What is skin grafting? [ Hot oil burns, second ( 2nd) degree deep and third ( 3rd ) degree burns, a discussion on skin grafting]

Dear doctor,

My husband suffered burns to his arm from hot oil and he was admitted in the hospital for treatment.

He was given first aid, painkillers ,antibiotics, and the wound was dressed with a white cream(silver sulphadiazine), Now it is three weeks after the burn and though most of the areas have healed, a small patch still remains about 5cm x 6cm, which looks red and refuses to heal. The attending surgeon feels that a skin transplant is needed.

He seems very busy and has not given us a good idea about this procedure. Doc, could you please tell us more.. Is it safe?? What happens if we don’t do it?

Thanks for your time,

Lucy.

Dear Lucy

Thank you very much for the letter. Am sorry to hear your husband suffered a burn.

Hot oil burns are a serious affair, since oil when heated can reach temperatures of more than 200 degree Celsius compared to boiling water. The burns are therefore often deep, sometimes 3rd degree. It will also depend on the time of contact and temperature of the oil itself.

In your husband’s case, it appears that only a small part has been a third degree burns, as the rest of the areas have already healed in two- three weeks. The red area of this unhealed burn wound appears to be area which has no skin. The body tissue cells and blood vessels grow within it forming ‘granulation tissue’. 

Wounds heal by two ways-

A) The remnants of skin element within the wound itself grow and form new skin

B) If no skin elements are present within the wound, the skin cells at the edge of wound multiply and slowly corner the wound.

Small tiny wound can heal like this but big wounds may never heal or heal very slowly. Leaving a large non healing wound open for a long time can lead to infection spreading to the whole body. Besides even when they heal they form a lot of scar tissue which can be troublesome. Scars can be painful, itchy and even restrict movement, especially when they from across a joint leading to ‘contractures’. The picture below shows a young unfortunate lady who suffered deep 2nd degree and third degree burns and ended up in scars and contractures.

Hence wounds which are unlikely to heal by themselves must be supported by bringing in new skin – a procedure called ‘skin grafting’. The grafted skin must also be of adequate size replacing the lost skin or otherwise again hypertrophic scars,  keloid scars and contractures may result.

What is skin grafting?

Skin grafting is a surgical procedure where the skin is taken from one part of the body and applied over another area where there is no skin.

The part from which it is taken is called the ‘donor site’ and the part or wound over which the skin is applied is called the ‘recipient site’

Doc, if you take the skin from the donor site won't it leave a wound?

Well, the skin has two layers- the dermis and the epidermis and there are two ways to take a skin graft:

a)    Full thickness skin graft

b)    Split thickness graft

By full thickness we mean both the epidermis and the dermis layers- This means that the donor area will have no skin and therefore either it must be closed, sutured or stitched primarily, otherwise  you may have to apply another split skin graft over it. Sometimes when large areas of full thickness skin is needed then the donor area may be expanded by a tissue expander where a silicone balloon is inserted under the skin and slowly expanded by filling saline water.

When the adequate size is reached the balloon is removed and the extra stretched skin is used as a skin graft. By this technique we get extra skin from the donor site.

By split thickness or partial thickness we mean a graft which has epidermis and small part of dermis. Here the donor area can heal on its own as part of the dermis is still left behind (usually two weeks)

Doc, what sites can be used on a skin graft?

Technically any site can be used as a skin graft.

In burn patients with major burns sometimes we even take skin from the scalp, foot and hands as there is shortage of unburnt skin.

Usually the preferred donor sites are the unexposed areas of the body like the thighs and buttock since they are covered by normal clothing. But one can take skin from the legs, abdomen, chest and back areas. The burn surgeon must discuss all these options with the patient before planning a skin graft procedure as different patients will have different ideas and needs.

Doc, how is the skin graft taken?

Skin grafts are taken depending on what types of grafts are needed and how big an area is to be covered. In major burns large skin pieces are needed and therefore split skin grafts are preferred, Here the donor area usually heals in 2 weeks. These split skin grafts are taken either manually using a blade - called the humby knife, or by an electric dermatome   that is motorized and helps to take skin grafts. For small skin grafts the silver blade or knife is good and can be used. Experienced surgeons can manage to take small grafts even with the regular humby knife. The picture below show the humby knife and the Aesculap  (division of the B. Braun Melsungen AG) ( http://www.bbraun.com/ ) electric dermatome that is often used to harvest skin grafts.

Doc, my three year old son has a bad burn on his hand from an electrical socket shock. The surgeon feels he has to do a skin graft procedure. Can I donate skin from my body to my son, he seems so fragile and I don’t want the doctor to create another injury on his body. Will this work permanently?
nigella
Goa

No, this is a temporary procedure as we are not doing a skin transplant but a skin graft.

In organ transplant procedures like the kidney transplant or liver transplants, the tissues are matched so that no rejection occurs and immunosuppressants (medications used to reduce our immune reaction so that the foreign donor organ is not rejected) are freely used to prevent rejections.

However in skin grafting a donor matching is not done and medications are not given therefore once this skin from the mother is applied, it stays on and provides some temporary cover. Sometimes the burn wound underneath may heal if the burn is not very deep. Otherwise one will have to get a skin graft procedure done again, this time the skin from the same individual has to be used if we must have a permanent graft.
Skin grafts from live humans are taken only in exceptional cases as we have other alternatives.

Animal skins from the pig (porcine skin grafts) are also used in the same way. Similarly (Cadaver skin) skin from cadavers (Human dead bodies) is also used as temporary covers. These skins are often taken and stored in skin banks by aseptic techniques.

The cadaver from which the skin is harvested must be free from HIV, hepatitis and other communicable diseases otherwise the recipient stands the risk of getting these diseases.
 Skin substitutes like 'Integra' is another option.

Doc, what about the donor site, how long does it take to heal?

Well, the donor site from where the graft is taken usually heals in about 2 weeks. If the donor site is not soaked with discharge then the dressings need not be changed. However if one suspects infection or finds excessive soakage of the dressing then it should be changed. Some pain is expected but routine painkiller medications are adequate. Once healed, the donor site may take time to get back its original skin color. Also one has to use moisturizers as the new skin will need some support till it regains all its functions and direct sunlight over the site must be avoided to prevent hyper pigmentation.

The video below shows a hand of a patient who suffered 2nd degree deep burns and third degree burns and needed a skin grafting procedure. The video shows how full function of the hand can be achieved after skin grafting which is very important for the patient though this may not be possible all the time and will depend on the burn damage.

(an original article from @asktheburnsurgeon+)

Doc, what is a cryogenic burn?

 ( Liquid nitrogen burns, cryogenic liquid burns, liquid propane, hydrogen, methane, liquefied natural gas, aerosol sprays, R22 Chlorodifluromethane gas- air conditioner and refrigerant gas, liquid ammonia burns, frost bite, cold burns++…..)

Cryogenic liquids  are gases that are liquefied at very low temperatures and high pressures. In their liquid state they are extremely cold (-150 deg C) and small quantities of liquid can expand to large volumes of gas. When these liquids are converted to gases or vapors they condense the moisture in the air and create a visible fog. Some cryogenic liquids are flammable when converted to gas like: hydrogen, methane and liquefied natural gas, while others are inert like nitrogen, helium, neon, argon and krypton. Other cryogenic liquids include liquid ammonia, propane, aerosol sprays and R22 Chlorodifluromethane gas that is used in refrigerators and air conditioners. Cryogenic liquids are stored in special containers that are able to withstand varying temperature and pressure changes.
 
Cryogenic liquids are dangerous and should be handled with great care. They can cause injury due to their extremely low temperatures by producing skin and tissue changes similar to a thermal burn. The nature of the injury will depend on the temperature, time of exposure and the chemical constituent of the cryogenic liquid itself. The eye has delicate structures like the cornea which can get severely damaged by contact as well as by the cold vapours. Sudden contact with cryogenic liquids can cause the skin to stick to the metal that is cooled by the liquid and trying to pull away the skin can cause a skin tear. Another mode of injury occurs by breathing the cold gases and vapours which can cause lung damage. Small amounts of cryogenic liquid can turn into very large volumes of gas when warmed or released into air. These cold gases are heavier than air and displace the air thereby reducing the oxygen available to the victim who may then suffer from asphyxiation or oxygen deficiency which can be fatal especially in closed spaces. The chemical nature of the cryogenic liquid can itself add to the danger. Some of them are flammable like liquid oxygen and fires and explosions can result. Non combustible substances like carbon, cast iron, aluminium and steel can burn in the presence of liquid oxygen. Sudden change of temperatures and rapid expansions can lead to dangerous explosions and blast injuries.

When liquid propane is sprayed on the skin for 12 seconds epidermal damage or necrosis can occur. Similarly the spraying of aerosols on the skin for 20 seconds can result in temperature of -150 deg centigrade. The initial appearance depends on the depth of the burn and the cold temperatures reached and the time of exposure. Thus the burn may be superficial or deep and if deep may even extend to the underlying muscles and bone. For identifying the depth of burn please refer to our previous article: http://asktheburnsurgeon.blogspot.com/2009/11/1.html

Cold burns or frostbite must receive medical attention as early as possible. First aid treatment must be aimed at getting the temperature slowly back to normal. The victim must be first removed from the site of the accident to a safe zone and all tight clothing must be loosened. The burn area should be placed in tepid water (40-42 deg c) or one can pour tepid water over the area for about half an hour or till the skin returns back to pink or red color. Water temperatures above 45 deg c can itself cause a burn to the tissues and therefore direct heat or hot water must be avoided. Arrangement should be made to shift the patient to the nearest casualty department. If a large area of the body has been exposed to the cold injury then hypothermia or lowered body temperature may result which can be fatal. The body needs to be rewarmed without much delay. One can place the patient in a warm water bath (40-42 deg C). Monitoring the patient is important as shock or circulatory failure may result. As the frozen tissues are thawed, cellular disruption, swelling and edema can occur. Analgesics should be given to avoid pain and antibiotics must be added to decrease the chance of infection. The burn wound from a cryogenic liquid will have to be treated like a thermal burn wound.
Here we present a cryogenic burn from liquid nitrogen suffered by one of our readers Mr Carlos Martinez . The events that followed over 4-5 weeks have been described in detail by Mr Carlos. We hope that this story will be helpful to our readers in handling such unusual burns.



Week one..
Mr Carlos wrote....
Dear doc,
I was testing a Nitrogen system a couple of days ago and got into a pool of it with both my feet for a few minutes. I thought there was only gas but it was actually liquid Nitrogen. When I felt some pain I jumped out of it and couldn't make a clear assessment to what happened. After a couple of minutes of walking (I was only wearing socks) a sudden shock of pain hit me. It was excruciating. I felt dizzy and almost passed out. We searched what to do on the Internet but couldn't find anything related with this extreme cold, only frostbite. I put my feet in warm water waiting for the doctor to arrive.

He told me he hoped it was only a superficial wound but it remained to be seen after 24 hours. We waited. The result is clear and you can see it in the attached pictures. After a bit more than a day, the doctor excised most of the blisters, since more were not fully formed and treated the wound with a closed dressing, using a sterile gauze soaked with Argentafil. Pain was bearable now, especially after the excision. The day after, he removed the dressing and, in some small spots, it adhered to the profusely exuding wound that's been moist since skin removal and is still exuding clear and fresh serum. More blisters are forming slowly in places where everything seemed OK. He removed more skin today and dressed the wound with Acticoat after immersing the film in sterile water for two minutes, added a pad of gauze to keep it in place and a larger and thicker apposite of gauze and cotton. The wounds (sorry, both feet were burnt but with very different sizes of wounds) are still exuding clear serum through the Acticoat dressing. He also brought a different film from a different manufacturer. He wants to try it after nine days (when Acticoat is used completely).

The pain after removing the first dressing was huge where I felt it sort of adhered to the wound, and it happened on both feet. The dermis underneath is pink or reddish. There is more skin to be removed, maybe some 10% of the whole wound, especially the very edges of it that go about 1cm above the sides of the soles that are just starting to blister.
That's the story, now the questions:
My doctor is not a traumatologist or dedicated to burn patient but has treated a lot of diabetic foot wounds (smaller ones). Should I find a specialist?
He's a good surgeon and did the job really fast since the first day. Is he doing the right treatment?
As for healing: will it be 3 to 4 weeks to recover functional skin on my feet. (this I ask because of the super intense stress our feet are subject to)
Should I do anything else?
How can I minimize the intense pain from dressing removal? (I am concerned because I feel I'm passing out when the procedure is done)
Thanks a lot for being there for us and your time for reading this. I suppose there's a lot to be said on cryogenic burns since the Internet (and most physicians) know very little about them.

Best Regards,
Carlos M. Martinez

asktheburnsurgeon replies.....
Dear Mr Carlos,
Thank you very much for your letter. I am sorry to hear you had a burn. What you have is a like a frostbite or a cold burn that is similar to a thermal burn. Since liquid nitrogen is at very low temperature the burn can be a deep one. The back of the heel appears to be on the deeper side. the one on the side appears to be less deep. You are lucky that the area is small. Blistering usually is a sign of a superficial 2nd degree burn.
About your concerns here are a few points: your doc is doing fine. Continue with the debridements as and when required. Continue with you dressings as is being done. If the pain is not very severe then regular pain killers may be adequate, but if the pain is severe while the dressing is done, your doc may give you some intravenous medications. If signs of infection are found then an antibiotic may be needed. Check out our article: http://asktheburnsurgeon.blogspot.com/2010/01/management-of-2nd-degree-superficial.html
for the basics of wound care and pain management. The back part of the heel burn which now appears to be red needs a good follow up. and if it appears to be really deep then you may need a skin graft there. Still the heel skin is quite thick, as compared to the skin of the other areas of the body, so keep you fingers crossed and pray that the wound may heal without the need for any surgery. We will have to wait and continue with the present treatment till the depth of the burn manifest itself over time. Burn healing takes time!!
best regards
asktheburnsurgeon+

week 2..
Carlos Martinez writes again....
Dear doc,
Thanks a lot for your response. Tomorrow I'll go through surgical removal of dead skin and debridement. We'll replace the Acticoat dressing.
I have a couple more questions:
One of my toes has a blister but everything seems evolving as a normal second grade burn: should we remove all the skin there or just let it drain and treat it as a small wound?
Second: can Aquacel AG do the function of Acticoat for 14 days? We read that Aquacel can be doing its job as it gets integrated with the fluids and is not necessary to have dressing removals every four days as with Acticoat.
I infer it's a better strategy to cause less trauma to the wounds on every redress and it avoids going under anesthesia so often.
I'll keep you posted and I'll pray for the heel wound not to evolve badly. Personally I really appreciate your words and concern for my case. I should've been a Doctor myself! I've done this so many times for others and feel a bit lost when it comes to myself!
Best regards and 1000 thanks again,
Carlos


asktheburnsurgeon replies....
dear Carlos,
thank you very much for keeping me updated. It is nice to know that you are doing fine.

Aquacel is a hydrofibre dressing that is highly absorbent and locks in exudate and at the same time provides a moist environment for wound healing .While Aquacel Ag is  the same but has silver ions impregnated in them that gives an additional antimicrobial activity.
http://www.convatec.com/en/cvtus-aqcdrwsbus/cvt-portallev1/0/detail/0/1441/1836/aquacel-dressing.html
Acticoat consist of Silver coated high density polyethylene meshes designed to be barriers against microbial infection of a wound. It also has a Rayon/polyester absorbent inner core which helps to maintain the moist environment that can facilitate wound healing. The silver provides additional antimicrobial activity.
http://global.smith-nephew.com/master/ACTICOAT_27517.htm

 The small blisters can be punctured or slit open to let the fluid out as other wise with the blisters getting tense pain can result. Keeping a burn wound closed for a long time is not a good idea especially if its deep. If there is a lot of oozing of serous fluid, the whole wound and skin around can get very soggy and may even get infected. Besides you don’t even know whats going on down in the wound. So changing the dressing at least by 3 or 4 days should be a better idea in your case.
best regards,
asktheburnsurgeon +

week 3..
Mr Carlos writes again....
Dear doc,
Thanks a lot for the input. I'm sending you some other photos as of the day before yesterday. Tomorrow, all Aquacel AG will be replaced. There are no odors or strange smells, just a small bleeding spot at the very bottom of the right heel. The instructions in the Aquacel AG say they should be left on for three days at the beginning, and when the wound seems to be re-epithelizing, the dressings could be left for up to 14 days. Should we change dressings every 2-3 days? Is the bleeding spot strange? My surgeon seems to be pretty happy with the evolution, but I'm concerned about that spot and now about the dressings! The wounds have been progressively drying as new skin grows, there are only small spots of still-fresh wounds that were revealed a couple of days ago after removing the remaining blistered skin. It seems that the silver coming from the dressings keeps the infections at bay, but I don't want to risk it all just to that idea, even when the left foot wound has evolved amazingly well.
Thanks a lot again for your time and input!
Hope the photos come in handy to better assess the injury.
Carlos

asktheburnsurgeon replies..
dear Carlos,
thank you very much for your letter. I am glad to know that you are doing well. As new epithelium forms sometimes you can get small bleeding since the capillaries are also newly forming- these being delicate can easily bleed, especially when you are changing the dressing. As the wound gets better and as the fluid discharge from the wound decreases the Aquacel Ag dressing can be kept for a longer time. The silver ions help the combat the microorganisms causing infection.
With best regards,
asktheburnsurgeon+

week 4....
Carlos Martinez writes again...
Dear doc,
I feel really blessed, indeed. Every thing's dried up and new skin is almost everywhere. No more fluids at all, except for a small bleeding from a blood scar a few days ago: clear and iron smelling red stuff. There are just two very small spots with these kind of scars. I'm working on stretching the new skin and using light pressure to make it more supple.
I do thank God for all these things and for all the people who have been helping me with their support, their knowledge and their commitment. I must give back a lot after this thing ends. My sight is on the 7th floor of our Civil Hospital. It's the Burn Center for Children. I owe you at least three. I'll send in the pics after Friday's assessment. I hope they'll be good news. I just can't go tiptoeing forever!
Thanks a lot again!
Carlos

asktheburnsurgeon replies...
Dear Carlos,
Thanks for the update.
You seem to be doing fine by God's grace.
Change the dressing more frequently if the discharge is too much or smelly.
Besides that, we have to wait and watch the healing process.
best regards,
asktheburnsurgeon+

week 4....
Carlos writes again...
dear doc,
OK!!!
I'm still tiptoeing, since my toes were just little less than scalded -and just a couple of them, both balls of my feet are healthy: I can go to the washroom and take a shower without much fuss.
What I don't have the slightest idea about is how to assess when should I try to put my weight on the much more damaged heels and the right side of the right foot... I feel there's still some scar tissue to come out on itself and new epithelium to emerge, but these spots are the ones that feel pretty tight still.
Tomorrow will be the most revealing day, I hope. I'll keep you posted and have my fingers still crossed and lots of people praying for me... I'm trying to bounce these to the thousands who suffer terrible wounds everyday.
And... thanks again!
Carlos

week 4 …
asktheburnsurgeon replies....
dear Carlos,
good to hear you are feeling and doing fine. praise God!!
burn wound healing always takes time and one must have patience.
let the burn areas heal completely before you try exercising as the new delicate skin may break up and avoid any weight bearing on the healing areas.
best wishes,
asktheburnsurgeon+

 week 5.....
Carlos writes again....

Dear doc,
here's how the wound feels presently:
1. itchy if scabbing (very tolerable)
2. Extremely sensitive to the touch or dressing contact (sort of a cautionary pin-point pain spot) on the very edge of the heels and the larger tender (or scab) spot there
3. There are some spots that are almost insensitive but with good blood flow on two toes
4. I've been exercising by flexing both feet and now everything seems looser, except for the tight spots where scabbing occurred.
Just one more question: how long can it take the skin to bear weight?
Cheers and thanks again!
Carlos

week 5..
asktheburnsurgeon replies....
Dear Mr Carlos,
Thank you very much for the mail and keeping me updated. You seem to have done very well by God's grace. I was worried in the beginning since cryogenic burns can be deep and some of the ones i have treated needed skin grafting !!
To answer your question about weight bearing:
Once the wounds have healed, avoid direct weight bearing for two weeks.
Then gradually start bearing some weight on the foot. see how its going and then gradually increase the weight bearing. If the skin starts to break down or appears unhealthy avoid this. Usually it takes about 6 weeks before one can be back to being completely normal.
best regards,
asktheburnsurgeon+ ++

week 1- liquid nitrogen burns, heel, foot burns (cryogenic burns,
cold burn, frost bite)



week 1- liquid nitrogen burns, heel, foot burns (cryogenic burns,
cold burn, frost bite)





week 2- liquid nitrogen burns, heel, foot burns (cryogenic burns,
cold burn, frost bite)





week 2- liquid nitrogen burns, heel, foot burns (cryogenic burns,
cold burn, frost bite)



                                                             



week 3- liquid nitrogen burns,  acquacel dressing (cryogenic burns,
heel, foot burns, cold burn, frost bite)





week 5- healed liquid nitrogen burns, heel, foot burns
(cryogenic burns, cold burn, frost bite)



week 5- healed liquid nitrogen burns, (cryogenic burns,
heel, foot burns, cold burn, frost bite)



week 5- healed liquid nitrogen burns, (cryogenic burns,
cold burn, frost bite)