Acute Management: Tangential Excision and Skin Grafting



Acute Management: Tangential Excision and Skin Grafting


Yvonne L. Karanas





ANATOMY



  • Burns and traumatic injuries can result in partial-thickness and full-thickness injuries. These terms refer to the depth of the injury into the skin.


  • Partial-thickness injuries involve the epidermis and some portion of the dermis.


  • Full-thickness injuries involve the epidermis and the entire dermis and can even include the subcutaneous fat.


PATHOGENESIS



  • Full- or partial-thickness skin necrosis may occur with trauma, burn injury, and severe soft tissue infections.


  • There are approximately 486 000 burn injuries per year in the United States with 40 000 requiring hospitalization.2


  • Worldwide, the magnitude of the problem is even greater.


NATURAL HISTORY



  • Burns or traumatic injuries may initially appear as superficial injuries, but with time (72-96 hours), they may progress to full-thickness injuries.


  • Judicious early debridement and serial wound care preserve all viable tissue while preventing wound infection.


  • When the wound evolution is complete, areas of full-thickness and partial-thickness burns should be clearly delineated. Definitive surgical treatment may then be performed as needed.


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Full-thickness injuries may present as white, yellow, or brown leathery, insensate areas that lack capillary refill. With time, they will progress to a black eschar (FIG 1).


  • Partial-thickness injuries may be superficial with pink, moist, sensate tissue that has capillary refill.



    • Deep partial-thickness burns may be cherry red in color, lack capillary refill, have decreased sensation, and may be dry. These burns are often described as “indeterminate thickness” as it is often unclear initially whether they will require surgical treatment or not.


    • Burns and traumatic injuries may result in wounds that are a combination of different depths of injury (FIG 2).


NONOPERATIVE MANAGEMENT



  • Partial-thickness burns may be managed with wound care alone.


  • In general full-thickness skin, necrosis requires surgical treatment. It may be managed conservatively in select situations, for example, small wounds that are less than 1% TBSA on the torso. A large burn is commonly defined as a burn greater than 20% TBSA.






    FIG 1 • Lower extremity full-thickness necrosis from a severe soft tissue infection.







    FIG 2A. Contact ankle burn with second-degree and third-degree components in a paraplegic patient. B. Flame burn to the thigh with mainly third-degree burns and small patches of second-degree burns.


  • Wound care may be performed once or twice daily with silver sulfadiazine to soften and debride the eschar and prevent infection. Eventually the eschar will separate from the underlying wound bed; however, this process may take weeks or even months and lead to poor scarring and contractures.


  • For large wounds, an expectant management strategy carries a high risk of wound infection.


  • Surgical treatment remains the standard of care for large full-thickness wounds.


SURGICAL MANAGEMENT


Preoperative Planning



  • Equipment for Tangential Excision



    • Watson Knives (FIG 3A)


    • Weck/Goulian Knives (FIG 3B)


    • Epinephrine solution


  • Equipment for Skin Grafting



    • Dermatome electric or air powered



      • Guards of different widths (FIG 3C)


    • Mineral Oil


    • Tumescent solution: I L crystalloid, 1 cc (1:1000) epinephrine, 0.25% Marcaine (30 cc)


    • Klein Infiltration Pump—allows for high-volume infusion of tumescent solution in a rapid fashion


  • Tangential excision is performed using a variety of knives designed for this purpose, or a dermatome may be used.


  • The choice of instrument is based on the location of the wound and the size and thickness of the eschar. Small burns or burns in delicate areas such as the hands, face, or feet are excised with a Weck knife. Larger, thicker burns on the extremities or trunk are excised with a Watson knife. The depth of the excision can be set by adjusting the guard on the Weck knife or on the Watson knife itself.


  • The Weck knife has three guards that can be placed over the blade to control for the depth of excision: 0.012, 0.010, and 0.008 in. The selection of the thickness of the excision is based on the surgeon’s perception of the depth of the wound and the thickness of the skin in that region. The narrower guards of the Weck knife are used for less deep burns and areas of thin skin such as the dorsum of the hand, foot, or nose (FIG 3D).

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Nov 24, 2019 | Posted by in Aesthetic plastic surgery | Comments Off on Acute Management: Tangential Excision and Skin Grafting
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