IMPROVEMENT IN TREATMENT OF PATIENTS WITH TRAUMATIC INJURIES TO SOFT TISSUES OF THE HEAD Bogdanov S.B., Karakulev A.V., Polyakov A.V., Marchenko D.N., Aladina V.A.
Scientific Research Institute – Ochapovsky Regional Clinic Hospital No.1,
Kuban State Medical University, Krasnodar, Russia
The problem of burns and extensive wounds is still actual and intricate in modern medicine. First of all, it is associated with significant increasing incidence of burns in population. So, it can be called the modern traumatic epidemy of big cities and industrial countries of the world. According to World Health Organization, burns take the second and third place among all locations since their incidence is quite high. Extensive wound defects of hairy part of the head often appear in deep burns and injuries to the head [1].
150 years passed from November 24, 2019, when Jaques Reverdin carried out the first free plasty of the skin. The techniques have been actively improving for one and a half the century.
For extensive injuries to the head with preservation of soft tissues, it is possible to conduct autodermoplasty with layer-by-layer autograft (Krasovitov's plasty) or with split autograft for lost amputated flap [2].
Most poor results of treatment of extensive skin defects of the head are related to non-survival of free skin autografts on bone tissue. For extensive wounds of the head without preservation of soft tissues, when the wound bed is bones of cranial vault, the staged surgical treatment is used with drilling holes to bleeding layer on cranial bones, with subsequent growth of granulation tissue during six months. After that, delayed autodermoplasty for granulating wound is performed [3].
Some researchers have an opinion that poor results of surgical management of extensive skin defects of the head are associated with non-survival of skin autografts on bone tissues owing to vascularization of wound bed [4].
For exposure of deep anatomic structures of the face and head, one of methods of choice is plasty with greater omentum on the pedicle, with subsequent skin plasty. The method of face transplantation has been improving [5].
Plasty with layer-by-layer skin autograft is optimal for achievement of positive functional and cosmetic results of treatment of patients with deep wound defects of the face [6, 7, 8].
Transplantation is conducted for deep total defects of the face [9].
A technique for treatment of extensive wounds of the head with exposure of skull bones has been developed in the burn center of Scientific Research Institute – Ochapovsky Regional Clinic Hospital No.1 of Healthcare of Krasnodar region.
The development of the technique was conducted in compliance with Helsinki Declare − Ethical Principles for Medical Research with Human Subjects, 2000, and with the Rules for clinical practice in the Russian Federation confirmed by the Order of Health Ministry of Russia on June 19, 2003, No. 266. The patient gave her informed consent for publication of the clinical case in public media.
CLINICAL CASE
The patient, female, age of 35, was admitted to the burn center of Scientific Research Institute – Ochapovsky Regional Clinic Hospital No.1 from the neighboring trauma unit on July 18, 2019. The diagnosis was: "The associated injury. Extensive posttraumatic injury to the head, 1000 cm2" (Fig. 1).
Figure 1
Patient, 35 years old, diagnosis: Concomitant injury. Extensive post-traumatic head wound of 1000 cm2
3 days after the injury, after stabilization of general condition, the surgery was conducted. After standard preparation of the surgical field, the surgical preparation of wounds was conducted: with scalpel, a bordering incision was made on the border of healthy skin and granulation tissue of the face; alternated borders of the wound bed were sparingly dissected; regions of necrotic tissues were tangentially dissected to viable layers. Hemostasis with electric coagulation and pressing dressings was conducted. Then, in the region of dry osteonecrosis, the oscillating saw was used for making the mutually crossing saw-cuts (under direct angle) over the same deepness through 1-1.5 cm to bleeding layer (Fig. 2). Using the scoop, osteonecrectomy was conducted over the same deepness within limits of vital lower cortical plate (Fig. 3).
Figure 2
Applying mutually intersecting right-angle cuts to the same depth through 1-1.5 cm to the bleeding layer.
Figure 3
Performed osteonecrectomy within a viable lower cortical layer
In concordance to precise marking of the wound defect, the electric dermatome D-100 was used for collection of three split thick skin autografts (thickness − 0.8 mm). The electric dermatome D-60 was used for collection of six split skin autografts (thickness − 0.3 mm). Donor beds in the region of collection of thick autografts were covered with perforated skin autografts (thickness − 0.3 mm) (perforation index − 1:4) (Fig. 4). The wound covering KhitoPran was applied over the site of skin plasty.
Figure 4
Donor beds in the area of the taking of thick autografts are covered with perforated skin autografts
Skin autografts (thickness − 0.8 mm) were transferred to surgically prepared wounds of the head. The borders of skin autografts with borders of the wound defect were sutured with continuous interrupted suture in toe-to-toe manner (Fig. 5). Perforated skin autografts (thickness − 0.3 mm) (perforation index − 1:2), which were fixed with interrupted stitches to borders of the wound, were placed onto the defect of cranial bone, and also in projection of hair growth (Fig. 6). Then mesh atraumatic dressings, vacuum sponge and the patch were applied onto the wound. Vacuum apparatus was connected, and pressure parameters were installed (110 mm Hg) (Fig. 7).
Figure 5
Skin autograft transplantation (0.8 mm thickness)
Figure 6
Skin plasty with perforated autografts (thickness of 0.3 mm) (perforation index 1:2)
Figure 7
Applying the vacuum dressing system
After 5 days from surgery, the vacuum dressing was removed, and zones of skin plasty were sanitated. The next dressing was performed on the 8th day. Another dressing was performed on the 12th day, and dressings on epithelized donor wounds were removed. On the 14th day, the last dressing was performed. Complete adaptation of skin plasty was observed (Fig. 8). The patient was discharged from the hospital.
Figure 8
14th day after surgery
RESULTS
The developed method allows fast recovery of skin surface in extensive wound defects of the head with cranial tissue exposure within a single surgical procedure, gives fine cosmetic and functional results after surgical intervention owing to use of thick autografts (0.7-1 mm), with excellent cosmetic and functional outcomes in donor wounds due to use of KhitoPran biological wound coverage. The vacuum dressing system, which provides proper fixation of autodermografts to the wound bed, allows minimizing the probability of displacement of autodermografts, and minimizing the development of hematomas under skin grafts which make negative influence on their survival. Vacuum dressing system allows taking up comfortable position in the bed, without concern of displacement of dressings.
DISCUSSION
Staged surgical treatment in exposure of cranial bones, which is conducted within six months and oriented to growth of granulation tissue along zone of bone demarkation, requires for drilling holes up to bleeding layer, and it is possibly associated with osteomyelitis, and needs for long term period of dressings and follow-up.
Our technique allows recovery of cranial skin cover within the first week after trauma. During osteonecrectomy it is optimally to perform presurgical CT and X-ray examination of the skull to assess the bone thickness. This instrumental examination allows optimization of surgical technique, and prevents exposure of dura mater during osteonecrectomy. Making of parallel saw-cuts on the skull (1-2 cm to bleeding layer) shows a healthy bone, which can be used for free skin autoplasty, and also serves as optimal technical manipulation during osteonecrectomy over the same deepness on spherical form of the skull.
In cosmetic aspects, alopecia remains in any type of free skin autoplasty of the skull. Alopecia is removed with expander dermotension, and with false hair for total defects.
CONCLUSION
Early post-trauma realization of osteonecrectomy up to bleeding layer allows primary free skin autoplasty with positive results. Creation of even pressure to the skin graft in the wound promotes complete engraftment of the skin, and fast adaptation. Skin plasty with layer-by-layer skin autograft on the face requires for additional skin graft for covering donor site, but it gives maximal cosmetic results on the face in long term perspective.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.