RU2618166C1 - Method of cutting out skin autotransplant - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to combustiology and plastic surgery. Model of percipient bed is formed in aseptic conditions. It is applied on the place of autotransplant cutting out. Transplant is sewn with holders and cellular tissue is separated from it. In the process of cutting out full-thickness transplant skin cut is performed to upper layers of subcutaneous-fatty cellular tissue, fragments of which are further ablated with scissors. From derma side transplant is aligned with dermatome, with excision of 0.1 mm layer, the total thickness of transplant1.0-2.0 mm being formed.

EFFECT: method of cutting out transplant of large size, which reduces operation time, improves the result of surgical intervention.

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Description

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

The basic principle of the treatment of deep burns is the surgical restoration of the integrity of the skin in areas of deep damage. The presence of a deep burn is an indication for surgical treatment, regardless of the timing of the burn injury, the area of the lesion, other clinical and organizational factors. Skin grafting on a granulating wound is performed according to its readiness as a receptive bed for a skin transplant (bright, fine-grained granulations, with scanty wound discharge and optimal preparation times). The main way to restore the anatomical integrity of the skin with deep burns is autodermoplasty with split autodermografts using a dermatome. The optimal thickness of the split autodermal graft is 0.2-0.4 mm. (Surgical treatment of burn victims // Methodical recommendations. - M .: 2015. - P. 4-8. Www.combustiolog.ru). However, the disadvantages of autoplasty with transplants of this thickness are their scarring and wrinkling, and the engraftment of the entire thickness on the granulating wound is insignificant due to their high whimsicality and engraftment only under aseptic conditions and on the receiving bed with good blood supply (Zolton J. Skin transplant. - Budapest, 1984 . - 304 p.).

An analogue of the present invention is a method of free skin grafting with a split autograft, taken by a dermatome, and described by B. Vikhreev. and Burmistrov V.M. (Burns: A Guide. - L.: Medicine, 1986. - 231 p.). The method provides for the possibility of collecting skin autografts with dermatomas of any models (in particular, dermatomas of the Kazan factory with manual drives; the Kiev factory with a powerful electric motor in the handle; the mechanical dermatome DPE-100; the dermatome with tangential movement developed by M.V. Kolokoltsev). Under anesthesia, from any skin-free areas of the skin, a split skin autograft is taken 0.2-0.3 mm thick, up to 40-60 cm long and 10 cm wide. Then autoplasty for wound defects is performed. If it is necessary to increase the area of donor skin and to improve drainage under the grafts, it is possible to perforate the latter with a perforation coefficient of 1: 2-1: 4.

The main disadvantages of this method are:

1. Subsequent scarring of the graft in the postoperative period.

2. The possibility of using autografts with a width of only 10 cm.

3. The need for plastic surgery only on the granulating wound.

4. The presence in the postoperative period of scar joints between autografts.

As the closest analogue, the method of taking a full-layer skin autograft according to Larin, described by Y. Janelidze, was adopted. (Free skin grafting. - Medgiz. 1952. - c). The perceptive bed should be small in aseptic conditions (usually after excision of scars of different 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 subcutaneous fat. After the borders of the future transplant are outlined, the graft is stitched from the edges with holders. A roller is placed on the future transplant and, using the holders, the graft is separated with a scalpel from the subcutaneous tissue. Further, the graft, if necessary, inside the scissors is freed from the remnants of the subcutaneous tissue and plastic surgery is performed. A donor wound is sutured with suturing on the skin.

The disadvantages of this method are:

1. The possibility of plastic surgery with a whole full-layer autograft of only a small size.

2. High risk of scarring of the postoperative donor suture due to soft tissue tension.

Tasks:

- to improve the method of collection followed by plastic surgery with a full-layer free skin autograft;

- to achieve the capture of a whole full-layer free skin autograft of a significant size;

- reduce the time of surgery due to the reduction of the time taken to take a whole full-layer free skin autograft;

- to improve cosmetic results in the postoperative period due to the use of a whole full-layer free skin autograft.

The essence of this method, in contrast to the known, is that they take a full-layer graft. In this case, the incision is made to the upper layers of subcutaneous fat, the fragments of which are then removed with scissors, and from the side of the dermis, the graft is aligned with a dermatome with excision of a layer of 0.1 mm, while the total thickness of the graft is formed in 1.0-2.0 mm .

Effect: the method allows to improve the fence of a full-layer solid skin autograft of a significant size. In connection with the fence of an autograft with subcutaneous fat, the operation time is reduced. Plastic surgery of a wound defect with a whole full-layer free skin autograft allows to reduce the risk of scar development in the postoperative period, thereby improving the cosmetic effect.

The implementation of the method of sampling a full-layer free whole skin autograft is as follows. In the presence of an extensive skin defect, as a rule, in the functional areas (face, hands, feet, open areas of the body), plastic is shown as a whole full-layer skin autograft. In the operating room, standard preparation and processing of the surgical field is performed. A skin defect is measured, and on a healthy area of the skin, the intended donor site of the appropriate size is marked. With a scalpel on a healthy area of the skin, a bordering incision is made of the required size. A skin autograft is taken onto the holders and excised with a scalpel with the upper sections of subcutaneous fat. From the inside, scissor-fat tissue is excised with scissors from the autograft and, from the dermis, the autograft is treated with a dermatome with a 0.1 mm thickness excision. dermis - to align it from the inside. The thickness of a full-layer whole skin autograft is 1-2 mm, depending on the thickness of the dermis. Then plastic surgery is performed with a solid free full-layer skin autograft. If necessary, cuts are formed in the whole full-layer skin autograft (for the mouth, nasal passages, eyes). In these areas and on the border with healthy skin, sutures are applied according to the rules of plastic surgery: dermis to the dermis, epidermis to the epidermis. Apply dressings with an antiseptic. The wound is tightly bandaged for 5-7 rounds with a medical bandage. After 3-5 days at the first ligation, the state of growth of granulations in the donor site and the engraftment of a whole full-layer skin autograft are assessed. After 5-10 days, when granulation tissue is formed on the donor site with an electrodermatome, free split skin autografts with a thickness of 0.2-0.3 mm are taken on free skin areas, perforated with a 1: 2 coefficient and the granulating wound is covered with a donor site of a full-layer autograft. The engraftment of skin split autografts is usually noted on 3-5 days, and full-layer - by 7-9 days after plastic surgery.

According to this method, 17 patients with deep burns were operated on under clinical conditions.

Example 1 .. Patient S., 2 years old, was admitted to the burn department. GBU3-NII KKB No. 1 named after 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 (Fig. 1). 20 days after the injury, under general anesthesia (mechanical ventilation) with a scalpel and dermatome on the face wound 15 × 24 cm, the upper layers of granulations were excised. 0.5-1 cm apart 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 (Fig. 2). A bordering incision 15 × 24 cm in size was made with a scalpel on the anterior abdominal wall. A bordering incision, 1.5 cm indented, circled the umbilical region, a full-layer skin autograft with upper layers of subcutaneous fat was taken with a scalpel (Fig. 3). Subcutaneous adipose tissue was removed from the inside of the autograft with scissors, from the dermis, the autograft was treated with a dermatome with excision of a thickness of 0.1 mm of the dermis to align it from the inside (Fig. 4). Autograft thickness 1.5 mm. Aseptic dressings are applied to the donor wound. A free skin autograft 15 × 24 cm, 1.5 mm thick, was placed on the face wound (Fig. 5). Slots for the mouth, nasal passages, and eyes were formed in it (Fig. 6). 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. After 9 days, during the formation of granulation tissue, skin autotransplants for plastic surgery of the donor site wound from the chest were 0.2 mm thick, the grafts were perforated 1: 2, placed on the wounds of the donor skin site on the anterior abdominal wall (Fig. 7). Further on the first ligation on day 5: the autograft adaptation is good. Extract after 3 weeks from the operation. Within 3 years of observation, scar tissue does not form (Fig. 8).

Example 2. Patient 3., 29 years old, was admitted to the burn department. GBUZ-NII KKB №1 named after prof. S.V. Ochapovsky 05/17/2012 with a diagnosis of Thermal burn (flame) of the right hand 2% IIIB-IV Art. 18 days after the injury, under general anesthesia, on the wound of the right hand on the back surface of 17x20 cm, the upper layers of granulations are excised with a scalpel and dermatome. 0.5 cm away from the granulations, a bordering incision was made with a scalpel, then from the inside of the wound to healthy skin the wound edges and marginal epithelization were excised. Hemostasis. A fringing incision 17 × 20 cm in size was made with a scalpel on the lateral surface of the right half of the chest. The skin autograft was taken on holders and excised with a scalpel with the upper layers of subcutaneous tissue. On the donor site - a bandage with an antiseptic solution. The subcutaneous fat was excised on the autograft with scissors and a dermatome. Plastic surgery was performed with an integral free full-layer skin autograft on the right hand. After 9 days, when granulations were formed on the donor site, skin autografts were taken along the anterolateral surface of the left thigh 0.25 mm thick, the grafts were perforated 1: 2, laid on the wounds of the donor skin site, and a bandage was applied. At the first dressing on day 3, the engraftment is complete. Within 3 years of observation, there are no indications for reconstructive operations.

Claims (1)

A method of sampling a skin autograft, including performing a model of the receiving bed under aseptic conditions, applying the model to the place of taking the autograft, flashing the graft onto the holders and separating it from the tissue, characterized in that when taking a full-layer graft, a skin incision is performed to the upper layers of subcutaneous fat, fragments of which are then removed with scissors, and from the side of the dermis, the graft is aligned with a dermatome, with a 0.1 mm layer excision, while the total thickness of the graft is comfort in 1.0-2.0 mm.

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