Plastics Notes

Controlled Environment for Treatment

• Controlled Environments: Used to ensure optimal conditions for healing and recovery.
  • Types include:
  • Laminar Air: A sterile air flow that reduces contamination risk.
  • Bubble: An enclosed area providing a controlled atmosphere.
  • Hyperbaric Chamber: Increases oxygen (O₂) levels under pressure to promote healing.

Infection Prevention and Management

• Isolation from Infection: Essential for preventing complications in healing processes.
• Hypothermia Prevention: Maintaining body temperature is crucial for recovery.
• Input and Output (I&O): Monitoring fluid intake and output during treatment.

Treatment Protocols

1. Replace Fluid: Ensuring adequate hydration and fluid balance.
2. Prevent Infection: Critical to avoid severe complications such as:
   • Septicemia: Infection in the bloodstream.
   • Pneumonia: Lung infection that can be fatal.

Types of Burns

• Burn Classifications: Based on their origin:
  1. Thermal Burns: Result from fire, hot liquids, or hot objects.
  2. Chemical Burns: Caused by acids or alkaline substances.
  3. Electrical Burns: Resulting from exposure to electric currents.
  4. Radiation Burns: Overexposure to radiant energy, such as from x-rays or the sun.

Classification of Burns by Depth

1. 1st Degree Burns:
   • Characteristics: Red, superficial, heals quickly.
   • Affects: Epidermis (outer dermis).
2. 2nd Degree Burns:
   • Characteristics: Blisters, pain, red and moist.
   • Affects: Extends through the epidermis.
3. 3rd Degree Burns:
   • Characteristics: Dry, white or charred appearance.
   • Affects: Full thickness of skin; may require grafting for healing.
   • Pain from nerve damage may be present in underlying tissues (bone, vessels, muscle).

Estimating the Extent of Burns

A. Lund & Browder Method

• Measures burn extent based on:
  • Age of the patient.
  • Specific location of the burns on the body.
  • Provides an estimate of body surface area (BSA) affected by burns.

B. Rule of Nines

• Rule of Nines: Divides the adult body into areas that equal approximately 9% of total body surface area.
  • Modified for infants and children to account for differences in body proportions.

Types of Skin Grafts

1. Autograft: Skin harvested from the patient's own body, transferred from uninjured areas to injured areas.
2. Homograft: Skin taken from a donor of the same species, can be from a living person or a cadaver.
3. Heterograft (Allograft): Skin from different species, commonly porcine (pig) skin.
   • Synthetic Skin: Lab-created materials used for dressing wounds to protect against fluid loss and infection.

Autografting Techniques

A. Tissue Flaps

• Used for significant tissue loss that requires a vascular supply to ensure healing.
• Preparation: The donor site is prepped first and is considered a clean site.

Supply Types for Tissue Flaps

• Pedicle Flap: Remains attached to donor site, includes two types:

  1. Local Flap: Taken from nearby tissue, e.g., from the area near the nose.
  2. Distant Flap: Transferred from a more remote site to the graft site.

• Free Flap: Detached tissue complete with a vascular bundle, applied to recipient site.

  • Tissue Expansion: Saline is used under tissue to increase graft area.
  • Myocutaneous Flap: Muscle and skin combined used wherever necessary.
  • Muscle Flap: Tissues containing blood supply, e.g., from gluteus maximus.
  • Neurosensory Flap: Donor tissue retains sensory nerves for better functionality.
  • Omental Flap: Mobilized to cover vital organs, particularly after trauma or radiation.

B. Free Graft Types

• Detached from donor site, revascularization occurs from the recipient site:
  1. Full Thickness Grafts:
  • Comprises epidermis, dermis, and fat; is thicker, fills in better, and minimizes contracture.
  • Ideal for aesthetically sensitive areas: face, neck, hands, elbows, knees, feet, axilla.
  • Requires closure of the donor site or additional grafting (commonly a split-thickness graft).
  • Not reusable after harvest.
  1. Split Thickness Grafts:
  • Comprises epidermis and part of dermis; thickness of $0.010 - 0.035 ext{ inches}$ (approximately $0.3 - 1 ext{ mm}$).
  • Used for larger areas, such as severe burns.
  • Harvested with a dermatome.
  • Skin at donor site can regenerate and be reused after approximately two weeks.

Dermatomes

• Dermatomes: Devices employed to harvest skin for grafting.

  1. Drum Dermatome: Contains a rotating blade; requires adhesive to adhere to skin before use.

  2. Oscillating Dermatome: Specific brands include Hall, Brown, Duval, and Paget.

     • Functionality:
     • Blade moves back and forth, can be electric, nitrogen, or battery-powered.
     • Best for flat and firm skin surfaces; sterile mineral oil aids in gliding during use.
     • Caution required during operations due to delicacy of the procedure.
     • Features disposable blades that must have safety guards and depth gauges set to adjust blade depth before harvesting.

  3. Skin Mesher: Expands graft skin to desired proportions via small slits.

     • Allows epithelial tissue to grow between slits, aiding drainage.
     • Ratio cards available (1:1, 1:2, 1:3, etc.) for various mesh expansions.

Care of Grafts

• Maintenance of Grafts:
  • Keep moist using options like: ear syringe, sponge, or saline basin.
  • Keep skin grafts physically safe throughout the healing process.
  • Prep and drape grafts separately from recipient sites.
• Securing Grafts: Utilize techniques to ensure adherence and healing:
  1. Maintain strict aseptic techniques during the operation.
  2. Ensure proper contact and stability of graft to the recipient site.
  3. Control bleeding and drainage effectively.
• Grafts secured to donor sites using different methodology (e.g., suture or mechanical fixtures).