RU2702303C1 - Skin graft sampling method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, combustiology and plastic surgery. Performing preoperative skin marking, skin and subcutaneous fat dissection with a fringe incision on the abdomen, separation of the skin graft from the donor bed, haemostasis, degreasing and thinning from the inside of the skin graft, plastic closure of the donor wound. Skin is taken around the umbilicus. An additional enclosing incision of the skin and subcutaneous fat surrounding the umbilicus is performed. Skin is cut out by a single unit and all adipose tissue to be applied under the skin graft to a superficial fascia, and a hole from the umbilicus formed during skin grafting is further placed above the natural physiological orifices of the face – eye or mouth slit, nasal passages.

EFFECT: method enables sampling a full-thickness skin graft with an umbilicus defect in the presence of a deficit of unaffected skin areas of the required size, providing localization of the donor site in an inconspicuous region, perform autoplasty of full-layer skin graft of aesthetically significant areas of body with available natural physiological holes, reduce risk of purulent-septic complications due to single-stage plastic wound closure of donor site, improve functional and aesthetic results of surgical treatment.

1 cl, 2 ex, 17 dwg

Description

The present invention relates to medicine, namely to surgery, combustiology, plastic surgery, and can be used in patients who require skin plastic surgery of wounds with a full-layer skin autograft.

The modern possibilities of combustiology make it possible to successfully treat victims with deep burns on an area of more than 50% of the body surface. With large areas of burn lesions, an urgent aspect of treatment is the rational use of skin donor resources. With extensive burns, restoration of the skin with continuous grafts is often not possible. Plastic surgery with whole autografts in such cases is performed only on parts of the body that are important in functional and cosmetic respects (Burns: A Guide for Doctors / Edited by B.S. Vikhriev and V.M. Burmistrov. - L .: Medicine, 1981. - P. 158). When choosing a free skin transplant, it is necessary to take into account that the tendency of full-layer grafts to secondary retraction is less compared to split ones (Azolov VV, Dmitriev GI Surgical treatment of burn consequences. - N. Novgorod: Dzerzhinsky Printing House OJSC, 1995. - S. 42, S. 57), and therefore it is preferable to use full-layer skin grafts on functionally and aesthetically significant parts of the body.

An analogue of the alleged invention is a method for plastic surgery with a full-layer skin graft. (Kazarezov M.V., Koroleva A.N., Golovnev V.A. Contractures. - Novosibirsk: Novosibirsk State Medical Academy, 2002. - P.119). Using a dermatome, a flap of the required size is taken over the entire thickness of the skin, and the resulting defect is replaced by a split flap. As a result, the engraftment of both skin flaps takes place.

The disadvantages of the method include:

1. The insufficient size of a full-layer skin graft, the width of which is limited by the technical characteristics of the dermatome (up to 10 cm).

2. The need to take several skin grafts to close large wound defects, followed by scarring along the lines of joints (areas of adjoining grafts to each other).

3. Technical difficulties or the inability to take a full-layer skin graft with a dermatome in the navel area in the absence of donor resources in other areas.

4. The decrease in the results of the engraftment of split skin grafts on the donor wound after taking a full-layer skin graft to subcutaneous fat.

As the closest analogue, we have adopted a method for taking a skin autograft (Bogdanov SB, Babichev R.G., RF patent for invention No. 2618166, application No. 2016103838 dated February 5, 2016, published on May 2, 2017, Bull. No. 13). The method includes performing a model of the receiving bed under aseptic conditions, applying the model to the place of autograft grafting, stitching the graft on the holders and separating it from the tissue, performing a skin incision to the upper layers of subcutaneous fat, the fragments of which are then removed using scissors, and from the dermis the graft is aligned with a dermatome, with a layer excision of 0.1 mm, while the total thickness of the graft is formed in 1.0-2.0 mm If necessary, cuts are formed in the whole full-layer skin autograft (for the mouth, nasal passages, eyes). After 3-5 days, at the first dressing, the growth of granulations in the donor site is evaluated; after 5-10 days, when granulation tissue is formed, plastic closure of the granulating donor wound is performed with split skin grafts 0.2-0.3 mm thick.

The disadvantages of the method include:

1. The risk of accidental perforation of a full-layer skin graft when it is separated at the level of the upper layers of subcutaneous fat, which will subsequently lead to the formation of a rough scar in the area of perforation and significantly worsen the aesthetic result of skin grafting.

2. The inability to perform simultaneous plastic closure of the wound of the donor site, because the result of the engraftment of skin grafts when transplanted to subcutaneous fat is significantly worse.

3. The need to perform skin plastic surgery of the donor site is delayed after maturation of the granulation tissue, which requires additional treatment for wounds of the donor site and increases the risk of purulent-septic complications.

4. The proposed method does not indicate the possibility of taking a full-layer skin graft on the stomach with an already existing defect from the navel, which is important in patients with a deficit of donor resources.

Tasks:

- to improve the technique of taking a full-layer skin graft;

- to optimize the use of skin donor resources by taking a full-layer skin graft of the required size with a defect from the navel in an inconspicuous (closed clothing) area;

- provide conditions for simultaneous plastic closure of the wound of the donor site;

- reduce the risk of purulent-septic complications during the collection of a full-layer skin graft;

- to improve the results of surgical treatment for skin grafting with a full-layer skin graft of aesthetically significant areas with existing natural physiological holes.

The essence of the invention, including preoperative marking of the skin, dissection of the skin and subcutaneous fat with a bordering incision on the abdomen, separation of the skin graft from the donor bed, hemostasis, degreasing and thinning from the inside of the skin graft, plastic closure of the donor wound, is as follows: skin is taken around the navel perform an additional bordering incision of the skin and subcutaneous fat around the navel, excise the skin and all the skin underneath the skin graft with a single block fiber to the superficial fascia, and the hole from the navel formed during the sampling of the skin graft is further placed above the natural physiological holes (eye or mouth gap, nasal passages).

Technical result: this method allows the collection of a full-layer skin graft with a defect from the navel in the presence of a deficiency of unaffected skin areas of the required size, to ensure localization of the donor site in an invisible (closed clothing) area, to perform autoplasty with a full-layer skin graft of wounds of aesthetically significant sites. bodies with existing natural physiological holes (on the face), reduce the risk of purulent-septic complications due to simultaneous plastic closure of the wound of the donor site, improve the functional and aesthetic results of surgical treatment.

The implementation of the method of sampling a skin graft is as follows. After standard preparation and processing of the surgical field on the abdomen, preoperative marking of the skin is performed, indicating the borders of the skin graft and the excision of the skin around the navel to further locate this defect in the skin graft above the 'natural physiological openings. Using a scalpel along the lines of the preoperative marking, the skin and subcutaneous fat are dissected, i.e. perform one bordering incision along the outer edge of the graft, and the other bordering incision around the navel. The graft to be grafted is taken on the stitches-holders. Next, the skin graft is separated from the donor bed, excising the skin and all the fatty tissue under the skin graft to the superficial fascia with a single block. They make hemostasis and plastic closure of the donor wound with split perforated skin grafts, aseptic dressings are applied. The skin graft is degreased and thinned from the inside with scissors and a dermatome. Perform surgical treatment of facial wounds, hemostasis. The prepared full-layer skin graft is placed on the treated face wound in such a way that the navel hole formed during the skin graft sampling is located above the natural physiological holes (eye or mouth gap, nasal passages). According to the testimony, the skin graft is additionally dissected over other natural physiological holes, after which the skin graft is fixed with sutures and bandages are applied. On the 7th day after the operation, the engraftment of split skin grafts was observed on the donor site of the abdomen; on the 9-11th day, the engraftment of a full-layer skin graft on the face was observed.

According to this method, 6 patients with deep thermal burns of the face were operated on under clinical conditions.

Example 1 (see Appendix 1). Patient S., 44 years old, was admitted to the burn department of GBUZ "Research Institute - KKB No. 1 named after prof. ST Ochapovsky "with a diagnosis of thermal burn (flame) of the face, trunk, limbs of 28% I-II-III degree, burn disease. After performing staged necrectomy on the face on the 23rd day after the injury (Fig. 1), the patient was taken to the operating room. After standard preparation and processing of the surgical field on the abdomen, preoperative marking of the skin was performed, indicating the boundaries of the skin graft and the excision of the skin around the navel to further locate this defect in the skin graft above the right palpebral fissure. A scalpel along the lines of the preoperative marking was used to dissect the skin and subcutaneous fat, i.e. one bordering incision was made along the outer edge of the graft, and the other bordering incision was made around the navel. The graft to be cut was taken on the stitches-holders. Next, the skin graft was separated from the donor bed by excision with a single block of skin and all the fatty tissue under the skin graft to the superficial fascia. Hemostasis and plastic closure of the donor wound with split perforated skin grafts were performed, aseptic dressings were applied. The skin graft was defatted and thinned from the inside with scissors and a dermatome. Surgical treatment of facial wounds and hemostasis was performed (Fig. 2). The prepared full-layer skin graft was placed on the treated face wound in such a way that the navel hole formed during the skin graft collection was located above the natural physiological hole (right palpebral fissure), after which the skin graft was fixed with sutures (Fig. 3) and applied dressings. On the 7th day after the operation, the engraftment of split skin grafts on the donor abdomen was observed; on the 10th day, the engraftment of a full-layer skin graft on the face was observed (Fig. 4).

Example 2. Patient A., 9 years old, was admitted to the burn department of GBUZ "Research Institute - KKB No. 1 named after prof. ST Ochapovsky "with a diagnosis of thermal burn (flame) of the head, neck, trunk, buttocks, limbs 41% I-II-III degree, thermo-inhalation injury, burn disease. After performing staged necrectomy on the face on the 21st day after the injury (Fig. 5), the patient was taken to the operating room. After standard preparation and processing of the surgical field (Fig. 6), a preoperative marking of the skin was performed on the abdomen (Fig. 7), marking the borders - the skin graft and the excision of the skin around the navel for the further location of this defect in the skin graft above the nasal passages. A scalpel along the lines of the preoperative marking was used to dissect the skin and subcutaneous fat, i.e. one bordering incision was made along the outer edge of the graft, and the other bordering incision was made around the navel (Fig. 8). The graft to be cut was taken on the stitches-holders. Further, the skin graft was separated from the donor bed by excision with a single block of skin and all the fatty tissue under the skin graft to the superficial fascia (Fig. 9). Hemostasis and plastic closure of the donor wound with split perforated skin grafts were performed (Fig. 10), aseptic dressings were applied. The skin graft was defatted and thinned from the inside with scissors and a dermatome (Fig. 11). Surgical treatment of facial wounds and hemostasis was performed (Fig. 13). The prepared full-layer skin graft (Fig. 12) was placed on the treated face wound (Fig. 14) so that the navel hole formed during the skin graft collection was located above the natural physiological holes (nasal passages), after which the skin graft was fixed sutures (Fig. 15) and bandages were applied. On the 7th day after the operation, the engraftment of split skin grafts in the donor abdomen was observed; on the 10th day, the engraftment of a full-layer skin graft on the face was observed. The patient was discharged on the 63rd day after the injury after complete recovery, damaged by a burn of the skin and the healing of donor wounds. We observed complete engraftment of a full-layer skin graft on the face without a tendency to retraction (Fig. 16) and a satisfactory condition of the restored skin on the donor abdomen (Fig. 17).

Claims (1)

A method of collecting a skin graft on the abdomen, including preoperative marking of the skin, dissection of the skin and subcutaneous fat with a bordering incision on the abdomen, separation of the skin graft from the donor bed, hemostasis, degreasing and thinning from the inside of the skin graft, plastic closure of the donor wound, characterized in that skin is taken around the umbilicus, an additional bordering incision of the skin and subcutaneous fat around the umbilicus is performed, the skin and all the skin underneath are excised with a single block ozhnym adipose tissue graft to the superficial fascia, and formed with a hole fence skin graft from the navel subsequently positioned over the natural physiological holes face (eye or mouth slit, nasal passages).

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