being maintained for nourishment. In this method it has to be taken from the nearest areas. It is used for closing of wounds of 3-angle, 4-angle, and round form. If there is a need the rotation or transposition could be done. Sometimes there is a need to close tendons, bones, joints which need the external nutrition and in that cases rotated skin-fat flaps are used. And secondary defects that will appear should be closed by free graft. It is combine plastic, the main point of which is skin-fat rotated flap.

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Free plastic

Wounds deficient in surface covering require closure by a skin graft or skin flap. In case of free plastic the skin grafts are used. Skin graft is a segment of dermis and epidermis which has been completely separated from its blood supply and donor-site attachment before being transplanted to another area of the body, its recipient site. Skin grafts consist of the epidermis and a portion of the dermis if they are of the split-thickness skin grafts. The full- thickness type contains the epidermis and all of the dermis. All such grafts contain varying portions of the sweat glands, sebaceous glands, hair follicles, and capillaries of the skin, depending on their thickness. Skin grafts can be used to close any wound in the body which has a blood supply sufficient to produce the growth of granulation tissue. The most notable exceptions are cortical bone, cartilage, tendon, nerve. Most skin grafts are used to serve as permanent coverage for a wound. By the way split-thickness skin grafts are preferred for replacing the skin lost from burned surfaces. When thin split-thickness skin grafts are used, a new “crop” of skin can be taken from the same donor site about every 2 or 3 weeks. 15 or 16 days is the best time to take a second thin split-thickness skin grafts.

The color, texture, vascularity, thickness, and hair-bearing nature of skin varies markedly from one area of the body to another. In general, the nearer the donor site is to the recipient site, the more closely will the skin match. Skin grafts to the face from above the clavicle will retain their natural blush state, whereas those from below the clavicle will take on a yellowish or brownish hue. The post auricular surface of the ear and adjoining mastoid area serve as excellent sources for grafts of full-thickness skin which match the skin of the face. It’s color and texture are similar to that of facial skin.

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Vascularization of skin grafts.

There are three definite events: 1. Absorbtion of plasma in the graft

2. Inosculation of blood vessels

3. In growth of new capillaries

Good contact between a skin graft and its recipient bed is essential for vascularization of a graft and its survival. The thin fibrin network that begins to form almost immediately between the graft and its bed seems to serve as a glue to hold the surfaces together and prevent one from slipping on the other. Factors preventing proper contact between the graft and its recipient bed are improper tension on the graft, a collection of fluid beneath it, and movement between the graft and its bed.

Cutting the skin graft.

Three basic types of instruments have been designed for removing a graft of split-thickness skin from its donor site: the Humby knife, the drum-type dermatome, and the electrical dermatome. The principle on which all of these instruments are based is that of a sharp blade moving back and forth to cut a piece of skin whose thickness is controlled by a calibrated setting on the instrument or by the surgeon himself.

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Postoperative Care of skin grafts

1) removal of hematomas and seromas

2) care of the infected skin grafts

3) hyperbaric oxygen

Care of the donor site

After the split-thickness skin graft has been removed from a donor site, it heals by a process of reepithelialization. We use xenotransplants in this cases.

Characteristics of grafted skin that should be taken into account:

- contraction of grafted skin (primary, secondary)

- color of grafted skin

- accessory skin structures in grafted skin

- sensation of grafted skin

- durability and grows of grafted skin

The plastic from far located tissues

Italian plastic and Filatov’s (migrated) flap

It means the usage of skin flaps that can be constructed at a distance from the defect and then transferred to it, either directly (e.g., by raising a skin flap on the chest wall and positioning the defect on a hand under the flap) or indirectly (e.g. by raising a skin flap on the anterior aspect of the trunk and then using the wrist as a carrier to transfer it to surface a large defect on the face).

Direct flaps are usually obtained from, or transferred to, an extremity, because the mobility of the extremity is an important advantage in this surgery. Some examples of direct flaps from a distance are direct flaps from the trunk usually transferred to the upper extremity, direct flaps from an upper extremity for repairing the contra lateral upper extremity or the face, direct flaps from a lower extremity used on the opposite leg.

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Indirect flaps are rather seldom and are transferred to a distant site by a carrier (e. g., the wrist) or by migration. Such flaps are almost always tubed. Some examples of these indirect flaps are indirect flaps from the trunk, indirect flaps from the neck, and from the lower extremity. The anterior surface of the trunk is the preferred site for forming large skin flaps, cause it can supply great amounts of tissues to any part of the body.

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Our progression in choosing the type of skin coverage should be from skin graft, to local skin flap, to distant skin flap – from the simple to the most complex.

Correction of scars

Scars (also called cicatrices) are areas of fibrous tissue that replace normal skin (or other tissue) after injury. A scar results from the biologic process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound (e.g. after accident, disease, or surgery) results in some degree of scarring. Scar tissue is not identical to the tissue that it replaces and is usually of inferior functional quality. For example, scars in the skin are less resistant to ultraviolet radiation, and sweat glands and hair follicles do not grow back within scar tissue. A myocardial infarction, commonly known as a heart attack, causes scar formation in the heart muscle, which leads to loss of muscular power and possibly heart failure. However, there are some tissues (e.g. bone) that can heal without any structural or functional deterioration.

Fig.18 A very minor scar from a cut to the forearm,

approx. one year since wound.

The word scar was derived from the Greek word eschara, meaning place of fire (fireplace).

A scar is a natural part of the healing process. Skin scars occur when the deep, thick layer of skin (the dermis) is damaged. The worse the damage is, the worse the scar will be.

Most skin scars are flat, pale and leave a trace of the original injury that caused them. The redness that often follows an injury to the skin is not a scar, and is generally not permanent. The time it takes for it to go away may, however, range from a few days to, in some serious and rare cases, a few years. Various treatments can speed up the process in serious cases.

Scars form differently based on the location of the injury on the body and the age of the person who was injured.

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A Cesarean section scar visible 7 weeks after childbirth.

To mend the damage, the body has to lay down new collagen fibres (a naturally occurring protein that is produced by the body). Recent research has implicated the gene osteopontin in scarring and developed a gel that inhibits the process ^[2].

This process results in a fortuna scar. Because the body cannot re-build the tissue exactly as it was, the new scar tissue will have a different texture and quality than the surrounding normal tissue. An injury does not become a scar until the wound has completely healed.

Transforming Growth Factors (TGF) play a critical role in scar development and current research is investigating the manipulation of these TGFs for drug development to prevent scarring from the emergency adult wound healing process. As well, a recent American study implicated the protein Ribosomal s6 kinase (RSK) in the formation of scar tissue and found that the introduction of a chemical to counteract RSK could halt the formation of Cirrhosis. This treatment also has the potential to reduce or even prevent altogether other types of scarring.^[3]

Type of grows of scar tissue

Norma trophy

Stable

Atrophic

Stable, with thin areas

Hyper trophy

Are growing

Keloid

Are growing with invasion to neighboring tissues

Spreading of scar tissue

Line scars

Surgical excision

Scar areas

Combine therapy

Scar contractures

Scar deformations

Two types of scars are the result of the body overproducing collagen, which causes the scar to be raised above the surrounding skin. Hypertrophic scars take the form of a red raised lump on the skin, but do not grow beyond the boundaries of the original wound, and they often improve in appearance after a few years.

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Keloid scars are a more serious form of scarring, because they can carry on growing indefinitely into a large, tumorous (although benign) growth.

Keloid scars can be caused by burns, surgery, an accident, by acne or, sometimes, from body piercings. In some people, keloid scars form spontaneously.

Although they can be a cosmetic problem, keloid scars are only inert masses of collagen and therefore completely harmless and non-contagious. However, they can be itchy or painful in some individuals. They tend to be most common on the shoulders and chest.

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Alternately, a scar can take the form of a sunken recess in the skin, which has a pitted appearance. These are caused when underlying structures supporting the skin, such as fat or muscle, are lost. This type of scarring is commonly associated with acne, but can be caused by chickenpox, surgery or an accident.

Scars can also take the form of stretched skin. These are called striae and are caused when the skin is stretched rapidly (for instance during pregnancy, significant weight gain or adolescent growth spurts), or when skin is put under tension during the healing process, (usually near joints). This type of scar usually improves in appearance after a few years.

Contracture scars. If your skin has been burned, you may have a contracture scar, which causes tightening of skin that can impair your ability to move; additionally, this type of scar may go deeper to affect muscles and nerves.

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Atrophic scars appear mostly in older patients.

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Factors that are dealing with scar growth

1. Total

1.1. Age

1.2. Heredity

1.3. Race

1.4. Immune status

1.5. Pathology that caused trauma

2. Local (that are not dealing with surgeon)

2.1. Localization of injury

2.2. Character and depth of injury

2.3. Area of injury

2.4. Infection of wounds

3. Local (that are dealing with surgeon)

3.1. Localization of suture to skin lines

3.2. Method of surgical closing or conservative treatment

of wound

3.3. Right usage of standard of treatment

Scar treatment

Primary scar treatment standard

Methods of first line:

“Wait and Look”

Noninvasive care

12 month

Pressure therapy

Gel sheeting

Corticosteroids ointments application

Static and dynamic splints

Antihistamine drugs

Hydrotherapy

Methods of second line:

Noninvasive and Invasive care

After 12 month

Peel, dermabrasion

Laser therapy,

Cryosurgery,

Excision (revision surgery),

Radiotherapy

Combination therapy

Methods of third line

Invasive care

After 24 month +

Post operative correction

Excision (revision surgery)

Cryosurgery

Reconstructive surgery

Combination therapy

Exception:

surgical technique of incision or excision is possible and should be done on early stages, when scars prevent grows of children or cause acute limiting of moves in joints, it means in case of risk of secondary degenerative changes of deeper organs ( bones, joints).

4. THE CHARACTERISTICS OF LYOPHILIZED XENODERM GRAFTS

Lyophilized xenoderm grafts (the size - 100-200-250-300 cm², the thickness - 0,3-0,4 mm) are sterile, processed, packed and can be used as skin substitutes in the treatment of the burns (II-III AB, IV degree), donor and scalping lesions, trophic ulcers. These implants can be preserved in the fridge at +2 up to +4 degrees C for 3 years. They are light; one package weighs 70-120 gr. The products are transported within 1- 2 days in any season without any alterations of their therapeutic properties.

After microscopic investigations of the lyophilized skin, the signs of autolytic and necrobiotic alterations and their deep structural abnormalities have not been found in the epidermis and in the papillary layer of the dermis. Well-preserved nuclei and epidermocyte and fibroblast cytoplasm are present in the majority of the cells; pycnosis and vacuolization are only detected episodically. The cell membranes are not distorted; the exfoliation of the epidermis from the dermis is absent. The collagen dermal fibers of the grafts are contoured, forming the network and being placed loosely in the papillary layer. The edema and homogenization of some parts of the collagen fibers and, in some cases, - their fragmentation is present in the deep layers of the dermis.

At picrofuxin staining by Weigert Van Gieson, the collagen fibers are mostly stained intensively red with fuchsin. The part of the elastic network is interwoven with clear contoured fine elastic fibers.

The vitality of the of xenoderm grafts is determined microscopically. All the investigations clearly reveal plasma membranes, intercellular junctions of the growing layer of the epidermis. Euchromatin dominates in the nuclei signifying the activity preservation of the epitheliocyte nuclear apparatus. The fibroblasts, which are characterized by the developed protein synthesis apparatus and insignificant mitochondria distortions, predominate in the cells of the papillary dermis. The nuclear contours are regular and a lot of granules of the ribosomal origin can be seen in the nuclei. But destabilization and destruction of the plasma, nuclear and organic membranes are present episodically in some cells; heterochromatin is predominant in the nuclei signifying the reduced function.

The morphologic investigations have proved that lyophilized xenoderm grafts developed and manufactured by our enterprise are not significantly different from the xenoderm grafts before the conservation. (Figure 1, 1a)

Fig. 1. Stratified epidermocyte placement is preserved concerning regular basal membrane. Basophilic nuclei, vacuolization of separate cells.

Fig. 1а. The microscopic organization of the basal layer epidermocytes. Desmosomal junctions are preserved; Intercellular spaces are significantly widened. Moderate karyolemma invaginations and homogeneous nuclear karyoplasm, the destruction of the separate organelles.

1. THE INDICATIONS FOR THE LYOPHILIZED XENODERM GRAFTS

Lyophilized porcine xenoderm grafts are used as temporary skin substitutes in the treatment of the burns (II-III AB, IV degree), donor and scalping lesions, trophic ulcers.

At the application of xenoderm grafts in the complex therapy of the patients with burns the general state of the patients, their sleep and appetite improve; the body temperature is normalized; the deficiency of the homeostasis indices is reduced; the indices of the blood serum toxicity are decreased; the epithelization of the superficial burns, boundary and insular epithelization of the deep burns is accelerated leading to the decrease of the granular lesions by 23%. The hospitalization of the patients is reduced to 16-18 days; the mortality of the major burn patients is reduced by 30 %.

The number of the lyophilized xenoderm grafts necessary for the skin coverage depends on the surface area, depth of the burns and the age of the patient. (Table 1).

Table 1

The number of the lyophilized xenoderm grafts necessary for the treatment of the burn patients depending on the age of the patient

№

Age

The necessary number of the lyophilized xenoderm grafts (cm2) at the burn surface area 1 %

Infants

6 months - 2 years

2-3 years

4-5 years

6-8 years

9-13 years

110

14 years <

180-220

2. THE PREPARATION OF THE APPLICATION OF THE LYOPHILIZED XENODERM GRAFTS

2.1. Before the application of the xenoderm grafts, the package integrity and the expiration date stamped on the package are checked.

2.2. In the dressing or operating room, the package is antisepticised with the special burn solution and incised; the xenoderm grafts are removed from the package and placed in the container with warm physiologic solution (15-20ºС) with the antibiotic for 10-15 minutes taking into account wound microflora susceptibility.

2.3. The xenoderm grafts are taken out from the container; 4-6 perforations of 100 cm2 are performed on them with a scalpel; the grafts are applied to the clean wounds with the epidermal side upwards; the wounds are wrapped with antisepticised gauze pads and fixed with a dressing.

3. THE APPLICATION OF THE XENODERM GRAFTS

3.1. Superficial burns (ІІ-ІІІА degree)

After the patient hospitalization and hemodynamic stabilization, the wounds are antisepticised at narcosis in the clean dressing or operating room. The skin around the burn is debrided and cleaned with antiseptic solutions – iodine, povidone-iodine, chlorhexidine, dexane. In case of significant contamination (home or industrial dust, soot, smut), the burn area should be sprinkled with antiseptic sterile solutions. After the wound antiseptics, most II degree burn areas are likely to be covered with the perforated lyophilized xenoderm grafts. It relieves the graft modulation at joint areas. The wound epithelization under the lyophilized xenoderm grafts terminates on the 10-12 days. (Figure 2)

Fig. 2 The wound epithelization (46 %) under the lyophilized xenoderm grafts

In case of III degree burns the skin dermal layer undergoes partial necrosis (the vital sebaceous and sudoriferous glands and their excretory ducts are preserved), creating preconditions for wound suppuration caused by the development of the pathogenic microflora in the necrotically changed superficial skin tissues. To create the conditions for the active insular and marginal epithelization with the application of the preserved skin derivatives it is necessary to debride the wound and to conquer wound infections. Thus, sequential (superficial) necrotomy and the wound coverage with lyophilized xenoderm grafts have to be performed to the patients with IIIA degree burns during the early stage after the trauma (2-3 days) (Fig. 3). It prevents the burn disease development, accompanied complications, the scar formation and frequent painful dressings and also promotes wound healing.

Figure 3 III degree burns. The performance of the early necrotomy (the 2^nd day after the trauma).

The xenoderm grafts are closely applied to the skin, resulting in the improvement of the patient’s general state, significant reduction or liquidation of the pain syndrome, the body temperature normalization.

The first dressing is applied the next day after the tangential and sequential necrotomy with xenoplasty. The following dressing are applied daily or once in two days respectively depending on the character of engraftment. When hematomas or accumulated purulent discharge occur under the xenoderm grafts, the grafts are removed, the wound is cleansed and the new xenoderm grafts or wet to dry drying dressings are applied. On the 8-9 day after the trauma the xenoderm grafts dry up at the ends of the wound; the graft rejection and the epithelization of the wound surface are observed. In the other areas of the wound the xenoderm grafts are closely fixed to the adjacent tissues.

On the 11-12 days the xenoderm grafts thicken and fall off. The wound surface is covered with well-developed epithelial regenerator. (Fig. 4)

Thus, the application of the lyophilized xenoderm grafts in the treatment of the surface burns shortens the patient hospitalization (from 6 to 8 days), reduces the risk of the hypertrophic and keloid scar formation by 38%

Fig. 4 The wound epithelization under xenoderm grafts (12 day after the trauma).

Taking into account that the number of patients with ІІ-ІІІА degree burns makes up 70 % of all the burnt, the application of the lyophilized xenoderm grafts allows to avoid painful daily dressings, promotes wound healing, prevents wound purulence, facilitates the course of the disease without the loss of proteins, water and electrolytes. The expenditures on the purchase of the lyophilized xenoderm grafts are less than those on the purchase of ointments, bandages, solutions, narcotic drugs etc. Thus, the described treatment method is said to be not only clinically but also economically efficient.

3.2. Deep burns (ІІІB-IV degree)

The deep burns can be treated with the application of the early necrotomy or without it.

3.2.1. The application of the early necrotomy

The final aim of the local treatment of the deep burns lies in operative restoration of the burnt cutaneous covering. The early surgical interventions fully correspond with the principles of the preventive surgery. During surgical interventions, necrotic tissues are removed tangentially or perifascially on the area up to 10-15 % of the body surface; the formed wounds are temporarily covered with the lyophilized xenoderm grafts that are removed in 2-3 days and after additional necrotomy the wounds are covered with the autodermal grafts

The repeated interventions are performed in 2-3 days. Afterwards daily dressings are applied at narcosis and xenoderm and autodermal grafts are cleansed on the wounds.

The application of the lyophilized xenoderm grafts allows to increase the area of the one-phase removal of the necrotic tissues, to reduce the traumatism of the interventions, to detect the areas of the incomplete debridement and it also creates conditions for quick compensation of the postoperative homeostasis violations.

Additional debridement of the unvital tissues promotes better autodermal engraftment. The application of the early necrotomy with xenodermoplasty prevents progressive intoxication of the lesion focus and the development of the wound infection, reduces the possibility of the burn disease development and promotes skin restoration within a short time.

Fig. 5 The ІІ-ІІІAB degree burn of the left side of the trunk, upper extremity, 26 (18) % of the body surface. Early necrotomy. Xenoplasty. Autodermoplasty.

3.2.2. The treatment of the deep burns without the application of the early necrotomy

The main task of the burn treatment is the preparation of the burn lesions to autodermoplasty. Spontaneous necrotic tissue rejection lasts 4-5 weeks. The presence of the specially wet eschar on the burn and the wound microflora vegetation (frequently as gram-positive or gram-negative flora) often lead to the burn complications

The deep burns are treated without the application of the early necrotomy in the late evacuated patients with purulent wounds and also in the patients with the complicated disease course and accompanied diseases that limit the application of the early necrotomy.

After the chemical and phased necrotomy and deep wound debridement the autodermoplasty is performed. During the autodermoplasty the wounds that remain uncovered with the autodermal grafts, donor wounds and perforated autoskin grafts are covered with the lyophilized xenoderm grafts.

Fig. 6 IIIB-IV degree burns, 70 % of the body surface. Auto- and xenoplasty.

The xenoderm grafts can remain fixed up to 2,5-3,5 weeks. The application of the lyophilized xenoderm grafts reduces pain syndrome, plasma loss and the frequency of the wound purulence.

At the same time the granular tissue with the cells of the histogenic and haematogenic origin (fibroblasts and histiocytes) ripens under the xenotransplants.

The hypertrophy of the protein synthesis structures and energy exchange are detected microscopically in the fibroblast cells. (Figure 7).

Fig. 7 The ultrastructure of the active fibroblast and the formation of the intercellular substance components of the connective

After the xenoderm grafts removal autodermoplasty can be performed (Figure 8).

Fig. 8 ІІІ B – IV degree burn wounds after the xenoderm grafts removal. The 14^th day after xenoplasty. The granular tissue is well manifested.

Simultaneously with the granular tissue formation the wound surface is epithelized more actively; the local epithelization in the form of wide cell growth from the preserved skin derivatives occurs together with the marginal epithelization (Figure 9). It promotes reducing the wound surface due to the absence of the secondary wound deepening and necrosis and intensifies the marginal and insular epithelization of the deep burn lesions under the xenoderm grafts.

Fig. 9 ІІІА-B degree burns covered with the xenoderm grafts. The 12^th day after xenoplasty. Active proliferation of the epitheliocytes in the preserved hair follicles and sebaceous glands. The formation of the epidermal layer on the wound surface.

3.3. The coverage of the donor lesions

The xenoderm grafts are efficiently used in the treatment of the donor lesions. Thus, there is no necessity in dressings. The epithelization of the donor lesions under the xenoderm grafts occurs on the 6-8 day. So the application of the xenoderm grafts in the coverage of the donor lesions promotes faster epithelization ((4±1) day) and if necessary earlier autotransplant removal for the recurrent plasty.

3.4. The coverage of the perforated autodermal grafts

The perforated autodermal grafts on the wounds can be covered with the xenoderm grafts. There is no need to remove xenoderm grafts during dressings; the epithelization of the wounds in the autografts occurs under the xenoderm grafts. After the complete wound epithelization between the membranes of the perforated autodermal grafts, the xenoderm grafts dry out and fall off.

3.5. The treatment of the scalping lesions and trophic ulcers.

Clean scalping lesions and trophic ulcers are covered with the xenoderm grafts. The reduction of the inflammatory process, the activation of the marginal and insular epithelization promoting wound self-healing can be observed under the engrafted xenoderm grafts. When the lesion area is big, the xenografts have to be substituted with the autodermal grafts on the 7-8 day (the local blood circulation in the wound is the best during this period).

3.6. The treatment of the lesions after the scar cryodestruction

Cryotherapy

Indications: persistent scars in phase of

heighten over the skin, keloid scars.

Onetime 30 sec freezing by liquid nitrogen of hypertrophy and colloid scars

Action

n physical depressing 2 nd stage of wound process

n Activation of functional activity of fibroblasts

n remodel zing of extra cellular matrix (collagen 1 type)

On the 2 day after the cryodestruction, the area (the serous cyst and the skin around it) is cleaned with antiseptic solutions – iodine, povidone-iodine, chlorhexidine, dexane; the serous cyst is removed; the wound is dried up with the sterile pads and the lyophilized xenoderm grafts are applied.

On the 6-7-8 day after the procedure, the drying of the xenoderm graft at the wound edges, its rejection and complete epithelization can be observed. The period of the epithelization depends on the size of the lesion formed after cryodestruction

Fig. 10 Posttraumatic keloid scars. The cryodestruction with the further xenoplasty.

HOME CARE MANAGEMENT

The client with severe bums is often discharged from the acute care setting when life-threatening complications are resolved and minimal wound areas remain open. During the initial weeks at home after discharge, the client usually continues to require at least daily wound care, rehabilitative therapy, nutritional support, symptom management, and drug therapy.

Although the client usually views the prospect of going home in a positive light, the difficulties associated with physical care and the psychological stresses associated with changes in appearance, role, function, and lifestyle are numerous and may overwhelm the client and family. Successful discharge depends on extensive planning and preparation of the client, family, and home environment through education and the involvement of appropriate support agencies and services.

Preparation for discharge includes assessment of the family and home care situation from physical and social perspectives. The nurse considers the needs of the client when evaluating the environment for cleanliness; access to bathing facilities, electricity, and running water; stairways; number of occupants; temperature control; and safety. If the bum injuries are a result of a fire at home, a new residence may need to be established.

HEALTH TEACHING

Education about burn care and living with the consequences of burn injuries begins when the client is admitted to the hospital or bum center. A weekly plan for client education is outlined; the primary goal is progression toward independence for the client and family. Critical for this goal is teaching clients, family members, or significant others to perform specific care tasks, such as dressing changes. Clients and family members first observe the nurse changing the dressings, then assist in performing the changes, and finally change the dressings independently under the supervision of the bum care nurse.

Before discharge, all people who will be involved in the client's home care participate in discharge planning and teaching sessions. In addition to details about dressing changes, the nurse or doctor explains the following:

• Signs and symptoms of infection

• Medication regimens

• Proper use of prosthetic and positioning devices

• Correct application and care of pressure garments

• Comfort measures to reduce pruritus

• Dates for follow-up appointments

IMPAIRED PHYSICAL MOBILITY

INTERVENTIONS. Interventions aim to maintain the client's preburn range of joint motion and prevent contracture formation.

NONSURGICAL MANAGEMENT. Nonsurgical management includes positioning, range-of-motion exercises, ambu-lation, and pressure dressings.

POSITIONING. Positioning is critical for clients with burn injuries because the position of comfort for the client is often one of joint flexion, which predisposes him or her to the development of contractures. Care is taken to maintain the client in a neutral body position with minimal flexion.

Splints and other conforming devices may assist in maintaining position. These devices are used most frequently on the joints of the hands, elbows, knees, neck, and axillae.

RANGE-OF-MOTION EXERCISES. Range-of-motion exercises are performed actively at least three times a day. If the client cannot move a joint actively, the nurse performs passive range-of-motion exercises. Burned hands are given special attention. The client is encouraged to perform active range-of-motion exercises for the hand, thumb, and fingers every hour while awake.

AMBULATION. Ambulation is started as soon as possible after the fluid shifts have resolved. Clients with a variety of attached equipment (IV catheters, nasogastric tubes, electro-cardio graphic leads, extensive dressings) can ambulate with preparation and assistance. Ambulation is performed two or three times a day and progresses in length each time. Ambulation inhibits the loss of bone density, strengthens muscles, stimulates immune function, promotes ventilation, and prevents a wide variety of complications.

PRESSURE DRESSINGS. After the graft heals, pressure dressings are implemented to assist in the prevention of contractures and tight hypertrophy scars, which can inhibit mobility. These dressings also inhibit venous engorgement and edema formation in areas with decreased lymphatic outflow. Pressure dressings may be elastic wraps or specially designed, custom-fitted, elasticized clothing that provide continuous and uniform pressure over burned surfaces. Figure 2 illustrates such garments. For maximal effectiveness, pressure garments should be worn at least 23 hours a day, every day, until the scar tissue is mature (12 to 24 months). Pressure garments generally cause an increase in warmth and itchiness and often are seen as very uncomfortable by the client. The nurse must reinforce to the client that wearing pressure garments is extremely beneficial in maintaining mobility and reducing hypertrophy scarring.

Figure 2 Models wearing pressure garments. (Courtesy Beiersdorf-Jobst, Inc., Charlotte, NC.)

Besides special silicon plates could be used with the same aim for the prevention and treatment of postburn scars and contractures (read below).

More detail about pressure therapy of scars and contractures below.

DISTURBED BODY IMAGE

PLANNING: EXPECTED OUTCOMES. Following intervention, the client with a burn injury in the acute phase is expected to have a positive perception of his or her own appearance and body functions as evidenced by a willingness to touch the affected body part, adjustment to changes in body function, a willingness to use strategies to enhance appearance and function, a successful progression through the grieving process, and the use of support systems.

INTERVENTIONS. Nonsurgical and surgical interventions can assist clients who experience body image disturbances as a result of burn injury.

NONSURGICAL MANAGEMENT. Understanding the stages of grief is helpful for the client, family. It has to be assessed which stage of grief the client is currently experiencing and helps interpret his or her behaviors. The client often is unaware of or is confused by his or her feelings. Feelings of grief, loss, anxiety, anger, fear, and guilt are normal. The client may be grieving the loss of body parts, appearance, role identity, and social identity.

It has to be accepted the physical and psychological characteristics of the client. Clients and families are presented with realistic expected outcomes for the client's functional capacity and physical appearance. Information sessions and counseling for the family or significant others can identify previous and current patterns of support that are effective for the client and family.

Engaging in decision making and independent activities fosters feelings of self-worth, which are closely linked to body image. To this end, it has to be planed and encouraged the client's participation in self-care activities. Family members are assisted in understanding that it is more beneficial for the client to perform these activities than to have them performed by someone else. Families are encouraged to include the client in family decision making to the same degree that he or she participated in this process before the injury.

SURGICAL MANAGEMENT. Reconstructive and cosmetic surgery can be performed for many years after the burn injury. Restoration of function and improvement of physical appearance through surgical techniques often increase the client's feelings of self-worth and promote a positive body image. Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state.

Instructions for Patients

Do's and Don'ts:

Do eat at diet high in calories and protein: take a multivitamin until all wounds are closed
Do continue your physical therapy at home
Do wear a hat and long sleeves while in the sun: always wear sunscreen
Do keep all follow up clinic and physical therapy appointments
Do wear pressure garments 23 hours a day to help reduce scaring
Do change all dressings once daily or as directed
Do call for any signs or symptoms of infection: severe chills or fever, excessive pain, redness, swelling, or new drainage, odor at the site of the burn dressing
Don 't go in the sun without sunscreen and coverage
Don 't pick or scratch at your wounds. This may cause bleeding and infection
Avoid strenuous activity, driving, heavy lifting, and contact sports until cleared by doctor
Don 't wear tight fitting clothes that may rub against burn areas and cause friction blisters and skin damage.

IV. References:

Essential reading:

1. http://intranet.tdmu.edu.ua/data/kafedra/internal/zagalna_surgery/classes_stud/комбустіологія/медичний/6%20курс/english/reconstructive%20surgery.htm

2. Green's operative hand surgery—6th ed. / [edited by] Scott W. Wolfe, Robert N. Hotchkiss, William C. Pederson, Scott H. Kozin, 2011.

3. Siemionow, Maria Z.; Eisenmann-Klein, Marita (Eds.) Plastic and Reconstructive Surgery—1st Edition., 2010, XVIII, 778 p.

4. Siemionow, Maria Z. (Ed.) The Know-How of Face Transplantation—1st Edition., 2011, XVIII, 494 p.