j_vrferna..f/otto) Co~~~~ re55 ovr Researc.h i 17
`-
`Bw r t1 c.
`?d > Pra.lj t~ e ;
`I CJ 7 D .
`Research in Burns
`
`Edited by
`P. Matter, Basle
`T. L.Barclay, Bradford
`Z. Konickova, Prague
`
`Hans Huber Publishers Bern Stuttgart Vienna
`
`

`

`HARVARD MEDICAL LIBRARY
`IN THE
`r
`•.
`"'
`-
`••
`FRANCIS A. C0U N f WAY
`UBRARY_ OF MEDICINE
`Transactions of the Third International Congress on Research in Burns, held
`in Prague, September 20- 25, 1970
`
`wu
`70~
`T Vl ~I
`17Dr
`cop~ I
`
`-/
`
`©. J97l _by Hans Huber Publishers Bern
`Prmted m Switzerland
`by Zollikofer & Co. Ltd. St. Gall
`
`

`

`Contents
`
`Chapter 5
`Skin replacement
`
`The principles of skin grafting in burns. D.M. Jackson (Birmingham)
`Studies on the recipient areas for grafts. J.C. Lawrence and A.R. Groves
`(Birmingham) ................................................ .
`Acidometric investigation of the granulation tissue. P. Cesanj (Trinec) .
`Multiple uses of cadaver homograft skin in burned patients J.M. Shuck,
`B.A. Pmitt Jr. and J.A. Moncrief(Albuquerque/Ft. Sam Houston/
`Charleston) ........................... .. ..................... .
`Use of preserved cadaver homografts in combination with autografts in
`the operative treatment of severe burns 3rd and 4th degree in
`children. D. Ranev (Sofia) ....................... . ............. .
`Fetal calf skin and nucleic acids in the surgical treatment of extensive
`burns. H. Seinfeld, W. Brendel and H. Bohmer! (Munich) .......... .
`Clinical experience with porcine xenografts. E.J. Law, P. Nathan and
`B.G. MacMillan (Cincinnati) ........ ... ... . . . .................. .
`Pig skin biological dressings on burn wounds. !. C. Song and
`B.E. Bromberg (New York) .................................... .
`The use of xenomaterial for the local burn care. J. Kalina and M. Jeiek
`(Ostrava) ................... . .. . .................. . .......... .
`Preparation of chorion and/or amnion grafts used in burns. R. Klen
`(Hradec Kralove) .............................. .... .......... .
`The use of homografts and heterografts in burn management.
`L.D. Stern (San Jose) ........... . ........... : . ............... 1 ..
`Application of early necrectomy and grafting in deep dermal burns in
`children. I . Pedisic (Zagreb) ........................ . .... . ..... .
`The partial excision in the treatment of burns. A.N. Mindikoglu a nd
`F. Oz ([stanbul) ........................................... .. . .
`Primary excision of full thickness burns up to 40 % of body surface
`followed by micro- or meshgrafts. R .P. Hermans (Beverwijk) ....... .
`Mesh grafting of extensive burns. J.A. Boswick Jr. (Chicago) ......... .
`The use of expansion meshed grafts in the acute and reconstructive
`management of thermal injuries. E.J. Law, B. G. MacMillan and
`W.A. Altemeier (Cincinnati) ............................... .... .
`Wide mesh skin grafts. J.C. Tanner (Atlanta) . ....... .. ......... ... .
`Fixation of skin grafts by adhesives. W.D. Muhlbauer (Munich) ...... .
`Split skin and full skin grafts in burns. Indication and technique of
`transplantation. H. Reichert (Stuttgart) .................. ... ..... .
`A comparative study of means of skin graft immobilization.
`T.S. Wilkinson and F.X. Paletta (St.Louis) ....... .. .............. .
`
`9
`
`264
`
`267
`271
`
`273
`
`276
`
`277 .......
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`281
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`285
`
`287
`
`289
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`292
`
`295
`
`299
`
`301
`303
`
`306
`307
`307
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`309
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`312
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`Slin replacement
`
`289
`
`The hardened collagen sponge was available to us as well, in special spongious
`plates, 3- S mm thick, with an area of 12 x l4cm. We used it for transplantations
`as well. The results are very good.
`It can be sta ted, tha t the use of xenotransplants is indicated in the treatment of
`large burns, especially if the technique of " biological dressing" is used. As the
`most advantageous method we consider the use of the ha rdened collagen sponge
`and lyophilized embryonal skin. We do not consider the pig skin useful. From
`our experiences we can state that we did not observe a ny side effects in patients
`treated with the above biological dressing.
`
`Preparation of chorion and/or amnion grafts used in
`burns
`
`R. Klen (Hradec Kra love)
`
`Even in the countries where legislation or habits do not prevent tissue with(cid:173)
`drawal and where tissues securing is well organized, there exist in normal times
`situations resulting in shortage of grafts. Therefore it is necessary to use substitu(cid:173)
`tions of different kinds. Biological substitutes of skin include foetal membranes
`the use of\\ hich havi ng been described already at the beginning of this century
`(I). - The task of this report is to describe in brief the preparation of these grafts
`according to a method practised in the Tissue Bank Factulty Hospital in Hradec
`Kralove, CSSR.
`ormal placenta of healthy parturients are used for the preparation of am(cid:173)
`nion, chorion and combined amnion-chorion gra fts. Their data are gained in the
`histories of delivery and are registered in the book of donors. Placenta are placed
`between two sterile operating basins and only in the case when they could not be
`prepared immediately after delivery they are kept in cold. This period did not
`exceed eight hours. At the beginning of the prepara tion the umbilical cord is tied
`to prevent bleeding. As the placenta is usually situated excentrically, we put it
`with the side where the umbilical cord is attached on a bottom of the basin in
`order to have a good survey about the dimensions of membranes. At the site of
`the smallest distance between the margin of the placenta and membranes, we cut
`these radially, to the umbilical cord. Then the amnion is cut circula rly following
`the border of the chorion, and the chorion again along the margin of the
`placenta which enables us to gain the largest grafts. Some time ago we had
`preserved the complete amnion from the surface of the chorion and placenta.
`The membranes a re submerged into the saline washing away the majority of
`blood-clots. On the arranged stripes of the plastic net we stretched membranes
`which are cut along the shape of the stripes. The stripes fulfill the function of a
`
`

`

`290
`
`Research in burns
`
`support for the stretched tissues and faci li tate drying. Then the smears for the
`bacteriological examination a re performed. T he grafts are covered by T)le~ol
`a nd rolled up. The rolls are inserted into the vessels which are plugged and filled
`with sterile n itrogen and then stored under deep temperature up to the time
`when sufficient qua ntity of preserves for freeze-drying is collected. Before placing
`the vessels into freeze-dryi ng appara tus, we put the colour indicator of moisture
`into the vessels. The changes of its colour define the data of e\-piry more precise·
`ly, but a lso protect t he graft from a possible influence of a small quantit) of
`water (2). The sublimation period takes twenty-four hours. The initial tempera·
`ture of the tissue is equa l to - 25 degrees C. The secondary drying also takes
`twenty-four hours with the tempe ra ture achieving the maximum oft 39 degrees C
`a nd with the vacuum usually reaching 80fL. The residual moisture is tested b) the
`d ifference of loss of weight at the temperature of + 57 degrees C and at the room
`tempera ture and ranges from 2 per cent to 4 per cent. The vacuum is replaced b)
`sterile nitrogen. The necks of the plugged bottles a re covered with gelatin caps.
`The preserves are stored a t room temperature in a dry and dark place. For the
`time being the period of expiry is not yet known precise!), fi-<:ed for 11\ehe
`months a nd written on a la bel. Each preserve has its instructions for preparation
`and a questionnaire on use and result which is secret. The bacteriological control
`consists of aerobic and anaerobic cultivation in broth which is inoculated on
`aga r plates. The grafts in which the pathogens or surplus of saphrophytic
`microbes are found are excluded from the clinical use.
`The preparation of preserves before opera tion is carried out by the remo1al of
`the indicator a nd by adding of sterile water wi th a nt ibiotics and with gluconic
`calcium. After submerging for about ten minutes the tissue is prepared for use.
`The rolls are taken out, opened and the membranes on T ylexol are removed
`quite easily. Grafts being adjusted to a proper size of the wound are put on.
`It is interesting to compare the permeability of different grafts after rehydra(cid:173)
`tion. Even if it is substantially higher, for saline and a lbumin as fresh skin it is
`possible to make u se of this property for application of antibiotics or substances
`effecting healing (3). Besides the application in burns, these grafts have been
`~mployed wi th surprisingly good results: in skin defects caused by leprosy (4. 5),
`m ophthalmology a t burns of the cornea (6), and in varicose ulcers (7). The
`results in 61 patients with ulcers treated in this way were evaluated statisticall) to
`pro:e the share of certain features on the results. It is possible to use some data
`a~hteved even for problems of burns. As far as the data concerning the donor, 11e
`dtd not find phenomena effecting the healing. This is not the proof, howe1er,
`that such factors do not exist. The evidence for this statement can be found in
`o ur previous work concerning skin grafts (8).
`Jmportant data, however, were found by means o f the statistical method for
`the preparation of tissue preserves. The grafts prepared within two hours after
`
`

`

`Skin replacement
`
`291
`
`delivery are more successful than those prepared after a longer period. With the
`greatest probability it gives evidence for the fact that the effective complex of
`substances is highly sensitive and undergoes undesirable changes quite easily. It
`has resulted in the instruction to perform the preparation after the delivery as
`soon as possible. The second statistical datum concerns the storage of the pre(cid:173)
`served rolls up to the time when they a re freeze-dried. We have proved that after
`freezing a t the temperature of - 25 degrees C lasting for a longer period than a
`\~eek, the grafts are less successful than those frozen for a shorter period. This
`fact again has given evidence concerning the sensitivity of the effective complex
`of healing su bstances and has led us to store the preserves prepared for drying in
`a place with a deeper temperature and, first of all, to perform freeze-drying as
`early as possible. To a certain extent, it may be considered as a favourable
`control of our work that the time of the storage of a dry tissue is of no impor(cid:173)
`tance. As the preserves were used within a short time, we were not able to solve
`the problem of expiration . Even these two results are not surprising, but -
`beyond any dispute - they a re a valuable control of this work, a nd on their basis
`it is possible to improve the results.
`These conclusions have become stimulating for the work trying to isolate the
`complex of effective substances. It is a work which needs a large quantity of
`material, and using complicated isolation and test methods.
`The mentioned grafts are currently used at the Burn Units in Prague and
`Ostrava and the results will be referred by the representatives of these units in the
`discussion. It must be stressed that the good results achieved with chorion
`and/or amnion gra fts a re a lso supported by the important fact tha t they are easy
`to gain in a great quantity.
`
`Summary
`As the chorion grafts were found in Burns departments of Prague and Ostrava
`as a successful substitute of skin homografts in burned persons of the 2nd degree
`the exact way of preparation of freeze-dried chorion preserves accord ing to
`method performed in Tissue Bank Faculty H ospital in H radec Knilove (CSSR)
`is described. These grafts are easy to secure and it is, in addition to the medical
`
`Table I. Permeability after 24 hours
`
`Albumine 1131
`
`Saline 1131
`
`Fresh skin
`Rehydrated freeze-dried skin
`Rehydrated freeze-dried chorion
`Rehyd rated freeze-dried amnion
`
`0.31 %
`1.4 %
`6.4 %
`13.9 %
`
`%
`2.42 %
`56 %
`63.2 %
`
`According to Dahinterova and Dobrkovsky.
`
`

`

`292
`
`Research in burns
`
`Table 2. Statistical evaluat ion o f some data of chorion graft
`
`Phenomenon
`
`F
`
`F o.ot
`
`Fo .ol
`
`In/atoll/ of
`
`Urelof
`significance
`inperctnt
`
`Duration of preservation 2 1.07
`24.02
`Duration of cooling
`
`6.88
`6.88
`
`3.93
`3.93
`
`Shoter time
`Shoter ume
`
`s uitability, one other important reason why we suppose the grafts will be in the
`next future a new method of grafting in burned persons.
`
`Bibliogra phy
`I Stern, M .: JAMA 60, 973 {19 13).
`2 Klen, R., H eger, J. : Suppl. Sbornlku ved. praci LF KU v Hradci Kr:ilo\e 10 5, 553
`{1967).
`3 Daltinterova, J ., and D obrkovskJi, M. : Suppi.Sbornlku ved. praci LF K U \ Hrad.:t
`Kra1ove 11/5, 513 (1968).
`4 Shalt, J.S. : Personal commu nica t ion.
`5 S edkicek, J. : Persona l communication.
`6 lserle, J .: Personal communication.
`7 Klen, R ., Dlabalova, H ., and Skalska, H.: The treatment or various ulcer b) means
`of c horion grafts. (fn prepa ra t ion.)
`8 Klen, R ., and Dobrkovsk)', M ., eta/. : Plast. Rec. Surg. 41/5, 471 (1968).
`
`The use of homografts and heterografts in burn
`management
`
`L . D. Stem (San Jose, Calif.)
`
`For centuries large burns have been looked upon as hopeless problems, to be
`treated compassionately, but fatalistically, since little could be done to combat
`the shock and infection that followed. In the last half century some of these
`attitudes have been changed, owing to mo re aggressive treatment. and new drugs
`and equipment avai lable for the first time. Ma ny a rticles and books in the past
`ten yea rs bear witness to the aggressive intelligent approach which is nowe,ideni
`throughout the scientific world ( I ). This a rticle is not m eant to duplicate the
`excellent work described by the leading treatment centers, but rather to report
`the experiences in one phase of burn therapy utilized in community hospitals
`with no resident teaching or s tudent population.
`As originally stated in 188 1 by G irdner (2) and Schede (3), and recently by
`Zaroff et al. (4), the uses of cutaneous homografts have made a great difference
`
`