Preservation of devitalized calvarium following high-voltage electrical injury: case reports

Three victims of electrical injury with necrosis of a portion of the skull had excision of overlying necrotic soft tissue soon after injury with immediate coverage of the devitalized bone with soft-tissue flaps. In two instances, the flap was from adjacent scalp; in the other a free myocutaneous flap was used. All wounds healed without sequestration of bone. Necrosis of the calvarium was substantiated by evidence of nonperfusion on a radionucleotide bone scan. In each instance, a followup bone scan showed evidence of regeneration of bone. This experience supports an earlier observation which suggested that devitalized but intact calvarium following electrical injury does not need to be removed and is the perfect in situ bone graft.     

Management of scalp defects due to high-voltage electrical burns: a case series and proposed algorithm to treat calvarium injury

Background

Multiple modalities to manage scalp and underlying skull defect due to high-voltage electrical burns have been discussed. We aimed to describe our experience and to propose an algorithm for the management of skull injury which could be helpful in decision-making.

Methods

A retrospective study of patients who sustained electrical burns to the head from May 2007 to April 2012 was carried out. Sex, age, size of scalp defect, and method of reconstruction and management were analyzed.

Results

Thirteen patients were identified. Out of 13, 11 patients had scalp defects which were covered using local scalp flap. Free latissimus dorsi (LD) muscle flap and pedicle trapezius flap were used in two patients. The largest defect covered with local scalp flap was the size of 80 cm². Free LD flap was used to cover a defect of 144 cm². Of the nine patients who presented early (immediately after injury), seven required debridement of the outer table and the other two patients required full-thickness excision of the skull. The remaining four patients who presented late (after 3 months) were found to have osteomyelitic segments which required full thickness excision of the skull.

Conclusions

Most of the soft tissue defects of the scalp due to high-voltage electrical burns can be managed with local scalp flaps. However, if the local tissue is injured or not sufficient to close the defect, then free flap should be considered. In management of calvarium injury, the emphasis should be debridement of necrotic bone to provide infection-free site followed by soft tissue cover.Level of Evidence: Level IV, therapeutic study.

     

广泛头皮深度烧伤伴颅骨全层坏死的治疗

我们自１９９０年４月至１９９３年５月共治疗８例广泛头皮深度烧伤伴有颅骨全层坏死的病例，早期经头颅ＣＴ及￣９９ｍ锝同位素颅骨扫描检查明确颅内损伤及颅骨坏死范围后，采用吻合血管的血流量大的肌皮瓣或游离皮瓣移植，在保留坏死颅骨情况下Ⅰ期修复创面。８例中４例创面Ⅰ期愈合，另３例在已愈合皮瓣保护下多次清创去除死骨。经术后１～４年随访表明，坏死颅骨作为修复支架保留，避免了颅骨缺损可能造成的并发症及后遗症。本组仅１例于入院后２４ｈ因颅脑严重损伤而死亡。我们所介绍的这一方法为类似严重病例的治疗提供了有效手段。     

Surgical management of the burned scalp

Alopecia from scalp burns can present psychological problems. Reconstructive surgery with rotating hair-bearing skin flaps has been useful in the rehabilitation of these patients. In many patients, one flap shift can establish an acceptable hair line. In extensive cases, multiple operations are necessary, including fractional excision of small burns that have been skin-grafted or fractional excision of the donor site when large hair flaps were rotated. It is remarkable how the occipital flap can reach the forehead by a series of transfers without delay, using a rotation of 90 to 180 degrees. Worthen presented an interesting case of revascularization of the skull in a victim of an electrical burn. In conclusion, scalding hot liquids accidentally spilled on the young child's scalp will produce a deep burn with loss of hair. Small areas of alopecia that are skin-grafted can be handled by staged fractional excision. The hair line can be reestablished in larger areas of alopecia by a series of operative procedures that require years to accomplish. When the periosteum of the skull is affected, resection of the outer table of bone and skin grafting will expedite wound healing.     

Regeneration of full layer necrosis of the skull following high voltage electrical injury

Scalp and skull necrosis often follow high voltage electrical injury to the head. Classically reconstruction of the scalp and skull is performed after sequestration of the necrotic bone. The relatively frequent complication of epidural infection, however, detracts from this approach. As an alternative we have attempted to induce regeneration of devitalized bone by covering it with a vascular tissue flap. A typical patient is described in this report with results which indicate that at least partial regeneration of the necrotic tissue can occur, thus one-stage management of such wounds is possible.     

Reconstruction of refractory defect of scalp and skull using microsurgical free flap transfer

Ten patients—six with acute burns, two with old accident or surgical trauma, and two with cranial carcinoma—experienced extensive full-thickness necrosis of the scalp and necrosis or defect of underlying skull bone. Microsurgical free flaps were used for the repair. Four latissimus dorsi, two rectus abdominis, one greater omentum, one prefabricated omentum-cutaneous flap, and two vascularized outer-table of the cranial bone flaps were used with complete survival. The heat-devitalized cranial bone covered by living tissue flaps healed well and substantial “regeneration” of previously necrosed bone was shown by roentgenogram, bone scan, and histopathological examination in the postoperative follow-up. Choosing an artery with high perfusion, bypassing from the carotid artery to support a massive free flap, is recommended. © 1994 Wiley-Liss, Inc.     

Secondary intention healing of exposed scalp and forehead bone after Mohs surgery

For Mohs surgical wounds that show exposed bone (ie, bone denuded of periosteum), healing by secondary intention may be preferable to surgical reconstruction. To determine the appropriateness of secondary intention healing, we reviewed surgical outcome in 205 patients with Mohs wounds of the scalp and forehead that had healed by secondary intention. Of these patients, 38 had Mohs wounds showing exposed bone. The mean area of exposed bone was 1074 mm(2); the mean area of exposed soft tissue was 1575 mm(2). The mean time for wounds with intact periosteum to epithelialize was 7 weeks; the mean time for bare bone to epithelialize was 13 weeks. All wounds healed without infection or tissue breakdown. We conclude that secondary intention healing of scalp and forehead wounds showing exposed bone is a safe and effective method of wound management after Mohs surgery.     

Burns of the skull with underlying intracranial meningioma.

A 68-year-old white-skinned male fell head first into a fireplace while having a seizure. Extensive burns of the skull were sustained requiring removal of the necrotic bone. The patient had an underlying meningioma. Healing of the skull was obtained using a latissimus dorsi flap. After the scalp was completely healed, the meningioma was successfully resected with significant improvement in the patient's mental function.     

皮肤软组织扩张术在烧伤外科的应用

目的 总结采用皮肤软组织扩张术的方法修复大面积严重烧伤后畸形及颅骨深度电烧伤新鲜创面的临床效果。方法 １９９８年以来,应用皮肤软组织扩张术８３例１６０个扩张器,对大面积严重烧伤后畸形、全鼻缺损患者,于前额烧伤后植皮皮下及额肌下行组织扩张术,设计带血管蒂的软组织扩张后烧伤植皮岛状皮瓣,切取肋软骨为支架,完全全鼻再造。对颅骨深度电烧伤,应用软组织扩张术将新鲜颅骨深度烧伤创面修复与后期烧伤后头皮瘢痕秃发     

The use of artificial dermis for reconstruction of full thickness scalp burn involving the calvaria

The incidence of extensive full thickness scalp burn involving the calvaria is rare and can be very difficult to reconstruct, as the application of local or free tissue transfer is limited. Although wound closure can be achieved with bone debridement and immediate or delayed split-thickness autografting, the result may be problematic due to unstable skin graft surface. The use of artificial dermis that may provide stable thick coverage in the treatment scalp and skull burn has rarely been reported in literature. We encountered two patients who suffered from severe head burns involving the calvarium. Following debridement including the necrotic bone, the artificial dermis (Integra) was used for immediate wound coverage which was 15 cmx10 cm in one case and 5 cmx6 cm in another. Three weeks later, ultra-thin skin grafting was placed on the neodermis. Compared to split-thickness skin graft, this technique provides a thicker coverage for wound closure. Neither skin breakdown nor ulceration was noted in the 1-year follow-up. This paper reports the successful use of artificial dermis for reconstruction of severe scalp burn with calvarial bone involvement.     

Healing of burns of the skull: a histological study

A histological study of burns of the calvarium is reported with reference to depth of necrosis, pyogenic infection and, especially, repair processes. It is based on 14 specimens from 9 subjects—biopsies in 6 cases and necropsy specimens in the 3 others. They ranged from 6 days to 12 months after the accident, most being between 4 and 15 weeks. Necrosis in some extended through the full thickness of the skull (full-thickness necrosis), but deep parts had remained viable in others (partial-thickness necrosis). Necrosis seems largely ischaemic in origin, through heat destruction of the epicranial blood supply. Pyogenic infection of necrotic bone was common, invading through the outer table, and was usually clinically silent. It could be restricted to the outer table or extend deep into the diploë, and certain specimens showed gross histological infection of the whole thickness of the skull. One was a sequestrum.Repair seems slow in onset and is prolonged. The earliest evidence of healing was in a specimen at 4 weeks after burning. Healing proceeded from viable soft tissue within the calvarial plate after partial-thickness necrosis and from the dural membrane after both partial-thickness and full-thickness necrosis. In the former mode, fibrovascular proliferation and invasion within diploëic spaces is associated with appositional seams of new bone on old trabeculae, but much new spongy bone had also formed in the diploë in one case. Osteoclastic resorption was common. Healing from the dura is manifest as fibrovascular invasion of the diploë via Volkmann's canals and sometimes also by new bone deposition on the surface of the inner table. Healing from the periphery into the necrotic centre was studied in one case and was very limited. The question of progressive creeping substitution of necrotic bone by new bone is discussed with reference to possible final replacement by a new calvarial plate. For this, early skin closure of the burn is likely to be required to prevent or reduce pyogenic bone infection.     

面颈部电烧伤骨外露头皮瓣移植后再回植

目的　探讨面颈部电烧伤骨外露用头皮瓣移植后再回植的临床疗效。　方法　采用早期扩创 ,保留坏死骨质 ,用邻近的带血管头皮瓣移植覆盖创面 ,电性坏死骨质在血循环良好的皮瓣覆盖下 ,为周边及基底健康骨质生长起到支架作用 ,3～ 6个月后将头皮瓣回植原位 ,保留颅骨表面的软组织 ,以利再移植的中厚皮成活。　结果　 8例面颈部高压电烧伤患者应用头皮瓣共 10个 ,最大面积为 2 4cm× 10cm ,全部成活 ,未出现感染坏死 ,创面一次性封闭。　结论　面颈部电烧伤骨外露头皮瓣移植后再回植的方法可缩短创面愈合时间 ,外形较好 ,效果满意     

肿胀技术下皮肤软组织扩张术治疗头皮缺损伴颅骨外露

目的:探讨皮肤软组织扩张术与肿胀技术相结合,修复头皮缺损伴颅骨外露的外科治疗效果.方法:将皮肤软组织扩张术与肿胀技术相结合,修复头皮缺损伴颅骨外露8例患者,与以往9例未采用肿胀技术的病例在术中出血、术后早期疼痛及术后血肿发生率进行比较.结果:应用该方法为8例患者修复头皮缺损伴颅骨外露,术中出血少,术后早期疼痛减轻,术后血肿发生率低.经术后3个月～2年的随诊,疗效满意.结论:肿胀技术下皮肤软组织扩张术治疗头皮缺损伴颅骨外露是一种安全可靠实用的方法,值得临床推广应用.     

Tactics of treatment for extended burns of various affection depth

Investigation was based on analysis of the treatment results of 75 children, suffering extended superficial and deep skin burns squared 15-30% of body surface. There was proved, that sequence of excision of superficial and deep necrotic scab influences the burn disease course. There was elaborated algorithm of sequence of the operative treatment stages in patients, suffering extended superficial skin burns, coexisting with deep burns, the superficial necrotic scab definitely, was excised after trauma and a deep one--in the second stage. The superficial and deep necrotic scab excision before 7-9th day after trauma have promoted significant reduction of the intoxication syndrome severity, the middle molecular mass peptides, indices of peroxidal oxidization of lipids, oxidizing modification of proteins, clinical signs of SIRS, rate of septic complications in 1.75 times, the stationary treatment time of severely ill patients by (7.2 +/- 1.5) days.     

Tangential excision of scalp burns: experience from the Bradford fire disaster

Tangential excision of deep dermal scalp burns does not appear to be widely practised. During the Bradford Football fire victims sustained mixed depth scalp burns. These were mainly as a result of radiant heat, although falling molten bitumen was the cause of injury in a few patients. Deep dermal or full thickness burns of the scalp were tangentially excised and skin grafted. One patient did not have a graft applied after tangential excision. The early results of graft take were satisfactory. Subsequently, however, 56 per cent required further grafting; the reasons for this are discussed. Ten months after the incident there is no difference in appearance between areas of primary grafting and areas of secondary healing.     

The histology of early necrectomy

The healing of deep dermal burns after tangential excision and full-thickness burns after total excision was examined. The study was carried out in laboratory pigs. The results were compared with results obtained in unexcised burns. It appears that early excision of thermally damaged skin, even if the ensuing defect is left without further treatment, shortens considerably the process of healing both in tangentially excised deep dermal burns and excised full-thickness burns. (In full-thickness burns, the percentage of scar contraction during the process of healing is demonstrated and compared with scar contraction in unexcised full-thickness burns and in mechanical wounds.)     

Very deep high temperature burns associated with blunt abdomino-thoracic trauma

A 14-year-old boy with deep burns, blunt abdominal trauma and extensive muscle damage is described.The patient was operated on for a ruptured liver, developed acute tubular necrosis, had 3220 gr of necrotic tissue removed in serial tangential excisions, had an above elbow amputation of the left hand, removal of necrotic ribs and excisions of necrotic spinal processes, developed sepsis twice, empyema of right pleura, had open infected knee joints and was successfully treated until complete healing over a period of four months.The successful outcome seems to be due to early and aggressive surgical treatment, hemodialysis, total parenteral nutrition for over two months, antibiotic therapy, cryoprecipitate and devoted nursing, occupational and physiotherapy.     

Bone regeneration at rabbit skull defects treated with transforming growth factor-beta1 incorporated into hydrogels with different levels of biodegradability

OBJECT: Skull bone regeneration induced by transforming growth factor-beta1 (TGFbeta1)-containing gelatin hydrogels (TGFbeta1-hydrogels) was investigated using a rabbit skull defect model. Different strengths of TGFbeta1 were examined and compared: different TGFbeta1 doses in gelatin hydrogels with a fixed water content, different water contents in gelatin hydrogels with a fixed TGFbeta1 dose, and TGFbeta1 in solution form. In addition, regenerated skull bone was observed over long time periods after treatment. METHODS: Soft x-ray, dual energy x-ray absorptometry, and histological studies were performed to assess the time course of bone regeneration at a 6-mm-diameter skull defect in rabbits after treatment with TGFbeta1-hydrogels or other agents. The influence of TGFbeta1 dose and hydrogel water content on skull bone regeneration by TGFbeta1-hydrogels was evaluated. Gelatin hydrogels with a water content of 95 wt% that incorporated at least 0.1 microg of TGFbeta1 induced significant bone regeneration at the rabbit skull defect site 6 weeks after treatment, whereas TGFbeta1 in solution form was ineffective, regardless of dose. The in vivo degradability of the hydrogels, which varied according to water content, played an important role in skull bone regeneration induced by TGFbeta1 -hydrogels. In our hydrogel system, TGFbeta1 is released from hydrogels as a result of hydrogel degradation. When the hydrogel degrades too quickly, it does not retain TGFbeta1 or prevent ingrowth of soft tissues at the skull defect site and does not induce bone regeneration at the skull defect. It is likely that hydrogel that degrades too slowly physically impedes formation of new bone at the skull defect. Following treatment with 0.1-microg TGFbeta1-hydrogel (95 wt%), newly formed bone remained at the defect site without being resorbed 6 and 12 months later. The histological structure of the newly formed bone was similar to that of normal skull bone. Overgrowth of regenerated bone and tissue reaction were not observed after treatment with TGFbeta1 -hydrogels. CONCLUSIONS: A TGFbeta1-hydrogel with appropriate biodegradability will function not only as a release matrix for the TGFbeta1, but also as a space provider for bone regeneration. The TGFbeta1-hydrogel is a promising surgical tool for skull defect repair and skull base reconstruction.     

Efficacy of laser debridement with autologous split-thickness skin grafting in promoting improved healing of deep cutaneous sulfur mustard burns

The consequences of receiving a cutaneous sulfur mustard (SM) burn are prolonged wound healing and secondary infection. This study was undertaken to find a treatment that promotes quick healing with few complications and minimal disfigurement. Multiple deep SM burns (4 cm diameter) were generated on the ventrum of weanling pigs and treated at 48 h. Four treatments were compared: (1) full-thickness CO₂ laser debridement followed by skin grafting; (2) full-thickness sharp surgical tangential excision followed by skin grafting, the “Gold Standard” used in deep thermal burns management; (3) partial-thickness laser ablation with no grafting; and (4) partial-thickness sharp excision with no grafting. A computer controlled, raster scanned, high-powered continuous wave (cw) CO₂ laser was utilized. Ulceration, wound geometry, and wound contraction were evaluated during a 36-day healing period. Histopathological evaluations were conducted at the end of the healing period. Engraftment rates were similar between both methods of debridement. Laser debridement followed by skin grafting was as efficacious in improving the wound healing of deep SM burns as the “Gold Standard.” Full-thickness laser debridement of these small total body surface area (TBSA) burns was time efficient and provided adequate beds for split-thickness skin grafting. Laser debridement offered additional benefits that included hemostatic control during surgery and minimal debridement of normal perilesional skin. Mid-dermal debridement by sharp excision or laser ablation without grafting produced less desirable results but was better than no treatment.     

Denatured acellular dermal matrix seeded with bone marrow mesenchymal stem cells for wound healing in mice

It is the basic task of burn therapy to cover the wound with self-healthy skin timely and effectively. However, for patients with extensive burns, autologous skin is usually insufficient, and allogenic or heterogeneous skin leads to strong immune response. It is vital to choose an appropriate treatment for deep extensive burns. Nowadays, the dermal substitute combined with bone marrow mesenchymal stem cells (BM-MSCs) is a prospective strategy for burn wound healing. Denatured acellular dermal matrix (DADM), as one of dermal substitutes, which prepared by burn skin discarded in escharotomy, not only maintains a certain degree of 3D structure of collagen, but also has good biocompatibility. In this study, the preparation method of DADM was improved and DADM was seeded with BM-MSCs. Then BM-MSCs-seeded DADM (DADM/MSCs) was implanted into mice cutaneous wound, and the effect of DADM/MSCs dermal substitute was assessed on skin regeneration. As a result, BM-MSCs survived well and DADM/MSCs scaffolds significantly promoted wound healing in terms of angiogenesis, re-epithelialization and skin appendage regeneration. DADM/MSCs scaffold may represent an alternative promising therapy for wound healing in deep extensive burns.