In vitro effects of wound-dressings on key wound healing properties of dermal fibroblasts

Healing of complex wounds requires dressings that must, at least, not hinder and should ideally promote the activity of key healing cells, in particular fibroblasts. This in vitro study assessed the effects of three wound-dressings (a pure Ca2+ alginate: Algostéril®, a Ca2+ alginate + carboxymethylcellulose: Biatain alginate® and a polyacrylate impregnated with lipido-colloid matrix: UrgoClean®) on dermal fibroblast activity. The results showed the pure calcium alginate to be non-cytotoxic, whereas the other wound-dressings showed moderate to strong cytotoxicity. The two alginates stimulated fibroblast migration and proliferation, whereas the polyacrylate altered migration and had no effect on proliferation. The pure Ca2+ alginate significantly increased the TGF-β-induced fibroblast activation, which is essential to healing. This activation was confirmed by a significant increase in Vascular endothelial growth factor (VEGF) secretion and a higher collagen production. The other dressings reduced these fibroblast activities. The pure Ca2+ alginate was also able to counteract the inhibitory effect of NK cell supernatants on fibroblast migration. These in vitro results demonstrate that tested wound-dressings are not equivalent for fibroblast activation. Only Algostéril was found to promote all the fibroblast activities tested, which could contribute to its healing efficacy demonstrated in the clinic.

Dermal substitute: a safe and effective way in surgical management of adults post-burn dorsal foot contractures

OBJECTIVE

Neglected dorsal foοt burns may result in typical fοrefοοt defοrmities characterised by cοntractures leading tο hyperextensiοn οf the tοes and gait disturbance. These defοrmities usually cause a significant impairment in daily activities and difficulty in wearing shοes. This article presents a recοnstructiοn series οf severe fοrefοοt defοrmities by means of dermal regeneratiοn templates (also known as dermal substitutes) and split thickness skin grafts.

PATIENTS AND METHODS

We retrοspectively reviewed οur institutiοnal burn database from 2010 to 2020 focusing on all those dοrsal fοοt cοntractures treated with the use οf a dermal regeneratiοn template. The patients' demοgraphics, burn injury mechanisms, depth, lοcalizatiοn, surface, treatments and fοllοw-up were described.

RESULTS

Twelve patients underwent this prοcedure and the mean affected area was 75 cm2. The mean time between the dermal regeneratiοn template applicatiοn and the split thickness skin graft was 19.6 days. Just fοr one patient, an additiοnal skin grafting prοcedure was required. The mean fοllοw-up was 4.6 years. We did not register specific cοmplicatiοns at bοth the recipient (forefoot) and dοnοr sites (scalp). All patients were able tο wear shοes and walk after the procedure. Nο recurrence οf cοntractures were οbserved. All patients were satisfied with cοsmetic results, and they did not request any additiοnal prοcedure οf cοsmetic imprοvement.

CONCLUSIONS

The use οf the dermal regeneratiοn template can be cοnsidered as an extremely safe and efficient treatment οf severe post-burn fοrefοοt defοrmities.

Repair Of Palm Burns Of The Hand: A Contralateral Inner Arm Bag-Shaped Flap

Hands are one of the most often burnt parts of the body. Deep palmar burns are often the result of an electrical burn or a thermal burn from grasping a hot item. With a deep burn, joints, vasculo-nervous pedicles, tendons or bones can become exposed and lead to amputation. Different surgical repair methods are used depending on the area of the hand that is burnt. Most of the publications to date have described surgical techniques for dorsal hand burns. The abdominal bag-shaped flap is one of the main surgical techniques to cover dorsal deep tissue exposure. Bag-shaped flaps need time to achieve the vascular autonomy of the flap without any movement. Abdominal bagshaped flaps are particularly suitable for dorsal soft-tissue defects, while for palmar defects, it is an uncomfortable position to maintain for three weeks. A contralateral arm bag-shaped flap for palmar burns allows a comfortable position to be achieved as the upper burnt limb is positioned as if the patient has their arms crossed. Furthermore, as stated above, the contralateral arm bag-shaped flap has the advantage of allowing a flap to be used that is thinner than an abdominal bag-shaped flap. At the Saint Louis Burns Center, we recently treated two patients with deep palmar burns and deep tissue exposure. We performed a contralateral arm bag-shaped flap for both of these patients. In our experience, the use of the contralateral arm bag-shaped flap technique to cover palmar lesions resulted in favorable postoperative progression, with complete closure of the lesions, good functional outcomes, as well as other advantages such as a hidden scar at the donor site. This technique allows amputation of fingers to be avoided when pedicles, joints, or tendons are exposed and when the burnt area of the palm is extensive and no other flaps can be used.

Head and neck skin expansion: assessment of efficiency for the treatment of lesions in the lower half of the face

The treatment of sequelae for burns or other loss of perioral tissues is complex due to the site where they occur, its functional importance, and social and esthetic aspects. Functional consequences of burns to this area are cutaneous retraction and a lack of skin that can lead to an inability to close the oral aperture, compromising the provision of dental hygiene and intubation procedures. The aim of the present publication was to evaluate the efficacy of chin, labial and jugal cutaneous expansions for the treatment of perioral lesions and lesions of the lower half of the face in our retrospective series of patients. We collected data and photography from digital files for each patient. Proportion of scarred skin that could be treated by one or several expansion procedures was evaluated. The main outcome was the resection of 50% or more initial lesions. Side effects were assessed. Out of a total of 33 expanders, 28 were at the jugal level, 5 were chin expanders, and none were labial expanders. This equated to the inclusion of fourteen patients. The average percentage of the lesion that was removed after the perioral expansion protocol was 68.9% (40%-100%). 85% of patients had a positive outcome. 12% of procedures were complicated by hematoma, infection or prosthesis exposure. Each time that the lesional area could be fully (i.e. 100%) treated, only a single expansion was used. Head and neck expansion is the technique of choice for reconstruction of the lower half of the face and the horizontal part of the neck in terms of efficiency and safety.

Reconstruction Of The Burnt Nose Using A Carved Flap In Four Cases

Techniques for reconstructing nasal defects in burns are very limited because the surrounding scar tissue makes it difficult to use local flaps. The authors report their experience using the Converse scalping flap harvested from scarred skin, placed as a mass on the nasal area, then secondarily carved to shape the nose and covered by a skin graft. This is a retrospective study of 4 patients, 3 men and 1 woman, with an average age of 45 years, who were operated on between 1994 and 2013 using this technique for postburn nasal reconstruction. Patients had 45% burns on average. The flap was weaned from its donor site at the third week and the frontalis donor area grafted. Several months later, the flap was sculpted from the outside to the inside in the three dimensions, removing the scarred epidermal areas to restore the aesthetic units of the nose, which were grafted using a full thickness skin graft. The final aesthetic result of the nasal reconstruction was evaluated by the patient and the surgical team. The four nasal reconstructions were carried out to completion. Three were rated as 'very good' (75%) and one was rated as 'good' (25%). The Converse flap modification, referred to as the "carved flap", to reconstruct the burned nose is a reliable technique, possible on a scarred forehead with no additional donor site morbidity.

Electrical Burns and Late Spontaneous Artery Ruptures: About Three Cases

Electrical burns are responsible for arterial and venous thrombosis, as well as weakening of the arteries. Immediate or delayed arterial occlusions, secondary to the aggression of the intima, or aneurysms, secondary to the aggression of the media, sometimes lead to artery ruptures without any warning signs. Such ruptures may trigger a hemorrhagic shock whose period of onset is variable and unpredictable. We are presenting here three cases treated in our department for electrical burns, whose complications were marked by hemorrhagic shock, secondary to late artery ruptures, sometimes occurring several months following the event. These case reports required performance of emergency hemostasis in order to control sudden bleeding, with first approach being placement of a tourniquet at the base of the limb and/or a compression point. Through these cases, we thought it is crucial to closely monitor for a few weeks all patients who were victims of electrical injury, even more so if it was associated with a compartment syndrome of one or more limbs and high rhabdomyolysis, which seem to be predictive factors of late artery ruptures in our case reports.

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Chemical burns raise diagnostic and treatment issues because they have specific appearances and evolution. Our objective was to study the characteristics of chemical burns and to assess the quality of our treatment. This retrospective observational study examined the records of all patients admitted for chemical burns to the burn treatment center of Saint Louis Hospital in Paris from January 1, 1990, through December 31, 2015. During this period, 162 patients came to our center for chemical burn treatment. Most of them were men (67%). The majority of the burns were caused by alkalis (27%) and resulted from workplace accidents (29%). The average time before consultation was 5.36 days. The areas mainly damaged were the hands (36%) and the burn areas averaged 1.2% of the total body surface area (TBSA). Forty-eight patients had at least one deep patch. In total, 59 patients (36.4%) were hospitalized for an average duration of 4.18 days. Thirty-eight of them underwent surgery. Lastly, 92% of the operations had been anticipated from the first consultation. In our center, the population affected, the circumstances and the topography of our patients' burns were similar to the data from the literature. It appears that the principal specificity of our series is a very low body surface burned. This can be attributed to the prevention measures we have in France and underlines their importance. Only 8% of the patients who had surgery were underestimated or their burns became deeper secondarily. This number is lower than the data from other series.

Our 35 years' experience on postburn heterotopic ossification: A three-step treatment

Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January 1, 1979, and September 30, 2015. The mean age at the time of the burn was 43.3 years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8 months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2 recurrences of osteoma and 1 elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment - excision surgery, early rehabilitation, and antalgia - seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.

[Not Available]

The hands are the most commonly affected area in burn injuries and are involved approximately 80% of the time. Because of the thinness of the skin and superficial location of critical structures, the dorsum of the hand needs an optimal coverage to preserve maximum articular mobility and range of motion. The aim of this article is to detail the therapeutic alternatives to skin graft in cases of very deep burns on the dorsum of the hand, and to specify the indications. We reviewed all articles referenced on PubMed, and included all the original articles related to the management of acute burned hands and their different coverage techniques (dermal substitutes and flaps). We excluded articles that dealt only with skin grafting techniques, as well as articles about secondary management (sequelae and reconstruction). One hundred and sixteen articles were found and twenty of these were selected. Alternatives to full-thickness skin grafting are dermal substitutes (Alloderm®, Matriderm®, Integra®) and flaps. In cases of immediately usable autologous donor sites, the combination Matriderm® with a thin skin graft is preferred. Otherwise, we use Integra®. In cases of deep exposure of critical structures and doubtful vascularization quality on the wound, flaps can be discussed (cross-arm, abdominal wall flap…).

[Study of satisfaction concerning the navel after abdominal dermolipectomy with transposition: A report of 96 cases]

GOAL OF THE STUDY

The umbilicus has a major role in the aesthetics of the anterior abdominal wall. Many publications deal with abdominal dermolipectomies but few focus on umbilicoplasty. However, these are essential in assessing the aesthetic result. Umbilicoplasty in "aile de mouette" used in our service is reliable and easily reproducible. In this article, we evaluate the satisfaction of patients with abdominal dermolipectomy with this technique of transposition.

MATERIALS AND METHOD

In the plastic surgery department of the Saint-Louis Hospital in Paris, we carried out a retrospective study of patients undergoing abdominal dermolipectomy with transposition of the umbilicus, between 1 January 2012 and 31 December 2012. All patients were operated according to our technique of umbilicoplasty: disinsertion of the umbilicus in V, reinsertion of the umbilic in "aile de mouette", a degreasing periumbilical associated with a plication of the umbilical stem. The complications identified in patients medical records and satisfaction were assessed by a telephone questionnaire.

RESULTS

Ninety-six patients were included. No patient presented umbilical necrosis. The overall result of umbilical transposition was considered good to excellent for 92.7% of patients.

CONCLUSION

Umbilicoplasty in gull wing has many advantages: it is a simple, easily reproducible, reliable technique, the patients of which are for the most part very satisfied.

Burns caused by electronic vaping devices (e-cigarettes): A new classification proposal based on mechanisms

Introduction With more than 10 million of daily users, e-cigarettes encountered a great success. But in the past few years, the number of medical reports of injuries caused by the explosion of e-cigarettes has significantly increased. This article aims at reporting our series and reviewing the literature to propose a new classification based on the mechanisms of injuries related to e-cigarettes that can guide non-specialists and specialists in the management of these patients. Method We performed a retrospective review of our institutional burn database from June 2016 to July 2017 for injuries caused by or in the context of using an e-cigarette. The patients' demographics (age, gender), burn injury mechanisms, depth, localization, surface and interventions were described. Results Ten patients suffered from burns related to the use of e-cigarettes. The burns were located at the thigh (80%) and the hand (50%) with a mean surface of 3% of TBSA. Four different mechanisms could be described: Type A: thermal burns with flames due to the phenomenon of "thermal runaway", Type B: blasts lesions secondary to the explosion, Type C: chemical alkali burns caused by spreading of the electrolyte solution and Type D: thermal burns without flames due to overheating. These different mechanisms suggest specific surgical and non-surgical management. Conclusion Management of injuries sustained from e-cigarettes' explosions should be approached from the standpoint of mechanisms. Different mechanisms could be associated and should be considered in specific management.

Pressure guided surgery of compartment syndrome of the limbs in burn patients

Compartment syndrome is a serious complication of high voltage electrical burns, limb carbonization and deep circular burns with delayed escharotomy. Without treatment, ischemic tissue damage leads to irreversible necrosis. Treatment is emergency surgical decompression. The burned patient is usually not searchable and cannot always be readily examined because of bulky dressings; diagnosis of compartment syndrome is always hard to make. The pressure transducer used in central arterial catheters is easy available. We used it to measure pressure in muscular compartments. We measured compartment pressure three times at different depths in all cases of electrical burn, carbonization and deep circumferential burns with delayed escharotomy. We also took the pressure in the uninjured limb. The pressure assessment device was composed of a blood pressure transducer commonly used in arterial catheters for arterial pressure monitoring with three connecting branches. The first branch was connected to the 'arterial pressure exit' in the monitoring device. The second, an IV tube, was connected to one litre of physiological serum in a pressure bag inflated to 200 mmHg. The third, also an IV tube with a sterile extension cable, was directly connected to an 18G standard straight needle to be inserted in the tissues for which interstitial pressure had to be measured. In patients with thermal burns, we measured pressure before and after escharotomy. Threshold intracompartmental pressure was 35 mmHg. We carried out pressure assessment of all muscular compartments during and at the end of surgery. The pressure transducer provides a pressure value in all muscular compartments with a time of installation and measuring of less than 5 minutes. Sensitivity is measured at +/- 1 mmHg. Operation is simple, non-operator dependent, and accessible to medical and paramedic teams. The pressure transducer allows accurate diagnosis of early or established compartment syndrome. It requires no additional equipment and its application does not delay therapeutic management. Its use helps with fasciotomy decision, especially after escharotomy, guides the surgeon in the exploration of different compartments and verifies the effectiveness of surgery.