Wound healing requires adequate oxygen delivery to the area of injury which is dependent on circulating blood hemoglobin (hgb) levels.  So a common question is:  ‘What is the optimal hgb level for a patient in need of a split thickness skin graft?’.

Historically, a hgb of 10 g/dl has been felt to be low, but adequate for skin graft and donor site healing.  However, particularly in malaria prone areas, patients routinely have hgb levels lower than 10 on a chronic basis.  Many surgeons working in rural areas without easy access to blood transfusion capabilities and whose patients have chronic anemia, have felt that hgb levels as low as 8 or even 6 or g/dl can have successful skin grafting (“success” means that the graft takes and the donor site heals).  Now there is a study that supports this practice.

A study was published in the 2009 Indian J of Plastic Surgery by Agarwal, Prajapati and Sharma which shows that skin grafting can be successful in patients with hgb levels as low as  ~6 g/dl.   But in patients with malnutrition, dm, or other chronic conditions, higher hgb levels are warranted.

So save precious blood resources- skin grafts will heal despite these low hgb levels.  But remember, the patient will lose additional blood through harvesting of the skin graft and wound debridement.  So be careful, especially when doing large skin grafts.  A useful way to decrease blood loss at the graft donor site is to either:

• Inject the area with local anesthetic with epinephrine, and/or
• apply gauze soaked in dilute epinephrine (for example add one ml of 1:1000 epinephrine to 500ml of saline) to the donor site area after the skin graft has been harvested.

History

Although difficult to distinguish at first glance, this patient has a basal cell skin cancer  involving a large portion of the tip of his nose.  The resection will leave him with a significant open  wound, similar to one caused by bite or other traumatic injury.  This case illustrates some important  basic wound care concepts as well as demonstrates how to close a large nasal defect.

After excision

Physical Exam

The defect is large for the tip of the nose and measures 1.7 cm x 2.2 cm.  The surrounding skin is healthy, without signs of infection.  Necrotic tissue covers part of the wound.

What now? As with all wounds, you must start by anesthetizing the site to allow a thorough debridement and cleansing of the wound.

Now you can see that not only is it a large wound, but there is exposed cartilage which requires coverage.  This wound must not be allowed to  heal secondarily for several reasons:

• it will take many weeks for this wound to heal,
• the exposed cartilage will die,
• and the final result will have an unacceptable distortion of the nasal tip.

The exposed cartilage, requires full thickness skin with healthy circulation for coverage- a skin graft will not take because the overlying perichondrium has been removed.

Treatment options/what was done:

Feel the skin on your own nose.  The skin over the tip of the nose is quite adherent, whereas the skin over the bridge of the nose is more mobile.  One option is to create a flap- a bilobe flap from the nasal bridge to rotate into the defect.

This is an excellent option, but in plastic surgery, we always try to do the simplest thing first and use flaps as a back up.  Again feel the tip of your nose.  Note that it is actually quite soft and pliable.  If the skin is freed off of the underlying cartilage, it will actually move a fair distance because of the softness of the underlying cartilage and nasal mucosa.   So by dissecting the skin in the plane just above the cartilage and freeing the skin from its attachments widely, all the way around the defect and the entire tip of the nose, the skin can be brought together primarily to close the defect.

Which is what was done for this patient.

Here he is again a week later when the outer sutures were removed.  This will go on to smooth out and will heal quite nicely.

Corresponding chapters for further information:

Chapters:  6- evaluation of an acute wound; 10- secondary wound closure; 11- primary wound closure; 12- skin grafts

Dating back to ancient times, sugar, honey and other sugar containing substances have been applied to wounds to promote healing.   This modality is especially useful in areas where sugar is cheap and plentiful.

Sugar essentially works to by drawing moisture from the wound thereby creating an environment hostile to bacterial growth.  Sugar dressings have been noted to decrease odor, reduce wound drainage and surrounding edema, and stimulate growth of granulation tissue.   Remember, with time (hours), as fluid is drawn out of the wound, the sugar will become syrup-like and will thereby loose its antibacterial effects.  So additional sugar must be applied regularly to the area to remain effective.

Caution: Be careful in patients with pre-existing renal dysfunction.  There have been reports of severe hyponatremia and acute kidney failure in patients with these conditions.  Systemic effects such as impaired glucose intolerance have not been shown in patients treated with sugar dressings.

How to do it:

• Place gauze moistened with povidone-iodine solution or saline onto the wound.
• Coat this with granulated sugar (~0.5-0.75cm thickness)- honey works too!
• Within a few hours, as the sugar draws moisture from the wound, the sugar will become liquid, syrup-like.  As stated previously, when this occurs bacterial growth may be promoted, so it is critical to add more sugar to the dressing as needed, often several times/day.

I have personally never used this modality for wound care, although I have often heard about its utility.  If anyone has any actual experience doing sugar dressings, please let us know!

These 2 patients have what may appear to be similar wounds.  But upon close inspection, they are actually very different, with very different healing potentials.  In the table that follows, the first column lists the important issues which you must think about when examing a patient with a chronic wound.

2 wounds: similar in that they are chronic, open wounds, covered with granulation tissue.  But they are actually quite different….  How so? Does it matter?
Describe the wound	Almost circumferential wound of distal leg and proximal ankle.  Bland granulation with exudate	Anterior surface of distal leg onto dorsum of foot.  Beefy red granulation, minimal exudate
Infection present?	Probably not	Probably not
Describe the tissue surrounding the wound	Chronic edema, woody induration above wound, ankle with minimal range of motion	Minimal edema, surrounding skin supple, good ankle active/passive range of motion
Patient’s overall health status	~30.  Looks chronically ill, but nothing diagnosed	Healthy teenager
Etiology of wound	Small traumatic injury, that progressed	Acute, traumatic degloving injury of involved area
Duration of wound	Years	Weeks/month
Evidence of healing?	None	yes
Distal pulses	Present, but diminished	Yes, bounding
What the above tells you about hopes for getting this to heal… Options for closure.	Poor likelihood for healing.  Identify and treat any underlying medical issues (nutrition, immune disorder, etc..)  Could try debridement and STSG, but doubt success.  This is a very difficult problem and may only heal after amputation.	Good chance for this wound to heal.  Will eventually heal secondarily, but will take at least several more weeks and could cause significant contracture at ankle.  For best functional outcome, do a STSG.

Wound care is a challenge everywhere.  When you don’t have access to solutions useful for dressings, you can make your own.  Here are some “recipes”.

Make your own solutions for dressings, for cleansing wounds.

Saline solution:

Boil a liter of water for 15 min in a covered pot.

Add 1 tsp (5ml) of table salt or cooking salt to this solution.

Allow to cool, then store in a container with a well fitting lid.

Please note:  this solution should NOT TO BE USED AS AN EYEWASH SOLUTION

Dakin’s solution (dilute sodium hypochlorite solution)

Prepare a liter of saline solution (as described above).  Then…

The container should be protected from light by wrapping it in aluminum foil.

Once opened, these solutions should only be used for a few days.

Alternate dakin’s recipe, from Ohio State University Medical Center

http://www.survival-spot.com/survival-blog/make-your-own-antiseptic/

Boil 1 Liter of water in covered pot for 15 minutes

Then add ½ tsp baking soda

For ¼ strength solution: 1T + 2 tsp Clorox

For ½ strength solutions:  3T + ½ tsp Clorox

Transfer to sterile jar, cover tightly and protect from light.

While in the Democratic Republic of Congo, I had a chance to use a Lifebox – the low cost, very  reliable pulse oximeter developed as part of ‘safe surgery’ initiatives for low income countries.    http://www.lifebox.org Although I personally have some concerns with the promotion of this tool as  means for ensuring “safe surgery”, it is certainly a valuable tool in the operating room.

Particularly in low resource areas, where trained medical providers are in short supply, this device  could have more widespread application throughout the hospital,     For example:  in crowded  emergency/casualty wards- a quick pulse oximetry reading could assist with patient triage; in intensive  care/highcare units- it could help determine whether a patient was improving or not with therapy;  on regular wards- it could help determine if a patient was in need of more timely treatment or transfer to a highcare unit. And because it is so easy to use, non-physician providers can use this device to help identify those patients in need of additional attention from trained providers, thus better leveraging the skilled providers’ services.

The developers of Lifebox are to be congratulated,as this easy-to-use device has the potential to make a significant impact on patient outcomes throughout the hospital.

Having just returned from 2 weeks working in the eastern Democratic Republic of Congo- I am again humbled and saddened by the devastating effects of burn injuries.

Some patient examples:

older child with contracture of axilla and antecubital fossa

adult with neck and face keloid/contractures

As mentioned in my prior blog posting- prevention is key.

Prevention of the burn injury in the first place

Many burn injuries, especially those involving children are due to indoor cooking over an open fire.  Although inefficient in terms of use of natural resources (wood,coal) this way of preparing food is a major cause of burn injuries.  In addition, the indoor air pollution created is a significant contributor to pulmonary illness worldwide.  A number of initiatives are ongoing to create and distribute safer and more effective ways to cook and thereby prevent these debilitating conditions. The largest and most ambitious is the Global Alliance for Clean Cookstoves:  http://cleancookstoves.org

Prevention of contractures in patients who have sustained burn injuries

As mentioned in my prior post, it is far easier to prevent the contracture than to treat a longstanding joint contracture- as often it is more than just a “skin” problem. Longstanding contractures often lead to joint irregularities/arthritis, as well as tendon and ligament abnormalities, which can make normal function impossible despite operative intervention.

Splints, early skin grafting, regular physical therapy during the healing process are the keys.  This does not require high tech equipment- have the patient squeeze a rubber ball or use cloth to create a sling the patient can pull against.  The goal is to keep joints moving and supple- to try to prevent joint contractures and thereby prevent lifelong disability.

History: Over a year ago, this 3 year old boy burned the palm of his hand and fingers.His hand function is now severely limited because his fingers are essentially stuck into the palm of his hand.

Physical Exam: Tight scar tissue connects the fingers into the palm.  The thumb has  some free motion, but all of the other fingers are severely restricted.

Treatment options/what was done: This child was brought to the operating room  and the scar tissue connecting the fingers to the palm was cut out (remember to use an upper arm tourniquet so the operative field is bloodless).  This left a large open wound from the palm of the hand onto the base of the proximal phalanges.This wound must be covered with new tissue to prevent recurrence of the contracture.  Because the wound was covered with healthy tissue and there were no exposed tendons, a full thickness skin graft (taken from the child’s abdomen) was used to cover the wound.  After the graft was placed, the hand was put in a splint and wrapped in a bulky dressing for a few weeks.  The splint is critical to stabilize the graft and help the graft to heal. With an adult patient- the dressing would be removed in 5-7 days and the splint reapplied.  It is usually very difficult for a child this young to cooperate and wear a splint, so the dressing is kept in place for a longer period of time.

Here is the child’s hand after the dressing was removed. 

To prevent recurrence of the scar contracture, for the next several months the child (with help from the family) must regularly:

• do gentle range of motion finger exercises
• apply moisturizing cream to the graft and do gentle massage.

In addition, a splint is useful to keep the fingers out of the palm during the healing process, but this is challenging for young children.  An alternative may be to create some type of bulky dressing for the child to wear just when sleeping.  If a glove is available, this may serve as a substitute for a splint.  Just be careful taking the glove on and off, so it doesn’t shear the graft.

Corresponding chapters for further information:

• • chapter 12:  skin grafts
  • chapter 28:  hand splinting and general aftercare
  • chapter 34:  hand burns

Severe burns are a worldwide problem especially  in rural areas.  Aside from the immediate loss of life, the potential for long-term disability is great.  In subSaharan Africa, young children under the age 15, lose seven times the number of productive years from fires than from war.

In South Asia, more years of healthy life are lost for people between the ages of 0-29 due to fire (burn injury) than from TB, malaria, or HIV/AIDs.  In this region, as distinct from the rest of the developing world, women are disproportionally more affected than boys, with almost 72% of these burn injuries afflicting young girls and women.

These estimates are conservative at best.

Most general surgeons or clinical doctors with some surgical training have the skills to save lives- i.e., the acute resuscitation and basic burn wound care required for the patient with a significant burn injury.  But often, the more subtle issues relating to maintenance of function during the healing stages are not considered by providers without plastic surgical expertise.  Without proper attention to the need for splints (hand burns) or early burn excision and skin grafting (for large burns) the healing process can result in significant disability.  The resulting burn scar contractures (which can occur despite even the best of care) can result in significant disability.  And once the contracture has formed, it can be difficult to correct.

Some actual patients:

Patient 1: A 3 year old boy who burned the palm of his hand over a year earlier when he grabbed a hot pot.  The burn was not life-threatening, but due to lack of treatment, his fingers are now contracted and literally stuck into his palm- this child’s hand is essentially useless.

Patient 2: A 9 year old girl who suffered severe burns to the back of her hand as a young child.  Again this was not a life threatening burn, but the skin on the back of her hand was allowed to heal on its own and the result:   very tight scars which did not grow as she has grown.  She now has a severely disfigured and dysfunctional hand.

How these patients can be helped:

Prevention is key.  It doesn’t take fancy equipment or special skills to prevent these terrible outcomes.  The following three interventions can dramatically improve patient outcomes.

• Application of splints while the burn wounds are healing will help to prevent contractures.  You want to keep the hand and fingers in neutral position (wrist in slight extension, MP joints in flexion, and IP joints straight).
• In addition, regular physical therapy during the healing process will keep the joints mobile.  Encourage the patient/patient’s family to help them exercise their fingers several times a day.
• And particularly for burns that cross joint creases, early excision of the burned tissue followed by skin grafting can prevent or lessen the disability than can results from these injuries.

Applicable Book Chapters:

• Chapter 20:  Burns
• Chapter 28:  Hand Splinting and General Aftercare
• Chapter 34:  Hand Burns

If this were your hand, severely deformed from a previous burn injury,  you would want access to a plastic surgeon.

When considering the major disease control priorities in developing countries, the paucity of plastic surgeons is often ignored as a significant concern for health care delivery.  However, the current estimate of the global burden of surgical disease is 11-15% of the total global burden of disease.  And of this, 66% is attributed to injuries, malignancies, and congenital anomalies, three areas in which plastic surgical expertise are commonly required.

So, although not necessarily seen as a major player in issues related to global health, plastic surgeons are uniquely qualified to decrease the burden of surgical disease afflicting people in low and middle income countries as well as to decrease years of life lost due to disability from these treatable conditions.

complicated leg wound with soft tissue loss

Unfortunately, there is a significant shortage of plastic surgeons in many areas of the world.  The populous countries of China and India only have ~1.5 plastic surgeons per million people, while many countries in sub-Saharan Africa have far fewer and sometimes none in the entire country (in the United States there are ~6 per million people).  A challenge shared by all countries is that these specialists are concentrated in urban areas, far from the populous rural areas where much of the burden lies.

Where this website fits in:

The purpose of this website it to bring information regarding practical plastic surgery concepts and techniques to health care providers working in areas with little or no access to plastic surgeons.

This blog will offer short discussions on various plastic surgery topics.  Please send me questions or recommendations for topics you would like discussed.  Or if there is information you would like to share, please contact me and I’ll post it here.