Reconstruction Of Hand Is A Surgical Challenge After Extensive Skin Burn
Overview
Preserving and restoring hand function after burn injuries is a significant yet challenging task. This study evaluated the effectiveness of composite skin grafts over acellular dermal matrix (ADM) versus thick split-thickness skin grafts (STSG) in treating deep hand burns. Conducted at the First Affiliated Hospital of Wenzhou Medical University from September 2011 to January 2020, the study retrospectively identified patients who met specific inclusion criteria. Key factors examined included patient demographics, the interval from surgery to the initiation of active motion exercises, graft take rates at 7 days post-surgery, donor site recovery, complications, and time to complete healing. Scar quality was assessed using the Vancouver Scar Scale (VSS), and hand function was evaluated through total active motion (TAM) and the Jebsen–Taylor Hand Function Test (JTHFT) over a 12-month follow-up period.
The study included 38 patients (52 hands) who received either thin STSG on ADM or thick STSG. Significant differences were observed in donor site locations between Group A (thick STSG) and Group B (thin STSG + ADM) (p = 0.03). However, no significant differences were found in age, gender, underlying conditions, burn causes, burn areas, dominant hand, bilateral hand operations, and time from burn to surgery between the groups (p > 0.05). Additionally, there were no significant differences between the groups regarding the interval from surgery to the initiation of active motion exercises, graft take rates at 7 days post-surgery, and time to complete healing (p > 0.05). The necessity for donor site skin grafting was significantly lower in Group B compared to Group A (22.2% vs. 100%, p < 0.001). Complication rates showed no statistically significant differences between the two groups.
Introduction
Burn injuries, which account for approximately 265,000 deaths annually worldwide, are commonly caused by flames, hot liquids, chemicals, electricity, and ionizing radiation. The hands are particularly vulnerable to such injuries due to frequent exposure in daily activities. Burn-related hand deformities can significantly impact quality of life, emphasizing the necessity for wound repair and reconstructive surgery for patients with hand burns. Skin grafting has long been the standard surgical approach for full-thickness burn wounds, with grafts classified by thickness into thin split-thickness skin grafts (STSG) (0.3–0.45 mm) and thick STSG (0.45–0.6 mm).
Thick STSGs have been a cornerstone in reconstructive surgery for full-thickness burns, offering greater resistance to contractures and reducing the need for revision compared to thin STSGs. Clinical studies have shown contracture rates of 26% for thin STSGs and 11% for thick STSGs. Additionally, thick STSGs enhance flexibility and minimize scar hyperplasia, with improved aesthetic outcomes and reduced postoperative hyperpigmentation. However, the availability of donor skin can limit the use of thick STSGs in patients with extensive burns.
Innovative medical materials such as acellular dermal matrix (ADM) have emerged as valuable tools in burn treatment. ADM is a dermal allograft free from viruses, bacteria, and fungi, preventing immune response or graft rejection. Its matrix elements facilitate cell migration and revascularization, significantly enhancing skin quality and promoting scar-free healing. Combining ADM with autologous STSG has proven effective, offering benefits such as reduced scar contracture, functional retention, superior aesthetics, and cost efficiency.
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Several studies have documented the success of using ADM with STSG for direct reconstruction, including donor site coverage after flap surgery and treatment of deep facial burns. Additionally, ADM combined with STSG has shown promise in treating diabetic foot ulcers, demonstrating high tolerance to friction and pressure with a low incidence of ulceration.
Despite these advancements, it remains unclear whether thick STSG or ADM combined with thin STSG provides better functional outcomes for deep dermal burns on the dorsum of the hand. This clinical study aimed to fill this knowledge gap by comparing the therapeutic effects of these two techniques.
Methods
Inclusion Criteria
The study identified patients who met the following criteria:
- Age: Patients aged 10 years or older.
- Burn Severity: Patients with full-thickness hand burns encompassing the entire dorsum, including digits.
- Treatment Type: Patients who received either a thin split-thickness skin graft (STSG) over an acellular dermal matrix (ADM) or a thick STSG.
Exclusion Criteria
Patients were excluded based on the following conditions:
- Age Limitation: Patients older than 70 years.
- Underlying Health Conditions: Patients with malignancies, autoimmune diseases, or other significant comorbidities.
- Surgical Tolerance: Patients unable to tolerate the surgical procedure.
- Pre-existing Conditions: Patients with pre-existing dorsal hand scars or hand deformities.
- Surgical Technique: Patients who underwent two-stage grafting procedures for composite skin grafting.
By defining these criteria, the study ensured a focused and homogeneous patient population for evaluating the outcomes of skin graft surgery for full-thickness hand burns.
Analysis
Data analysis was performed using the Statistical Package for Social Sciences (SPSS) software, version 22.0 (SPSS, Inc., Chicago, IL, USA). The normality of continuous variables was evaluated using the Kolmogorov–Smirnov test. Normally distributed variables are reported as mean ± standard deviation, while non-normally distributed variables are expressed as median with interquartile range.
To assess between-group differences for continuous data, either Student’s t-test or the Mann–Whitney U test was employed, depending on the normality of the distribution. Descriptive analyses of categorical variables were conducted using percentages and frequencies. The chi-square test or Fisher’s exact test was used to analyze categorical data. All statistical tests were two-sided, and a p-value of less than 0.05 was considered to indicate statistical significance.
Results
Study Population and Group Division
From September 2011 to January 2020, a total of 38 patients with 52 hands met the inclusion criteria for this study and were retrospectively divided into two groups based on their surgical treatment. Group A, consisting of 23 patients with 34 hands, underwent thick split-thickness skin grafts (STSG), whereas Group B, composed of 15 patients with 18 hands, received thin STSG over an acellular dermal matrix (ADM). The average age of the patients was 41.1 ± 13.6 years, with 73.7% being male. Flames were identified as the primary cause of burns, accounting for 65.8% of cases. Donor site locations significantly differed between the two groups (p = 0.03). No significant differences were found between the groups in terms of age, gender, underlying disease, cause of burn, burn area, dominant hand, bilateral hand operations, and the interval from burn injury to surgery (p > 0.05).
Postoperative Course
Postoperative outcomes, including the time from surgery to the initiation of active motion exercises, skin graft take rates at 7 days post-surgery, and the duration to complete healing, showed no significant differences between Group A (thick STSG) and Group B (thin STSG + ADM) (p > 0.05). However, the necessity for donor site grafting was significantly lower in Group B compared to Group A (22.2% vs. 100%, p < 0.001). There were no statistically significant differences in postoperative complications between the groups (p = 0.12). Notably, two patients in Group B who had scalp donor sites experienced partial skin loss.
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Aesthetic Outcomes
Aesthetic outcomes assessed using the Vancouver Scar Scale (VSS) indicated that the pliability subscore was significantly better in Group A compared to Group B (0 [0–1] vs. 1 [0–1], p = 0.01). No significant differences were observed in the vascularity (p = 0.42), pigmentation (p = 0.31), and height subscores (p = 0.13).
Hand Function
Assessment of hand function using total active motion (TAM) and the Jebsen–Taylor Hand Function Test (JTHFT) revealed no significant differences between the two groups. TAM scores were 97% in Group A compared to 83% in Group B (p = 0.22), and JTHFT completion times were 62.3 seconds (51.5–92.1 seconds) in Group A versus 72.9 seconds (59.8–101.3 seconds) in Group B (p = 0.06). Examples of outcomes from both groups were documented for comparative analysis.
Discussion
Reconstructing hand injuries presents significant challenges due to the necessity of preserving functionality. Large burn areas often require the sacrifice of considerable amounts of normal skin to promote wound healing. Composite skin grafting over an acellular dermal matrix (ADM) scaffold is a promising method for addressing cutaneous defects. This study aimed to evaluate the postoperative outcomes of two grafting techniques used in our hospital.
The study found no significant differences in hand function between patients receiving thick split-thickness skin grafts (STSG) and those undergoing composite skin grafts (ADM combined with thin STSG). Both methods effectively repaired deep hand burns, achieving similar functional outcomes. Full-thickness burns generally necessitate surgical intervention as they do not heal autonomously. The primary limitation of autologous STSG is the scarcity of suitable donor sites, particularly in patients with extensive burns. In our study, the donor site skin graft rate was 100% in the thick STSG group, higher than in the composite skin graft group. Composite grafts of ADM with thin autologous microskin demonstrated a 94% survival rate, reduced donor site morbidity, faster donor site wound healing, and satisfactory graft effectiveness.
ADM has shown promise in reconstructing defects from skin cancer excisions, with low donor site morbidity and a high rate of successful grafting. Various studies, including those by Pan et al. and Li et al., have demonstrated the effectiveness of ADM combined with thin split-thickness skin in providing acceptable aesthetic outcomes and reducing scar hyperplasia at donor sites.
The development of tissue engineering has highlighted ADM’s potential, which continues to evolve. ADM products, such as AlloDerm®, DermaMatrix®, and Integra, have shown good results in wound repair. The ADM used in our study offered advantages by allowing one-step autologous skin graft coverage, saving time and costs compared to products like Integra that require delayed skin grafting.
Our study utilized three scoring systems—Vancouver Scar Scale (VSS), Total Active Motion (TAM), and Jebsen–Taylor Hand Function Test (JTHFT)—to evaluate scar quality and hand function. Both grafting techniques showed no significant differences in these evaluations. However, thick STSGs were noted to be superior in terms of plasticity.
We recommend using the back as a donor site for thick STSG due to its naturally thick skin. One-stage composite skin grafting is effective and feasible, reducing treatment time and complication rates compared to two-stage grafting. Early excision and grafting significantly decrease infection risks, shorten hospital stays, lower costs, and improve hand function recovery.
The main limitations of our study include a small sample size and its conduction in a single medical center. Additionally, it was not a randomized, double-blinded clinical trial. Further prospective studies with larger, multicenter patient populations are necessary to confirm these findings.
Conclusion
In this study, we observed no significant differences in hand function between patients treated with thick split-thickness skin grafts (STSG) and those receiving composite skin grafts comprising acellular dermal matrix (ADM) and thin STSG. However, the thick STSG demonstrated superior plasticity. The combination of ADM with thin STSG proved to be an effective method for managing deep and extensive hand burns, particularly notable for its low donor site morbidity. This approach yielded favorable aesthetic and functional outcomes, especially for patients with limited available donor sites.
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