Annals of plastic surgery
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Burn wound progression is a poorly understood process by which certain superficial partial-thickness burns spontaneously advance into deep partial-thickness or full-thickness wounds. Progression of an injury into deeper tissue is an important phenomenon in the treatment of thermal injury due to the fact that burn wound depth may be a significant determinant of morbidity and treatment. This article reviews current knowledge of the pathogenesis, molecular and cellular mechanisms, local and systemic factors, and treatment modalities related to wound conversion. ⋯ Burn wound progression is complex and caused by additive effects of inadequate tissue perfusion, free radical damage, and systemic alterations in the cytokine milieu of burn patients, leading to protein denaturation and necrosis. Even though insufficient evidence exists for causal inferences, infection, tissue desiccation, edema, circumferential eschar, impaired wound perfusion, metabolic derangements, advanced age, and poor general health play important roles. Although consensus-building research is ongoing, current mainstays of treatment include adequate fluid resuscitation, nutritional support, and local wound care, with an emphasis on topical antimicrobial agents and biosynthetic dressings. Identifying early indicators by elucidating possible interacting or synergistic mechanisms and by developing preventative strategies will enhance prevention and treatment.
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Annals of plastic surgery · Jul 2007
The effect of postoperative anticoagulation on microvascular thrombosis.
Numerous protocols exist to prevent thrombosis after free-tissue transfer. Many surgeons advocate using aspirin or other antiplatelet agents, but little objective evidence supports this practice. This study evaluates the rate of microvascular thrombosis in patients undergoing free-tissue transfer treated with or without antiplatelet agents. ⋯ Postoperative anticoagulation choice has no statistically significant effect on the incidence of free flap complications, including bleeding, thromboembolism, and flap loss. We conclude that aspirin or LMWH therapy demonstrates equivalent outcomes when used as single-agent postoperative anticoagulation in oncologic free flap reconstruction.
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Annals of plastic surgery · Jul 2007
Gustilo grade IIIB tibial fractures requiring microvascular free flaps: external fixation versus intramedullary rod fixation.
Gustilo IIIB fractures involve high-energy tibial fractures for which there is inadequate soft tissue coverage. In addition to orthopedic fixation, these injuries require soft tissue reconstruction, often in the form of a microvascular free flap. Although the majority of orthopedic literature favorably compares intramedullary rod fixation to external fixation in open tibial fractures, these studies have not focused on the role of either method of fixation in relation to the soft tissue reconstruction. ⋯ For Gustilo IIIB fractures that require free-flap coverage, the added bony and soft tissue manipulation required for intramedullary rodding may disrupt the surrounding blood supply and lead to higher rates of complications that threaten the overall success of the reconstruction. Plastic and orthopedic surgeons should discuss the optimal method of bony fixation for complex tibial fractures when a free flap will likely be needed for soft tissue coverage. This integrated team approach may help minimize complications.