RU2622979C1 - Method for surgical treatment of deep skin defects - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: 17-22 days after injury, granulating wound bottom surface is formed, for which the granulation tissue is cut to a depth of 1-2 mm parallel to the outer skin surface with a dermatome and a scalpel. Hemostasis is performed. Then, the skin is cut out with a fringing incision perpendicular to the wound surface formed by a scalpel, retreating to 0.5-2.0 cm from the wound edge. Next, plastic is prepared with a pre-prepared whole full-layer free skin autograft, with the size corresponding to the wound.

EFFECT: method allows to create conditions for engraftment of a single full-layer free skin autograft onto a granulating wound, to reduce the risk of autograft retraction and scar development in the postoperative period in the zone of transition to the healthy skin, to ensure qualitative elimination of the defect, and to achieve a good cosmetic effect.

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Description

The present invention relates to medicine, namely to plastic surgery, and can be used when performing skin autoplasty.

Surgical treatment of deep burns and wounds comes down to two main types of operations. The first of these involves the removal of dead tissue (necrectomy). The second is the restoration of lost skin. Dead tissue (scabs) are the cause of intoxication and microbial inflammation. Completely get rid of these undesirable consequences allows only the early removal of the scab, which accelerates the preparation of wounds for plastic closure (Paramonov B.A. et al. Burns: A Guide for Doctors. - SPb., 2000. - 489 p.).

Free skin grafting for wound defects is performed with thin (split) and thick (full-layer) autografts. Thin grafts have the following advantages: quick healing of donor sites; easy to take large sizes; almost always take root. The disadvantages of plastic thin grafts are: cosmetically defective; wrinkles; and in some places cannot protect the underlying tissues. Thick grafts have advantages: the cosmetic effect is superior to that obtained with thin grafts; in appearance it is very close to normal skin; tendency to contracture is minimal; transplanted to the entire thickness of the skin serves as sufficient protection for the underlying tissue. The main disadvantage of plastic surgery with a thick graft is that the chances of engraftment of a thick graft on a granulating surface are negligible (Dzhanelidze Yu. Yu. Free skin grafting. - Medgiz., 1952. - p.).

An analogue of this application is a method of free skin grafting with a split autograft taken by a dermatome described by Movchan K.N. et al. (The possibilities of apitherapy in the provision of medical care to victims of burns. - St. Petersburg: IIC VMA, 2007. - 256 p.). The method involves performing autoplasty with a split skin graft taken by a dermatome. When granulation is formed with an electrodermatome, grafts are cut from intact skin areas 0.2-0.3 mm thick. Most often, for the donor sites, the front, back and outer surfaces of the hips, legs, shoulders, and forearms are used. In functionally active zones, in the absence of a shortage of donor resources, plastic surgery is performed with whole grafts. With a noticeable shortage of donor resources, mesh transplants with a perforation ratio of 1: 2 - 1: 4 are used. Transplants placed on movable sites are fixed with separate sutures to the edges and bottom of the wound, and if necessary, are fastened together.

The main disadvantages of this method are:

1. The development in the postoperative period of scar tissue.

2. The need to use several grafts, with the development of scars in the joints.

3. Self-epithelization of marginal border burns with further development in this area of scars.

As the closest analogue, the method of plastics according to Parin was adopted, described by J. Zolton (Skin transplant. - Budapest, 1984. - 304 p.). The perceptive bed should be small in aseptic conditions (after excision of scars of various localization). First, a model of the receptive bed is made, which is superimposed on the graft site and circled with a section that penetrates to the base of the dermis. The graft is taken onto the holder, with the help of this holder the surgeon spreads the graft on his finger or roller and takes the graft to the subcutaneous tissue. Then, from the inside, on the graft, the scissors excise the excess dermis and subcutaneous tissue with scissors and hem the wound defect. Apply pressure dressings. The donor site is sutured with interrupted sutures.

The disadvantages of this method are:

1. The inability to take a large autograft due to the need to suture the donor site.

2. Poor engraftment on the granulating wound, and in this regard the need for repeated operations.

3. The presence in the postoperative period of scars in the area of the joints of the grafts and the marginal zone of transition to healthy skin.

Tasks:

- improve the method of treatment of deep skin lesions;

- eliminate tissue scarring in the transition zone between autoplasty and healthy skin;

- to improve cosmetic results in the postoperative period by using a whole full-layer free skin autograft.

The essence of the invention is the following: the bottom surface of the granulating wound is formed with a dermatome and a scalpel parallel to the outer skin surface to the lower layers of granulations, thereby creating conditions for the engraftment of a full-layer skin autograft, then the wound edges are excised perpendicularly to the surface with a scalpel and 0.5-2.0 cm perform the wound with a pre-prepared whole full-layer free skin autograft corresponding to the wound size.

Technical result: the method allows to create the conditions of engraftment of a full-layer free skin autograft on a granulating wound due to excision of the upper layers of granulation tissue. Due to excision of the wound edges, the risk of autograft retraction and the development of scars in the postoperative period in the zone of transition to healthy skin is reduced. The whole full-layer skin autograft, formed adequately to the damage to the patient’s skin, allows for the qualitative elimination of the defect, i.e. achieve a good cosmetic effect.

The implementation of the method of surgical treatment of a skin defect is as follows. After cleansing the wound from necrosis (scab) with a deep burn or wound, as a rule, 17-22 days after injury, when granulation tissue is formed, in the operating room, standard preparation and processing of the surgical field is performed. The upper layers of granulation tissue are excised with a dermatome and a scalpel in parallel to the skin surface to a depth of 1-2 mm in depth, to the lower layers of granulation tissue, with the condition that no subcutaneous fat is exposed. Make hemostasis, pressing the wound with dressings with a solution of adrenaline for 3-5 minutes. Then, with a scalpel, a bordering incision perpendicular to the skin surface, departing from the wound by 0.5-2 cm to healthy skin, the skin is dissected, thereby delimiting the zone of possible marginal cicatricial growth from areas of marginal epithelization. Then, with a scalpel perpendicular to the dissection of the skin in the direction from the wound to the edge of the healthy skin, the tissues are excised in the corners of the wound, thereby forming a parallel border of the autograft to fit to healthy skin. A parallel border allows plastic surgery according to the laws of plastic surgery: dermis to dermis, epidermis to epidermis. A whole full-layer free skin autograft is taken from healthy skin areas with a size equal to a defect, autodermoplasty is performed, and dressings with an antiseptic are applied. The wound is tightly bandaged in 5-7 rounds with a medical bandage. After 3-5 days, the condition of autografts is visually assessed by the first ligation. The engraftment of skin grafts is noted, as a rule, by 7-9 days.

According to this method, in clinical conditions GBUZ "Research Institute - Regional Clinical Hospital No. 1 named after Professor S.V. Ochapovsky "Ministry of Health of the Krasnodar Territory operated on 27 patients with deep burns and wounds, during 2010-2015.

The results of treatment with an assessment of the main functional and cosmetic indicators:

Example 1. Patient G., 60 years old, was admitted to the burn department. GBUZ-NII KKB№1 named. prof. S.V. Ochapovsky March 30, 2010 with a diagnosis of Thermal burn (flame) of the face, neck, trunk, upper limbs, buttocks, thighs 21% IIIB-IV Art. Burn of the upper respiratory tract. Burn disease in the stage of septicotoxemia. Hypertension 3 tbsp. risk 4. The main stages of treatment and plastic surgery with a full-layer free skin autograft are presented in Appendix 1 in Fig. 1-8. Upon admission on the 3rd day after the injury from the area, there was a deep burn of the face, with the formation of a scab (Fig. 1). 22 days after the injury, under general anesthesia (mechanical ventilation), on a face wound 28 × 17 cm in size (Fig. 2). The upper layers of granulations are excised with a scalpel and dermatome (Fig. 3). A wound was formed with the lower layers of granulations without exposure of subcutaneous fat (Fig. 4). 0.5-1.0 cm apart from granulations and around the oral cavity, nasal passages, and eyes, a bordering incision was made with a scalpel, then the wound edges and marginal epithelization were dissected from the inside of the wound to healthy skin. Nodal sutures were placed on the eyelids of both eyes with performing bloodless blepharography for 12-14 days for optimal adaptation of autoplasty and prevention of eversion of the eyelids. Hemostasis. A whole full-layer free skin autograft 17 × 28 cm in size was taken from the left thigh and placed on the face wound (Fig. 5). Slots for the mouth, nasal passages, eyes are formed in it. In these areas and on the border with healthy skin, sutures were applied according to the rules of plastic surgery: dermis to dermis, epidermis to epidermis (Fig. 6). Operation time 5 hours. Plastic surgery was performed with an integral free full-layer skin autograft (Fig. 7). Tile dressings with antiseptic solution on the face, pressure dressings applied. The result of the operation after 1.5 years (Fig. 8). During 4.5 years of follow-up, scar tissue does not form due to plastic surgery with a whole free full-layer skin autograft.

Example 2. Patient S., 2 years old, was admitted to the burn department. GBUZ-NII KKB№1 named. prof. S.V. Ochapovsky 03/22/2012 with a diagnosis of Thermal burn (flame) of the face, trunk, upper and lower extremities, buttocks 51% (51%) IIIB-IV Art. Burn of the upper respiratory tract. Burn disease in the stage of septicotoxemia. 20 days after the injury, under general anesthesia (mechanical ventilation), with a scalpel and dermatome on the face wound 15 × 24 cm, the upper granulation layers were excised to a depth of 2 mm. 0.5-1.0 cm away from the granulations and around the oral cavity, nasal passages, eyes, a bordering incision was made and the wound edges and marginal epithelization were excised. Nodal sutures were placed on the eyelids of both eyes with performing bloodless blepharography for 12-14 days for optimal adaptation of autoplasty and prevention of eversion of the eyelids. Hemostasis. With a scalpel on the anterior abdominal wall, a whole free full-layer skin autograft was taken. A free skin autograft 15 by 24 cm, 0.5-0.7 mm thick, is placed on the face wound. Slots for the mouth, nasal passages, eyes are formed in it. In these areas and at the border with healthy skin, stitches have been stitched. Dressings "tiled" with a solution of antiseptic on the face. Pressing bandages. In the future, on the first ligation on day 5, the adaptation of the autograft is good. Extract after 3 weeks from the operation. Within 3 years of observation, scar tissue does not form, there are no indications for reconstructive operations.

Claims (1)

A method for the surgical treatment of deep skin defects, including autotransplantation, characterized in that after 17-22 days after the injury, the bottom surface of the granulating wound is formed, for which parallel to the outer surface of the skin with a dermatome and scalpel, granulation tissue is excised to a depth of 1-2 mm, hemostasis is performed, then, with a scalpel, the skin is excised perpendicularly to the wound surface with a bordering incision, departing by 0.5-2.0 cm of the wound edge, then plastic is performed with a pre-prepared whole, full-layer with Rim skin autograft size corresponding to the wound.

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