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Saturday, February 6, 2010

Plastic Surgeon

I write, am not a writer,
I paint, am not a painter,
I mould, am not a sculptor,

I perform, am not an artist,
I cook, am not a chef,
I stitch, am not a tailor,

I think, am not a philosopher,
I plan, am not a strategist,
I direct, am not a manager,

I am, what I am,
The human body,
I cut and sew,

Endowed by a gift,
Bestowed on few,
Thank you, lord almighty!


Friday, February 5, 2010

Management of 2nd degree burns (deep), Skin grafting

My son burnt his hand while playing with a fire cracker and the doctor says he has a 2nd degree deep burn and will need new skin (skin grafting). Can you please explain what all this means?
Mrs. S Kempinsky+

Thank you Mrs. Kempinsky for your question. I am sorry your son has a burn that appears like a deep 2nd degree burn. Before I discuss this question, to understand 2nd degree deep burns as well as its management, please see my previous articles as links on the right side:
1) Degree of burn
2) Management of 2nd degree superficial burns

The picture on the right (fig 1) shows the right hand of a gentleman who suffered flame burns over the fingers and the dorsum of the right hand. You will notice that the epidermis or the outer layer of the skin has peeled off or removed over the dorsum of the hand. The fingers still have part of the epidermis which is dead and falling off. The dermis is exposed on the dorsum of the hand –
1) It appears pale
2) Non blanching (becoming pale on pressure).
3) There is some small dark blood stained area in addition.
4) There are no hair follicles.
5) However this burn area is not charred, hard, dry, leathery as in a 3rd degree burn.
This burn has all features of a 2nd degree deep burn which actually destroys the epidermis and the deeper layers of the dermis. Some dermis still survives.

Why is there no blanching on pressure?It does not blanch on pressure and appears pale because the superficial dermal vessels are damaged, burnt or coagulated.

Why is there less pain compared to a 2nd degree superficial burn?Pain is less because the superficial nerve endings are also damaged in the deep dermal burns.

Now look at the fingers- they are less burnt as compared to the dorsum of the hand and they have more features of a 2nd degree superficial burn (refer to blog on 2nd degree superficial burn to avoid repetition)

How do we go about this burnt hand?First of all this burn is to be handled by a burn professional (don’t treat him by surfing the web). The burn professional will handle these issues
1. Admission to ward
2. Pain
3. Infection
4. Care of the burn wound
5. Routine tests, splinting, physiotherapy, elevation of the hand.

Does he need to be admitted to the burn ward?
Well this is a deep 2nd degree burn of a critical area- the hand- if improperly treated will lead to loss of function of the hand. It is therefore important to admit this gentleman to the ward and treat him as an inpatient.

How do we manage pain?By using analgesics like paracetamol, ibuproffen, Diclofenac sodium, mafenemic acid, tramadol, morphine or pethedine- all depending on the severity of the pain, pain tolerance and other area of burns if present.

Should we use antibiotics?
This is a common question and the answer is simple. Should we inflate the air bag while going for a drive- fearing an accident?? (Sounds stupid!). Similarly we do not normally give antibiotics unless we see infection of the burn area or systemic signs of infection like fever, raised white cell count ,etc.

What we should do?1. Take a swab from the burn wound to culture and check for sensitivity if any organisms are present. This will give us a base line idea and a chance to use the correct antibiotic if infection should occur sometimes.
2. We do give antibiotics prophylactically when fearing an infection or anticipating an infection as in severe diabetic patients or immune compromised patients.
3. Do tell the doctor if you are allergic to any antibiotics.

How do we take care of the burn wound?
This again needs the burn professional. The nurse will clean the area with sterile saline solution. She will debride (cut out) all the dead epidermis and clean the burn wound thoroughly. She will then cover it with an ointment or cream.

Which ointment should I use?For a 2nd degree deep burn I often prefer flamazine (Silver sulphadiazine). It is soothening causes less pain and kills microorganism if present. One can use betadine solution or ointment (povidone iodine) which is good; kill’s microorganisms but sometimes the patient complains of pain more with the use of betadine.

What about Flammacerium?
Flammacerium has Cerium Nitrate Hexahydrate and Silver Sulfadiazine. After application it forms a hard shell over the burn area. When you change the dressing it is difficult to remove the shell completely. This is good when you are treating superficial 2nd degree burn and are sure that burn area will heal and not need any surgery. But in a burn as in fig 1 we know that it may not heal and will need to be reviewed on a regular basis. So avoid flammacerium in burns that will need to be regularly reviewed to decide about surgery or skin grafting.

It is good to put a layer of sofratulle or Vaseline gauze before you apply flamazine or betadine, this helps to prevent the gauze dressing from sticking to the burn wound and causing pain when you change the dressing the next day.
Use these layers over the burn wound
1. Sofratulle or Vaseline gauze
2. Flamazine/ Betadine
3. Gauze bandages
4. Crepe bandages

This is very important. Splinting will support the hand and maintain a functional position of the hand and cause less pain.

Should we splint the hand?

Why should we elevate the hand?Elevation of the hand by pillows or other support will help to reduce the edema (swelling) of the hand and relive pain and accelerate healing by increasing the circulation.

How often should we dress the wound?
Dressing the wound daily is a good idea in 2nd degree deep burns- if you wait longer they become soggy and foul – from all the discharge.

Does this hand need physiotherapy?

Definitely! We should start physiotherapy very early in burn patients- both active ( done by the patient himself) and passive movements ( movement assisted by other hand or by a therapist) should be encouraged, this will help to retain the movements of all joints and the functions of the hand, otherwise the joints will become stiff and it will delay the patient from returning to work.

What else will the burn surgeons do?
Well he will see if you have any additional illness which will hamper the wound healing or needs treatment while you are admitted in the ward such as diabetes, asthma and hypertension. He will ask for some investigations like
1. Complete blood count
2. Electrolytes- Na, K
3. Blood sugar
4. Blood urea
5. Serum creatinine
6. Liver function test
7. Serum Albumin
8. Serum protein
9. Chest X ray- this will serve as a base line especially if you have suffered smoke inhalation injury.
10. ECG if you are above 40 year.

Once all this has been done we come to the most important issue- will this burn heal??Yes by God’s Grace!

How will this burn wound heal?Well, to start with this is a 2nd degree deep burn( on the dorsum of the hand). The 2nd degree deep burn affects the deeper layer of the dermis (though not the whole dermis- as in 3rd degree burns). As the deeper layers of the dermis are destroyed- the hair follicles, sebaceous glands and the sweat glands are also damaged. It is therefore difficult for the new skin to form as the regenerative epithelial elements are damaged.

Will it never heal without surgery? Is the next question that the patient will ask.This burn wound may heal over a period of time- that’s how God made the human body. But when deep 2nd degree deep burns heal, the healing occurs with the formation of abnormal scar tissue (not normal skin). This scar tissue will have the following problems.
1. It will hypertrophy (become thick and large)
2. It will cause itching and pain.3. Most important it will restrict mobility and result in what are called contractures. I hope to explain scar / keloids/ contractures in a future blog.

The gentleman with the hand burn actually refused to undergo surgery and went home against medical advice. The picture on the right (figure- 2) shows his hand after 4 weeks when he came back to my clinic.
The burn on the fingers- which we diagnosed as 2nd degree superficial burns had healed, while the 2nd degree deep dermal burn on the dorsum of the hand failed to heal. It we wait further, the dead white tissue (eschar) seen will slowly disappear and will be replaced by raw red body tissue called granulation tissue that consists of body cells, fibroblasts and fine blood vessels( capillaries)- but no skin!

Now that we are convinced that the burn wound needs help to heal the answer is quite simple, if skin is damaged- replace it.

How can we replace damaged skin?By a simple procedure called skin grafting in which the skin from one part of the healthy body is removed and applied over the area lacking skin.

Can we use a person’s skin for another one?
This is a common question asked by mothers whose children are burnt. However this is not possible as it will only be a temporary measure and in about two to three weeks the skin will be rejected.

Doc, you guys are doing kidney and heart transplantation and you can’t do a simple skin transplant for my hand?
Well kidney and heart transplantations are highly complicated procedures and need lifelong immunosuppressives (drugs that will decrease your immune response so that the body will not reject the heart or kidney). These procedures can be fatal and one can die! Skin transplantation is neither feasible nor advisable in burns as of now. Presently, face transplantation is still in its infancy and not commonly done. Skin grafting is a simple procedure that does away with all these problems.

Do you take the whole skin?
No, only the part or upper layer of the skin. You know the skin has two layers- epidermis and dermis. In skin grafting we use a blade fixed to a device – called the Humby’s knife or an electric device called a dermatome and remove only epidermis and part of the dermis – called a split thickness graft. This will help the donor area of the body from which the skin graft has been taken to heal by itself in about two weeks. There will be some pain in the donor site which can be managed by analgesics like paracetamol, ibuprofen, mefenemic acid or injectables like pethedine or morphine depending on the pain tolerance and pain itself.

Figure 3 on the right shows the skin grafting of the right hand which has fully healed. The graft was taken from the thigh a common area as it is well hidden , but you can suggest the area that you want the graft to be taken from. The function is well maintained and the fingers can be flexed and extended. The problem of color match exists but they settle down over a period of time. Time is a great healer and burn surgeons as well as plastic surgeons rely on time a lot!!!!

So ms kempinsky I hope this answers your question and I wish your son a speedy recovery.

Wednesday, February 3, 2010

2nd degree burns (superficial) picture

Minor burns
Here a photograph of a child's hand is shown who suffered scald burns ( from hot water). The blisters have been deroofed and the underlying dermis is exposed which is pink and blanching. this is a second degree superficial burn similar to the one described before in detail. For a complete understanding and management of this burn read the article

watch out + for the next article on management of 2 nd degree burns (deep) !!!

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