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Hastened Attachment Of A Superficial Inf Epigastric Flap

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  • 1. The Vacuum-Assisted Closure (VAC) Device for Hastened Attachment of a Superficial Inferior-Epigastric Flap to Third-Degree Burns on Hand and Fingers Christian Weinand, MD, PhD The vacuum-assisted closure (VAC) device has a wide range of clinical applications, includ- ing treatment of infected surgical wounds, traumatic wounds, pressure ulcers, wounds with exposed bone and hardware, diabetic foot ulcers, and venous stasis ulcers. Increased release of growth factors has been described, leading to improved vascularization and thereby for- mation of new tissue. The system is also used in burn surgery for reconstructive purposes. In this case report, a patient suffered from a third-degree burn injury to the dorsum of the hand with exposure of tendons, necessitating the use of a flap reconstruction. The patient was treated with a superficial inferior-epigastric artery-based flap and the VAC system was applied in a created glove-like shape. Hastened attachment of the flap onto the exposed fin- gers was observed after 4 days. The author reports on the additional use of the VAC system to hasten flap attachment in a patient with a burn injury to the dorsum of the hand. (J Burn Care Res 2009;30:362–365) Thermal injuries to the hand are a common problem period of time. However, potential of failure has been in Burn Centers. Most burns are located at the dor- the basis for extensive investigation into optimal sum of the hand most of them are first to second wound care after grafting. Tie-over bolster dressings degree in nature and heal without operative interven- are popular in plastic and reconstructive surgery, im- tion.1,2 Traditional surgical approaches are early es- plying a bolster dressing made from foam or saline- charotomy and skin grafting within the first days after soaked cotton over the graft, which is hold in pace by burn.3 However, third-degree burns to the dorsum of sutures or an elastic bandage.9 Tie-over bolster dress- the hand lead to exposed tendons and need to be ings immobilize grafts, thus preventing shearing in operated, as functional deficits are very likely to oc- the critical plane between the graft and the wound. cur.1,2,4 When skin graft is not appropriate, different Thereby, graft survival is improved.10 types of flaps have been recommended for recon- The use of negative pressure in the dressing of split struction. These include local, regional, distant, and skin grafts has been shown to promote healing be- even free flaps3,5– 8 and could result in good func- yond that of immobilization dressing by a variety of tional outcomes. Flap outcomes vary tremendously mechanisms.10,11 These include dermal perfusion, from pedicled to microvascular anastomosed, the later decreased interstitial edema, decreased bacterial col- ones having a higher failure rate.6 onization, and stabilization of the graft, all of which Within a 2-week time period the blood supply to decrease the incidence of seroma and infection. The the flap from the forearm is usually established, and it systems use a foam dressing with an attached perfo- is safe to be separated form the harvesting area.6 At- rated drain, which connects to a vacuum unit used to tachment of the flap to the fingers is seen within this apply the appropriate negative pressure. Good results are reported using a subatmospheric pressure at 125 mm Hg at an alternating pressure cycle of 5 From the Division of Burns, Washington Hospital Center. minutes suction, followed by 2 minutes off suction.12 This study was made possible by the Special Purpose Fund, Burns Department. Commercial vacuum-assisted closure (VAC) dress- Address correspondence to Christian Weinand, MD, Burns ings successfully achieve the performance outcomes Department, The Washington Hospital Center, 110 Irving sought after for negative pressure dressings.13,14 The Street NW, Washington DC 20010. Copyright © 2009 by the American Burn Association. combination of above-mentioned mechanisms makes 1559-047X/2009 the VAC device an extremely versatile tool in the DOI: 10.1097/BCR.0b013e318198a77e armamentarim of wound healing. This is evident in 362
  • 2. Journal of Burn Care & Research Volume 30, Number 2 Weinand 363 the devices wide range of clinical applications, includ- debridement of the wounds, leading to direct opera- ing treatment of infected surgical wounds, traumatic tion for tendon coverage. wounds, pressure ulcers, wounds with exposed bone A vertical inferior-epigastric flap was created pedi- and hardware, diabetic foot ulcers, and venous stasis cled to the left superficial inferior-epigastric artery, ulcers.15–19 There are also case reports of the use of identified by Doppler ultrasound. The flap was laid the device in salvaging venous congested free-flaps.20 onto the wound, secured with 4/0 Nylon stitches to So far it has not been reported in use to decrease the index and little finger radially and ulnar, respec- attachment time of pedicled flaps in hand burns. We tively. Then a wound VAC with silvercoated sponge present the case of using the VAC system to hasten was carved into the shape of the palm and fingers and the attachment of a superficial inferior-epigastric ar- applied beneath the hand onto the abdomen (Figure tery flap to the fingers in a 33-year-old female patient. 2). It was hold in place by skin staples. Another sponge was cut to shape of the dorsum accordingly and placed onto the flap, secured by scarce use of skin CASE REPORT staples. Then the polyurethane was cut in quarters, A 33-year-old woman presented to the emergency thus a complete seal was achieved including the wrist room after having sustained a complete thickness of the patient. On the fourth postoperative day the burn to the dorsum of her left hand and fingers using patient was taken back to the operating room for flap a steam press during work. For surgical history so far maturation and delayed inset. The VAC was taken two C-sections had been performed. The patient did off; attachment of the flap to the finger wounds dor- not report any current medical problems, did not take sally was observed to about 80% (Figure 3). Especially any medication, and reported no allergies. She did an attachment to the dorsum of the middle and ring not smoke and denied alcohol or illicit drug intake. finger were observed, were no suture had been Physical examination showed the heart in sinus placed. A delayed inset was performed and the VAC rhythm, the patient being mild hypertensive due to system applied again. Furthermore, staged matura- pain. tion of the flap and delayed insets were performed Her left hand showed significant burn injuries of sec- two times, early functional physiotherapy was done, ond and third degree on the entire dorsum of the hand, starting on postoperative day 2 after the second- extending from the second to fifth finger. The dorsal staged flap maturation and delayed inset. Each time joint lines of distal interphalangeal joint and proximal after operation, the vacuum glove was applied again. interphalangeal joint were crossed by the thermal in- The patient was released after 2 weeks in a compres- jury, the patient was not able to complete closure of sion glove of the grafted hand. the fist (Figure 1). The extension of wrist and fingers showed also a lack overall of 10 degrees. The patient reported numbness over the burned area as well in all DISCUSSION injured fingers. Tendons were exposed after initial Third- and fourth-degree burns in hand injuries de- mand early treatment to cover exposed tendons and salvage movement; defects are mandatory covered by Figure 1. Second- and third-degree burn injury to the dorsum of the hand, involving extensively the dorsal fin- Figure 2. Second application of the carved VAC, the flap is gers. filleted for the fingers.
  • 3. Journal of Burn Care & Research 364 Weinand March/April 2009 bed that can lead to a lower rate of graft take. The flap coverage described ranges from local forearm flaps, regional island flaps, including posterior interossefor- earm island,4,26 radial forearm Chinese flap27 to dis- tant flaps such as preformed groin flaps5,6,17,28 or even free flaps.29 Compared with skin grafting, flaps have a smaller rate of contracture relapse and partial failure. Groin-based flaps usually provide a sufficient tissue coverage with fat, but because of their nature of origin have to be debulked for esthetic appearance. As tendons were exposed and abundant tissue from the groin was available, we decided on an ileo-epigastic artery based flap. The flap provided ample coverage of Figure 3. The flap shows about 80% of attachment to the the tissue defect on the dorsum of the hand; however, dorsum of the injured fingers after VAC treatment. some debulking had to be planned. The attachment of the flap tissue to the burn wounds takes in general 2 to 3 weeks. Establishment tissue transfer.2,5,6 Dorsal contractures are the most of blood supply may play a role for this time frame.6 common complications of the burned hand and need The VAC device is used to support granulation tissue to be avoided. The dorsum of the hand has thin and formation after flap harvest, formation of granulation mobile nonglabellar skin, allowing individual joint tissue in degloving injuries, or support attachment of motion. This thin dorsal skin and scant subcutaneous split thickness skin grafts or temporary skin replace- tissue offers little protection to the deeper structures. ments.15,16,30,31 We used the VAC system as a glove Consequently, burns of the dorsum are often deep, to apply negative atmospheric pressure onto the pedi- resulting in a spectrum of deformities.21 Dorsal hand cled ileo-epigastric flap as has been described similar burn wounds remain, even with intense medical in- for degloving injuries31 or to decrease venous stasis tervention, one of the most challenging injuries.22 edema in a flap.20 It is possible that the observed After arrival and examination, our patient was taken effect of hastened attachment is due to the VAC sys- immediately to the operating room for eschar de- tem described effects such as of recruiting granulation bridement. The decision was made as early surgical tissue, vascularization, and possible stem cells from therapy helps avoiding revisions and improves re- the underlying dermis.15,30,32 In our case, we ob- sults.23,24 Here, exposure of tendons resulted from served a hastened attachment of flap tissue to the the depth of the thermal injury. wounds within 4 days by using the wound VAC sys- As for the type of coverage several options exist. tem early on. This tissue attachment was at the fin- Any type of skin graft has its limitations and disadvan- gers, in particular at the middle and ring finger, were tages. If thin split skin graft is used, the risk of joint no sutures had been placed. contracture is considerable25 and also color mis- Although the effect of improved wound granula- matching could be disappointing. The alternative tion and attachment of split thickness skin grafts are thick split thickness graft usually yields reasonable not completely uncovered, the effects have been well results, provided the graft takes without complica- described.16 –19,30 –33 Increased release of growth fac- tion. However, the resulting donor site morbidity tors has been described, leading to improved vascu- and partial graft loss are among the reported prob- larization, and thereby formation of new tissue.32 lems, leaving the patient with resulting larger defects. Further studies are necessary to evaluate the effects of Compared with split thickness skin graft, full-thickness the VAC system to pedicled flaps. skin graft is usually associated with better functional and esthetic outcomes. Nevertheless, in large burn wound areas of the dorsum of the hand, partial failure REFERENCES may occur. Generally, graft dyspigmentation, contractures, 1. Kunzi W, Zellweger G. Therapeutic possibilities in hand ¨ burns. Helv Chir Acta 1989;56:139 – 41. donor, and/or recipient’s site morbidity are among 2. Zellner PR, Bugyi S. The burned hand. Handchir Mikrochir postoperative complications of the three variations of Plast Chir 1984;16:170 – 82. skin grafts.25 Utilization of flaps are considered in the 3. Mahler D, Benmeir P, Ben Yakar Y, et al. Treatment of the burned hand: early surgical treatment (1975– 85) vs. conser- event of exposure of joints and tendons and also when vative treatment (1964 –74). A comparative study. Burns Incl there are questions about the quality of the wound Therm Inj 1987;13:45– 8.
  • 4. Journal of Burn Care & Research Volume 30, Number 2 Weinand 365 4. Groenevelt F, Kreis RW. Burns of the hand. Neth J Surg 19. Schrank C, Mayr M, Overesch M, et al. Results of vacuum 1985;37:167–73. therapy (v.a.C.) of superficial and deep dermal burns. Zen- 5. Baack BR, Osler T, Nachbar JM, Harris V. Steam press burns tralbl Chir 2004;129(Suppl 1):S59 –S61. of the hand. Ann Plast Surg 1993;30:345–9. 20. Uygur F, Duman H, Ulkur E, Ceikoz B. The role of the ¨ ¨ 6. Hanumadass M, Kagan R, Matsuda T. Early coverage of deep vacuum-assisted closure therapy in the salvage of venous con- hand burns with groin flaps. J Trauma 1987;27:109 –14. gestion of the free flap. Int Wound J 2008;5:50 –3. 7. Lu LJ, Gong X, Liu ZG, Zhang ZX. Antebrachial reverse 21. Gousheh J, Arasteh E, Mafi P. Super-thin abdominal skin island flap with pedicle of posterior interosseous artery: a pedicle flap for the reconstruction of hypertrophic and con- report of 90 cases. Br J Plast Surg 2004;57:645–52. tracted dorsal hand burn scars. Burns 2008;34:400 –5. 8. Barillo DJ, Arabitg R, Cancio LC, Goodwin CW. Distant 22. Kurtzman LC, Stern PJ. Upper extremity burn contractures. pedicle flaps for soft tissue coverage of severely burned hands: Hand Clin 1990;6:261–79. an old idea revisited. Burns 2001;27:613–19. 23. Tambuscio A, Governa M, Caputo G, Barisoni D. Deep burn 9. Smahel J. The healing of skin grafts. Clin Plast Surg 1977;4: of the hand: early surgical treatment avoids the need for late 409 –24. revisions? Burns 2006;32:1000 – 4. 10. Vidrine DM, Kaler S, Rosenthal EL. A comparison of 24. Pegg SP, Cavaye D, Fowler D, Jones M. Results of early negative-pressure dressings versus bolster and splinting of excision and grafting in hand burns. Burns 1984;11:99 –103. the radial forearm donor site. Otolaryngol Head Neck Surg 25. Iwuagwa FC, Wilson D, Bailie F. The use of skin grafts in 2005;133:403– 6. postburn contracture release. Plast Reconstr Surg 1999;103: 11. Deva AK, Buckland GH, Fisher E. Topical negative pressure 1198 –204. in wound management. Md J Aust 2000;173:128 –31. 26. Qian YL. Reversed forearm island flap with dorsal interosse- 12. Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS. ous artery for reconstruction of post burn deformities of the Mechanisms and clinical applications of the vacuum-assisted hand—report of 6 cases. Zhonghua Zheng Xing Shao Shang closure (VAC) device: a review. Am J Clin Dermatol 2005; Wai Ke Za Zhi 1990;6:81–2. 6:185–94. 27. Hallock GG. The radial forearm flap in burn reconstruction. 13. Moisidis E, Heath T, Boorer C, Ho K, Deva AK. A prospec- J Burn Care Rehabil 1986;7:318 –22. tive, blinded, randomized, controlled clinical trial of topical 28. Pradier JP, Oberlin C, Bey E. Acute deep hand burns covered negative pressure use in skin grafting. Plast Reconstr Surg 2004;114:917–22. by a pocket flap-graft: long-term outcome based on nine 14. Philbeck TE Jr, Whittington KT, Millsap MH, Briones RB, cases. J Burns Wounds 2007;6:e1. Wight DG, Schroeder WJ. The clinical and cost effectiveness 29. Adani R, Tarallo L, Marcoccio I, Cipriani R, Gelati C, Inno- of externally applied negative pressure wound therapy in the centi M. Hand reconstruction using the thin anterolateral treatment of wounds in home healthcare Medicare patients. thigh flap. Plast Reconstr Surg 2005;116:467–73. Ostomy Wound Manage 1999;45:41–50. 30. Molnar JA, DeFranzo AJ, Hadaegh A, Morykwas MJ, Shen 15. Blackburn JH, Boemi L, Hall WW, et al. Negative-pressure P, Argenta LC. Acceleration of Integra incorporation in com- dressings as a bolster for skin grafts. Ann Plast Surg 1998;40: plex tissue defects with subatmospheric pressure. Plast Re- 453–7. constr Surg 2004;113:1339 – 46. 16. Kopp J, Bach A, Loos B, et al. Use of vacuum therapy during 31. Polykandriotis E, Kneser U, Kopp J, Horch RE. Modified defect coverage of the upper extremity with microsurgically gloving technique for vacuum therapy in the hand. Zentralbl grafted arterialized venous flaps. Zentralbl Chir 2004; Chir 2006;131(Suppl 1):S36 –S39. 129(Suppl 1):S82–S84. 32. Armstrong DG, Lavery LA; Diabetic Foot Study Consor- 17. Kopp J, Bach AD, Kneser U, Loos B, Horch RE. Use of tium. Negative pressure wound therapy after partial diabetic vacuum therapy in a huge arterialized venous flap to recon- foot amputation: a multicentre, randomised controlled trial. struct a complete avulsion of a thumb. Zentralbl Chir 2006; Lancet 2005;366:1704 –10. 131(Suppl 1):S3–S6. 33. Haslik W, Kamolz LP, Andel H, Meissl G, Frey M. The use of 18. Meara JG, Guo L, Smith JD, Pribaz JJ, Breuing KH, Orgill subatmospheric pressure to prevent burn wound progression: DP. Vacuum-assisted closure in the treatment of degloving first experiences in burn wound treatment. Zentralbl Chir injuries. Ann Plast Surg 1999;42:589 –94. 2004;129(Suppl 1):S62–S63.