RU2614100C1 - Method for hand skin plastics - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: general condition of the patient is pre-stabilized. An autograft is prepared. Necrotic tissues are removed, hemostasis and autoplasty are performed. At that, a fringing scalpel cut is made perpendicular to the skin surface at the border between the burn and the healthy skin in the interdigital spaces and on the side surfaces of the fingers. The skin is incised to the subcutaneous adipose tissue with formation of cuts in the form of angles and straight lines. Next, an electrodermatom is used on the hand dorsum, including the phalanges, to remove necrotic tissues down to the lower layers of the dermis, additionally in interdigital spaces and on the finger sides in the direction from the wound to the healthy skin and perpendicular to the bordering section, cuts are adhusted in the form of angles and straight lines to provide fit congruence of the solid free graft to the healthy skin.

EFFECT: method ensures fit congruence of the solid free graft to the healthy skin, prevents development of postoperative scarring syndactyly and flexion contractures of fingers.

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Description

The present invention relates to medicine, namely to plastic surgery, combustiology, and can be used in patients with deep burns of the hand.

One of the most frequent and difficult to prevent burn burns of the hand is the formation of syndactyly (fusion of the interdigital spaces) and cicatricial flexion contractures of the fingers. They usually develop after a burn of the metacarpal region, more often the back surface of the hand within the main phalanges, less often reach the middle phalanges and limit the breeding of the fingers. Syndactyly is a scar membrane located in the form of a roller on the sides or in the center of the interdigital space (Yudenich V.V., Grishkevich V.M. - Guidelines for the rehabilitation of burned women. Moscow, 1986, p. 274). With burns of the hand as a result of self-healing of superficial burns IIIA Art. quite often coarse scars form. (Azolov V.V., Dmitriev G.I. - Surgical treatment of the consequences of burns. N. Novogorod, - 1995. - P. 5). A deep burn of the rear of the fingers and metacarpus is always accompanied by a partial death of the skin of the interdigital spaces. With deep burns, self-healing of granulating wounds in these areas can occur even before the scabs are completely rejected due to marginal epithelization from the intact skin of the gap dome. (Vikhreev B.S., Burmistrov V.M. - Burns: Manual. - M.: Medicine, 1986. - 167 p.).

An analogue of the present invention is a method of free skin grafting with a split skin autograft of deep burns, described by V.V. Yudenich et al. (Treatment of burns and their consequences: Atlas. - M.: Medicine. - 1980. - S. 74-78). The method provides for the phased removal of the necrotic scab during deep burns during dressings, when a necrotic tissue is naturally rejected along the emerging demarcation line. By cutting the joints between the scab and the underlying tissues, the scab is gradually removed. In cases where there is a deep burn and its boundaries are clearly defined, excision of necrosis is possible according to the type of surgical treatment of the wound. The rejection of the dead areas during deep burns, as well as the formation of a granulation cover, always proceeds with a biologically determined, appropriate purulent-inflammatory process in the wound, aimed at cleaning its surface from the dead areas. However, with the accumulation of a large amount of pus under the exfoliated areas of necrotic scabs, the general condition of the patients significantly worsens, and shallow lesions turn into deep ones due to purulent fusion of the preserved skin derivatives, which are foci of islet epithelization. When granulation tissue is formed, free skin autoplasty is performed with a split graft taken by a dermatome from free skin sites.

The disadvantages of this method include:

1. Long-term preparation of the wound for delayed skin grafting with the possibility of skin grafting only by the end of the first month after the injury.

2. During the preparation of the wound for autoplasty, granulation tissue is formed, which subsequently affects the functional and cosmetic result of treatment.

As the closest analogue, the method of early removal of a scab with simultaneous skin autoplasty, described by S.P. Pakhomov and N.A. Ponomareva (Skin and plastic replacement of extensive burn wounds: Photo-atlas. - Nizhny Novgorod: FGU NIITL Rosmedtekhnologii 2008. - 32 p.). For 2-5 days after the injury, when the patient's general condition is stabilized and the boundaries of the deep burn are clarified, the scab is tangentially removed. For tangential necrectomy, a dermatome is used, which cut off dead tissue up to 2 mm thick. After necrectomy is completed, hemostasis is performed. Autografts are taken from healthy skin areas. Plastic surgery is performed with full confidence in the viability of the wound. Non-perforated grafts are used on functionally active areas (hands, feet, joints), and autografts with perforation are used on the remaining sites.

The disadvantages of the method include:

1. Self-epithelization of border burns with the formation of scar tissue in the postoperative period.

2. Expectant tactics to clarify the depth of burns.

3. The formation of scars in the interdigital spaces and on the lateral surfaces of the fingers.

Tasks:

- improve early necrectomy with primary skin autoplasty with deep burns of the hand;

- to exclude in the postoperative period scarring of the transition zone between the autograft and healthy skin;

- improve functional and cosmetic results in the interdigital spaces and on the lateral surfaces of the fingers.

The essence of the invention is the following: a bordering cut perpendicular to the skin surface, the skin is cut to subcutaneous fat with formation of cuts in the form of angles and parallel to the skin surface of the line along the cut line, after which necrotic tissue is excised to the lower layers of the dermis, then the edges are further excised after hemostasis wounds in the area of interdigital spaces and on the lateral surfaces of the fingers in the direction from the wound to healthy skin and perpendicular to the bordering dissection d additionally adjusting notches in the form of angles and straight to ensure congruence fit piece free graft to healthy skin.

Technical result: a bordering incision along the line in the form of angles and parallel in the interdigital spaces and on the lateral surfaces of the fingers with subsequent plastic surgery after necrectomy and marginal excision of the wound in the postoperative period prevents the development of cicatricial syndactyly and flexor contractures of the fingers.

The implementation of the method of plastic surgery of the skin of the hand in the area of the interdigital spaces and the lateral surfaces of the fingers after early necrectomy is performed as follows. On 2-7 days after receiving an injury after stabilization of the general condition of the patient, they are taken to the operating room. The operation begins after standard processing of the surgical field. Then an electrodermatome takes out skin autografts with an area equal to the estimated necrectomy. Dressings with antiseptics are applied to donor wounds. Then, on the affected area along the border of the burn and healthy skin in the area of the interdigital spaces and on the lateral surfaces of the fingers, with a fringing incision perpendicular to the skin surface, the skin is cut with a scalpel to the subcutaneous fat along lines in the form of angles and parallels, thereby limiting the area of the alleged necrectomy. The electrodermatome removes necrotic tissue to the lower layers of the dermis and subcutaneous tissue. Make hemostasis, pressing the wound with dressings with a solution of adrenaline for 3-5 minutes. Then, in the area of the interdigital spaces and on the lateral surfaces of the fingers, in the direction from the wound to healthy skin, the edges of the wound are cut perpendicular to the first cut, thereby forming a parallel border of the graft to fit on healthy skin. Hemostasis. Autoplasty is performed. Apply dressings with an antiseptic solution. The first dressing is performed on 3-5 days. Full adaptation of skin autografts is usually observed on the 5-7th day.

According to this method, 15 patients with deep burns of the back surface of the hand were operated on under clinical conditions.

Example 1. Patient K., 35 years old, was admitted to the burn department. GBU3-NII KKB No. 1 named after prof. S.V. Ochapovsky July 25, 2010 with a diagnosis of Thermal burn (flame) of the face, neck, trunk, both hands 10% 2-3 tbsp. The main stages of treatment and plasty with whole free skin autografts are presented in Appendix 1 in Fig. 1-8. 5 days after the injury, there is a deep burn of the back surface of the right hand (Fig. 1), the patient was taken to the operating room, under general anesthesia, after standard treatment of the surgical field with an electrodermatome, skin autografts were taken along the lateral surface of the right thigh 0.2-0.3 mm thick. On the right hand, along the border of the burn and healthy skin, in the region of the lateral surfaces of the fingers (Fig. 2) and the interdigital spaces (Fig. 3), a skin is cut into a subcutaneous adipose tissue with a bordering incision perpendicular to the skin surface, thereby limiting the area of suspected necrectomy along lines with the formation of angles and parallels. A scab on the back surface of the right hand, including the phalanges of the fingers to the lower viable layers of the dermis, is excised by the necrotome. Hemostasis. Then, additionally, in the area of the interdigital spaces and on the lateral surfaces of the fingers, in the direction from the wound to healthy skin, the wound edges are excised (Fig. 5), perpendicular to the first incision, thereby forming the border of the subsequent graft attachment to healthy skin (Fig. 6). Next, plastic surgery was performed with solid free skin autografts on the back surface of the right hand (Fig. 7, 8). Tiling with a solution of antiseptics on the area of the interdigital spaces. Engraftment is observed on 3-5 days. Due to skin grafting with the creation of a border between grafting and healthy skin in an indirect line in the area of the interdigital spaces and on the flexion surfaces of the fingers, cicatricial syndactyly and flexion contractures of the fingers are not formed within 3 years of observation.

Example 2. Patient A., 55 years old, was admitted to the burn department. GBU3-NII KKB No. 1 named after prof. S.V. Ochapovsky 08/19/2012 with a diagnosis of Thermal burn (flame) of the upper limbs 3% 2-3 tbsp. On admission, there was a forming burn scab of 3 tbsp. Of the rear surface of the left hand, including the phalanx of the fingers and the area of the interdigital spaces. 3 days after the injury, under general anesthesia, an electrodermatome, skin autografts were taken along the front surface of the right thigh 0.2-0.3 mm thick. Then, on the left hand, along the border of the burn and healthy skin in the area of the interdigital spaces and on the lateral surfaces of the fingers, bordering cuts perpendicular to the surface of the skin were made, the skin was cut with a scalpel to subcutaneous fat, thereby limiting the area of suspected necrectomy. A necrotome excised the forming scab on the back surface of the left hand, including the phalanges of the fingers to the lower viable layers of the dermis. Hemostasis. Further, additionally, in the area of the interdigital spaces and on the lateral surfaces of the fingers, in the direction from the wound to healthy skin, the edges of the wound are cut perpendicular to the first cut. Plastic surgery was performed with solid free skin autografts on the back surface of the left hand with a flap cut out along the contours of the wound bottom in the area of the interdigital spaces and lateral surfaces of the fingers, thus forming an indirect line. Engraftment on day 5 after surgery. Within 3 years of observation, cicatricial syndactelias and contractures are not formed.

Claims (1)

A method for plasticizing skin integuments of a brush, including preliminary stabilization of the general condition of the patient, preparation of an autograft, removal of necrotic tissue, hemostasis and autoplasty, characterized in that a bordering incision is made with a scalpel and is perpendicular to the skin surface along the border of the burn and healthy skin in the interdigital spaces and on the lateral surfaces fingers, while the skin is cut to subcutaneous fat with the formation of cuts in the form of angles and straight lines, then an electrodermatome on the back the surface of the hand, including the phalanges of the fingers, removes necrotic tissue to the lower layers of the dermis, additionally in the area of the interdigital spaces and on the lateral surfaces of the fingers in the direction from the wound to healthy skin and perpendicular to the bordering section, cut outs in the form of angles and straight lines to ensure congruency of the fit of the whole free transplant to healthy skin.

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