RU2753136C1 - Method for autodermoplasty with split-thickness graft for restoration of skin after burns - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly, to surgery, and can be used in surgery for treatment of patients in restoration of skin after burns by means of autodermoplasty. For this, the surgical area is treated with an antiseptic solution followed by taking a skin graft from the donor site, blood is taken from the patient and then divided into plasma, platelets and a layer of erythrocytes and leukocytes. Blood is therein taken from the patient during routine surgical treatment of burn surfaces from a peripheral or central vein in an amount of 9 ml into a sterile test tube containing an olefinoligomer. The blood is then centrifuged for 4 to 6 minutes at 3000 rpm, dividing into plasma, platelets and a layer of erythrocytes and leukocytes, separating the layer of plasma and the platelets into a syringe and injecting to the patient from the side of the wound into intact skin in portions of 0.1 ml inserting the needle at 0.2 to 0.3 cm in length at intervals of 0.5 to 1.0 cm along the perimeter of the entire wound. The wound bed is then treated with a platelet-enriched autoplasma by drip irrigation, covering the entire wound surface evenly. The procedure is performed 1 time per five days twice, and the skin graft is taken from the donor site at a depth of 0.2 mm with subsequent perforation thereof at 1:3, followed by placing the graft on the wound and then covering the donor wound and the transplantation area with sterile dressings with an antiseptic solution.

EFFECT: method allows accelerating healing of the wound and improving the cosmetic effect by stabilising spontaneous regeneration and reducing the imbalance between fibroplasia and fibre degeneration, ordering the positioning thereof when filling the wound, with simultaneous closing of extensive wounds, low injury rate and technical simplicity of the operation.

1 cl, 9 dwg, 4 ex

Description

The technical field to which the invention relates

The invention relates to medicine, in particular to a method of autodermoplasty with a split skin graft to restore the skin in case of burns, and can be used in surgery, by the method of autodermoplasty for treating patients with skin restoration in case of burns.

State of the art

There is a known method of skin grafting by cutting out a skin flap, separating skin elements into particles, mixing them with a stabilizing solution and applying the resulting suspension to the wound surface, while the epidermal skin flap is cut out on a leg, separated around the perimeter of the donor site of the dermis, dried in vacuum with cooling to 4-4 ° C, and then crushed to microparticles, while an antifibrinolytic agent is used as a stabilizing solution, and the epidermal skin flap is returned to the donor surface.

In the method, a 0.5-1.0% solution of ensilonaminocaproic acid is used as an antifibrinolytic agent.

In the method, the suspension is applied to the wound surface by means of an applicator.

In the method, the suspension is applied to the wound surface by injection under the burn scab.

In the method, the suspension is applied to the wound surface by injection with a needleless injector, after which the wound surface is covered with artificial skin (see US Pat. RU No. 2093083, MP K A61B 17/00, A61B 17/322, A61K 31/195 publ. 20.10.1997 G.).

The disadvantage of this method is the long terms of treatment.

Known allograft for the restoration of the skin, the method of obtaining it and the method of restoring the skin with damage is different and etiology:

- allograft for skin restoration, containing a polymer substrate with human cells applied to it, while the polymer substrate is made of cellophane, and certified cells of the diploid strain of human embryo lung fibroblasts L-68 at a concentration of 80-100 10 ⁶ cells are used as human cells / cm ² on the substrate.

- a method of obtaining an allograft for restoring the skin, while it includes processing a cellophane substrate with a detergent, washing it with distilled water, drying, defatting with ethyl alcohol, coating with 1% gelatin, applying certified cells of the diploid strain of human embryo L-68 at a concentration of 80 -100 10 ⁶ cells / cm ² on a substrate, previously grown in suspension, which is cultured for 1-5 days in a growth medium at 37 ° C and a CO ₂ incubator.

- a method of restoring the skin in case of damage of various etiology by applying an allograft on a polymer substrate with cells down to the wound, while the allograft obtained according to claim 2 is covered with an aseptic bandage, removed after the appearance of epithelialization (see US Pat. RU No. 2142820, IPC A61L 27 / 00, publ. 20.12.1999).

The disadvantage of this allograft for the restoration of the skin, the method of obtaining it and the method of its restoration is the complexity, long terms of treatment.

A known method of treating patients with deep thermal burns, including the use of cells of the stromal vascular fraction of adipose tissue, while after stabilizing the general condition of the patient and the positive dynamics of the local process in the wound during routine surgical treatments of burn surfaces, adipose tissue is taken in the lower third of the anterior abdominal wall By means of syringe liposuction, the stromal-vascular fraction of adipose tissue is isolated from the obtained lipoapirate by enzymatic treatment and directly during the procedure, a suspension of viable cells of the stromal-vascular fraction of adipose tissue is injected in an amount of 15 × 10 ⁶ in a volume of 2-4 ml of suspension at 10-15 points around each wound surface (see US Pat. RU No. 2668801, IPC A61M 5/00, A 61 K 35/28, A61P 41/00 publ. 02.10.2019).

The disadvantage of this method is the complexity of the operation, unsatisfactory cosmetic effect.

The closest in technical essence and the achieved positive effect and adopted by the authors as a prototype is a method of autodermoplasty with a split skin flap to restore the skin in case of burns, including the treatment of the operating field with an antiseptic solution, blood sampling from the patient, followed by separation into plasma, platelets and a layer of erythrocytes and leukocytes and collection from the donor site of the skin flap (see Alekseev A.A., Bobrovnikov A.E., Popov S.V. Modern technologies of surgical treatment of burn victims // Mat. their consequences' ". Donetsk, 2005. P. 114-116.

The disadvantage of this method is the long terms of treatment, low cosmetic effect due to the formation of scars.

Disclosure of invention

The objective of the present invention is to develop a method for autodermoplasty with a split skin graft for restoring the skin in case of burns, which has the ability to simultaneously close large wounds, low trauma and technical simplicity of the operation, shortening the operation time, accelerating wound healing and improving the cosmetic effect.

The technical result, which can be achieved with the help of the present invention, comes down to the possibility of one-step closure of extensive wounds, low trauma and technical simplicity of the operation, shortening the operation time, accelerating the healing of brine and improving the cosmetic effect.

The technical result is achieved using the method of autodermoplasty with a split skin graft to restore the skin in case of burns, including the treatment of the operating field with an antiseptic solution, blood sampling from the patient, followed by separation into plasma, platelets and a layer of erythrocytes and leukocytes and collection from the donor site of the skin graft, when In this case, blood sampling from the patient is carried out during routine surgical treatment of burn surfaces from a peripheral or central vein in an amount of 9 ml into a sterile tube containing olofinoligomer, which is then centrifuged for 4-6 minutes at 3000 rpm, dividing into plasma, platelets and a layer of erythrocytes and leukocytes, separate the plasma layer and platelets into the syringe and inject the patient from the side of the wound into the intact skin in portions of 0.1 ml by 0.2-0.3 cm injecting the needle in length with intervals of 0.5-1.0 cm but the perimeter the entire wound, then the wound bed is treated with platelet-rich autoplasma by drip irrigation with covering the entire wound surface evenly, and this procedure is carried out once every five days twice, and the sampling from the donor site of the skin flap is made to a depth of 0.2 mm, then it is perforated 1: 3 and placed on the wound, followed by covering with sterile dressings with an antiseptic solution donor brine and transplantation zones.

Thus, the plasty of wounds with a free split skin flap occupies a special place in purulent surgery and consists in closing the wound defect with moistened free thin skin flaps. Currently, the collection of skin flaps is carried out using a special dermatome device, which allows you to select the required flap thickness (most often 0.3-0.5 mm). The choice of donor surface depends on the goals of autodermoplasty and the presence of areas of unaffected skin. It is most convenient to take skin flaps to close large defects in the area of the thighs, legs, back and buttocks. If there is a lack of healthy skin in these areas, you can also use the skin of the chest and abdomen. In these cases, an isotopic solution of sodium chloride or a weak solution of novocaine is injected into the subcutaneous tissue to level the unevenness of the chest relief associated with the protrusion of the ribs.

The donor site should have mostly healthy skin, although the possibility of skin grafting with single folliculitis and uncomplicated small boils is not excluded. Skin grafts should be cut, if possible, on the side of the wound to be plasticized, so that in the postoperative period the patient does not lie on the donor surface.

The thickness of the skin graft taken can vary from 0.2 to 0.4 mm. Thicker flaps are transplanted to areas that carry a greater load - feet, palmar surface of the hands. On functionally active parts of the body (hands, joints, neck, face), skin grafts with a thickness of 0.3 ... 0.4 mm are transplanted. After cutting off the skin layer, donor sites are covered with several layers of gauze dipped in a furacilin solution. A cotton-gauze bandage with Vishnevsky's ointment is applied on top. On the 2nd day after the operation, the ointment bandage is removed, and the layers of gauze adhered and soaked in blood are dried with a hairdryer and strengthened with a bandage. Healing proceeds under the scab, and after 10-12 days the formed gauze crust is rejected on its own and the restored epithelial cover opens. If necessary, the skin can be re-sampled from this area. The skin grafts obtained in this way are perforated, placed and carefully fixed on a previously prepared wound surface. Engraftment occurs on the seventh day after the operation. The donor wound (the site of the graft collection) heals, as a rule, on the 12-14th day of the postoperative period, depending on the thickness of the removed skin.

The main advantages of the method are the possibility of simultaneous closure of extensive wounds, low trauma and technical ease of implementation. This operation does not lead to a deterioration in the general condition of the patient and an increase in the size of the wound even with an unfavorable course of the postoperative period, is not accompanied by significant blood loss, does not require complex types of anesthesia, which allows it to be successfully used in elderly and senile patients. It is also important that in the course of this surgical intervention, no serious damage is caused to the donor area. The disadvantages of free skin grafting with a split flap are associated with the fundamental impossibility of restoring a full-fledged skin integument, which in some cases can lead to unsatisfactory cosmetic and functional results of treatment, especially in the long term.

The essence of the method of autodermoplasty with a split skin graft to restore the skin in case of burns is as follows. The surgical field is treated with an antiseptic solution, then blood is taken from the patient, followed by division into plasma, platelets and a layer of erythrocytes and leukocytes and a collection from the donor site of the skin flap, while blood sampling from the patient is carried out during routine surgical treatment of burn surfaces from the peripheral or a central vein in the amount of 9 ml into a sterile tube containing an olefinoligomer, which is then centrifuged for 4-6 minutes at 3000 rpm, separating into plasma, platelets and a layer of erythrocytes and leukocytes, separating the plasma layer and platelets into a syringe and injecting the patient from the side wounds into intact skin in portions of 0.1 ml per 0.2-0.3 cm of insertion of a needle in length at intervals of 0.5-1.0 cm along the perimeter of the entire wound, then the wound bed is treated with platelet-rich autoplasma by drip irrigation with a coating uniformly throughout the entire wound surface, and this procedure is carried out 1 time in five days, and the collection from the donor site of skin The second flap is made to a depth of 0.2 mm, then it is perforated 1: 3 and placed on the brine, followed by covering with sterile dressings with an antiseptic solution of the donor brine and the transplantation zone.

Brief description of drawings and other materials

In FIG. 1 shows a method of autodermoplasty with a split skin graft to restore the skin in case of burns, donor wound after skin harvesting;

In FIG. 2, the same, the wound is covered with several layers of gauze;

FIG. 3, the same, healed donor wounds;

FIG. 4, the same, the collection of a skin flap with a disk electrodermatome;

FIG. 5, the same, granulating burn wound prepared for closure;

FIG. 6, the same, placement and adaptation of grafts on the wound;

FIG. 7, the same, engraftment of grafts;

FIG. 8, the same, burn after cleansing from necrosis;

FIG. 9, the same, the burn wound is closed with a mesh autodermotransplant.

Implementation of the invention

Examples of a specific implementation of the autodermoplasty method with a thawed skin graft to restore the skin in case of burns, which is carried out in the surgical and trauma departments of the Stavropol City Clinical Hospital No. 2 for eight years.

Example 1. More than 300 patients aged 10 to 64 years of both sexes with postoperative wounds, injuries and burns up to III B degree were studied. Of these, 268 patients were selected into the study groups on the basis of the comparability of injuries and surgical interventions, somatic status and methods of main treatment. All patients with postoperative and traumatic wounds were divided into 3 groups with an adequate ratio of pathologies in each of them:

- I, control, are 84 patients who receive complex physiotherapeutic treatment: magnetotherapy from the device "Polyus 01" from the 4th day of treatment, ultrasound exposure to the pan area 12 days later from the moment of injury or surgery using hydrocortisone ointment, electrophoresis of Karipazim from solution starting from the thirtieth day with a duration of ten procedures. A complex of physiotherapy procedures is performed on an outpatient basis. Repeat the course every 3 months for 2 years;

- Group II consists of 117 patients who receive primary prevention of pathological scarring in the early stages - from 2 days after injury or surgery, the Longidase enzyme is injected at a dosage of 1500-3000 VD deep intramuscularly 1 time in 4 days with a course of 10 injections, and starting from 2-5 days, using a thin layer, Kontraktubex gel is applied in a thin layer, which is a three-component drug with a pronounced antihyperproliferative activity, then at the end of wound epithelization, 10 ultraphonophoresis procedures with Kontraktubex gel are performed daily, that is, if there is a possibility of contact of the head of the apparatus with the skin surface. Since Kontraktubex consists of allantoin, heparin and onion extract, there were no contraindications in the form of hypersensitization to parabens, as well as side effects from the use of the drug. The use of Kontraktubex gel was continued independently by patients after discharge 3 times a day for 3 to 6 months. When applying the gel, elastic compression is used for injuries and wounds of the extremities, and silicone plasters on the head and trunk. Also, within the framework of this rehabilitation scheme, exercise therapy classes are carried out with an early start of functional exercises. The repetition of the course of epsimotherapy and phonophoresis is carried out after 3 months;

- Group III consists of 67 patients who receive an early start of anti-scar therapy in the form of a wound injection of platelet-rich autoplasma. obtained by step-by-step centrifugation of autologous blood, collected immediately before manipulation from the patient himself on day 2 after PXO or surgery. This procedure is carried out once every 5 days twice, as follows: blood is taken from the patient during routine surgical treatment of burn surfaces from a peripheral or central vein in an amount of 9 ml into a sterile tube containing an olefipolygomer, which is then centrifuged for 4-6 minutes at 3000 rpm, dividing into plasma, platelets and a layer of erythrocytes and leukocytes, the plasma layer and platelets are separated into a syringe and injected into the patient from the side of the wound into intact skin in portions but 0.1 ml by 0.2-0.3 cm. at intervals of 0.5-1.0 cm along the perimeter of the entire wound, then the wound bed is treated with platelet-rich autoplasma (OTA) by drip irrigation with uniform coverage of the entire wound surface, and platelet-rich plasma can be prepared only from non-coagulated blood, It cannot be prepared from clotted whole blood, from which serum is usually obtained, because most of the platelets remain in the formed with a bunch. Also, OTL cannot be prepared from serum, which is a clear liquid obtained from whole clotted blood and freed from cells and proteins involved in the clotting process. Serum contains very few platelets. Blood, for the preparation of OTL, is taken into a container with sodium citrate, which binds calcium ions, thereby blocking the entire coagulation cascade. This is followed by the centrifugation stage, which is carried out in one or two stages. In the first centrifugation, plasma and platelets are separated from red blood cells and white blood cells. Erythrocytes (7 microns in diameter) and leukocytes (7-15 microns in diameter) are much larger and heavier than platelets (2 microns in diameter) and are easily separated. The second centrifugation is carried out more gently and, as a result, OTL is concentrated; in the superpatant, platelet-poor plasma remains, while after the first injection of autoplasma there is an improvement in the regeneration process, the absence of inflammation and, as a result, a reduction in the wound healing time, due to the stabilization of spontaneous regeneration and a decrease in the imbalance between fibroplasia and fiber degeneration, their ordering in arrangement when filling the wound defect after stimulation by the introduction of platelet-rich plasma, a lesser formation of a leukocyte roll at the edges of the wound was noted, an acceleration of the convergence of the edges of the wound, stabilization of the wound with young tissue and, subsequently, less formation of a pathological scar. After the epithelialization is completed, Kontraktubex is applied to the area of injury or surgery 3 times a day and a silicone compression patch is permanently fixed or a pressure elastic bandage is worn.

The result was monitored in each case for at least 6 months by medical examination and dynamic examinations. The assessment was carried out according to the modified Vancouver scales for individual signs of scar development, where the best result was also obtained in group 3 of patients. Clinical examination was carried out and continues to be carried out on the basis of the department of purulent surgery of the MBUZ GKB No. 2. Passing examinations every 3 months, in addition to a clinical examination, if necessary, patients undergo an ultrasound examination of the scar-altered area for a more detailed control of the condition of the connective tissue, its thickness, density. In addition, patients independently keep a diary - a questionnaire, where they regularly, once a week, enter the characteristics of their problem, answering standard questions that are the same for everyone.

The obtained data were distributed as follows: In the control group, 48 patients (57%) developed hypertrophic scars requiring correction, 22 patients (26%) were bothered by pathological scars only from a cosmetic point of view, and in 14 (17%) patients healed with the formation of a normotrophic scar ...

In the second group, upon observation for 6 months, the formation of pronounced hypertrophic scars was noted in 21 patients (18%), while in the third group, cicatricial deformities were noted only in 9 patients (13%), while 53 people from group 2 (45%) ) noted discomfort in the area of forming scars; in group 3, similar complaints were found in 27 patients (40%). Cosmetic defect worried in the second group of 29 people (25%), in the third - II (16%). Functional disorders associated with the development of scars and tissue tension developed in group 2 in 19 patients (16%), and in group 3 - in 10 patients (15%).

As a result of the analysis of the data obtained from the study and the data of the study of the literature, the following conclusions are logical:

- hyperplasia of the connective tissue in the process of replacing a wound defect, despite the rapid and progressive darkness of the development of modern medicine, remains an extremely urgent problem for surgeons and traumatologists;

- the highest efficiency of complex therapy in the early stages of scar tissue formation with the use of autohemotherapy and topical Kontraktubex gel has been shown, and a rather high efficiency of an integrated approach to the prevention of pathological scarring with the use of systemic, local and physiotherapy has been shown.

The proposed prophylaxis complexes do not relieve doctors of the problem of hypertrophic scars, but nevertheless they can significantly reduce the need for surgical interventions to eliminate coarse cicatricial contractures, a good cosmetic effect is achieved and such undesirable consequences of the development of scars as itching, a feeling of constriction, and a violation of full-fledged function are largely eliminated. extremities, can significantly improve the outcomes of treatment of surgical patients, reduce the time of complete recovery and improve the quality of life of patients.

The use of prp for long-term non-healing wounds associated with impaired vascular trophism during reconstructive vascular operations and without eliminating the primary pathology. At the moment, there are 4 patients under observation with staged prp injections performed by the peripheral cut-off method of administration.

Examples of specific implementation on patients of the method of autodermoplasty with a split skin graft to restore the skin in case of burns.

Example 2.

Volnaya I., 44 years old (Case history No. 4865)

Ds: Thermal burn with boiling water 2-3 tbsp. left lower leg, thigh, moans S-14% p.t. (3 tbsp. 9% pl.)

Comorbidities: Chronic venous insufficiency type 2 diabetes.

Standard therapy was carried out using infusions, antibacterial drugs, anticoagulants, NSAIDs. On the 4th day after the burn injury, surgical treatment was performed - under spinal anesthesia, skin grafts were taken from the right thigh to a depth of 0.2 mm with a disk electrodermatome, the flaps were perforated 1 to 3. Donor wounds were covered with bandages with an antiseptic solution.

Burn brines are freed from non-viable tissues. From the patient's peripheral vein, 9 ml of blood was taken into a sterile blood test tube containing Olefinoligomer, after centrifugation, plasma with platelets was taken from the test tube with a sterile syringe, injected along the perimeter of the wounds, the remaining plasma was applied to the wounds by irrigation, perforated grafts and aseptic dressings were placed on top ... On the 2nd day of the postoperative period, the condition of the grafts is satisfactory, there are no signs of lysis, the fixation of the flaps to the wound surface is stable. On the 5th day, the repeated administration of OTL was performed according to an identical scheme. On the 7th day after the operation, the patient moves independently in the ward, 98% of the flaps are engrafted, and the longevity in the cells of the mesh grafts is good. She was discharged on day 9 with stable epithelialization without signs of inflammation, lysis, rejection. Dermoscopy and histology confirm epithelialization without signs of pathological scarring.

Example 3.

Free N, 39 years old, was admitted to the department with a diagnosis: Thermal flame burn of the right upper limb, chest, face, neck 2-3 tbsp. 24% p.t. (3 tbsp. 20% p.t.). Burn shock 1 tbsp. Inhalation thermal trauma.

After carrying out anti-shock measures for three days, on the 4th day after the injury, surgical treatment was performed: surgical treatment of wounds with the removal of all non-viable tissues in wounds under general anesthesia, skin grafts were taken from the right thigh to a depth of 0.2 mm, for laying on the face and the neck flaps were not perforated, for the upper limb a 1 to 3 perforation was made. Donor wounds were covered with sterile bandages. From a peripheral vein, 18 ml of blood was taken into two sterile blood tubes containing Olefinoligomer, after centrifugation, plasma with platelets was taken from the tubes with a sterile syringe, introduced along the perimeter of the wounds, the remaining plasma vapor was applied by irrigation, perforated grafts were placed on top and covered with aseptic dressings ... In the postoperative period, active engraftment of grafts was noted without signs of rejection and inflammation, and there was no growth of excess connective tissue. On the face and neck of 5 females, the flaps were fixed tightly; the repeated injection of the OTL was performed using an identical scheme. On the 11th day, the patient was discharged from 96% of epithelialized wounds, which was confirmed by dermoscopy. Donor wounds without signs of inflammation, epithelialization is satisfactory, not complete.

Example 4.

Patient D., 26 years old, presented with a chemical burn of the face, neck, chest and hands 2-3 tbsp. 10% PT .. No significant concomitant pathologies (identified. Taking into account the characteristics of chemical tissue damage, early surgical interventions are not indicated, the patient was operated on after the preparation of the wounds on the 9th day after the injury.

Under general anesthesia, surgical treatment of wounds was performed with excision of necrosis and granulations, treatment of the edges of wounds in connection with the development of connective tissue, skin grafts were taken from the lower limb with a disk electrodermatome to a depth of 0.2 mm with a total area of 360 cm per sq. 3. Donor wounds are covered with sterile dressings. From a peripheral vein, 18 ml of blood was taken into two sterile blood tubes containing Olefinoligomer, after centrifugation, plasma with platelets was taken from the tubes with a sterile syringe, injected along the perimeter of the wounds, the remaining plasma was applied to the wounds by irrigation, perforated grafts were placed on top and covered with aseptic dressings ... In the postoperative period, on the 3rd day after autodermotransplantation, the flaps are tightly fixed, without significant inflammation and signs of rejection or lysis. On the 5th day after the operation, OTA was administered according to an identical scheme. On the 8th day, active filling of the mesh graft was noted, confirmed by puncture and histological examination, as well as by dermoscopy. On the 10th day after the operation, epithelialization was identified as complete, the patient was discharged.

The proposed invention in comparison with the prototype and other known technical solutions has the following advantages:

- allows to increase the tightness of one-step closure of extensive wounds and accelerate the healing of postoperative wounds;

- has low trauma and technical simplicity of implementation;

- creates a good cosmetic effect due to the optimal adaptation of the wound edges and the absence of additional injection sites on the skin;

- accelerating the healing of brine and shortening the patient's stay in the hospital.

Claims (1)

The method of autodermoplasty with a split skin graft to restore the skin in case of burns, including the treatment of the operating field with an antiseptic solution, blood sampling from the patient, followed by separation into plasma, platelets and a layer of erythrocytes and leukocytes, and collection from the donor site of the skin graft, characterized in that blood sampling from the patient is carried out during routine surgical treatment of burn surfaces from a peripheral or central vein in an amount of 9 ml into a sterile tube containing an olefinoligomer, which is then centrifuged for 4-6 minutes at 3000 rpm, dividing into plasma, platelets and a layer of erythrocytes and leukocytes, separated a layer of plasma and platelets into a syringe and injected to the patient from the side of the wound into intact skin in portions but 0.1 ml per 0.2-0.3 cm of insertion of a needle in length with intervals of 0.5-1.0 cm along the perimeter of the entire brine, then the wound bed is treated with platelet-rich autoplasma by drip irrigation with a coating evenly throughout the wound th surface, and this procedure is carried out once every five days twice, and the sampling from the donor site of the skin flap is made to a depth of 0.2 mm, then it is perforated 1: 3 and placed on the wound, followed by covering with sterile dressings with an antiseptic solution of the donor wound and areas of transplantation.

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