TY - JOUR
AU - A, Farina Junior, Jayme
AB - Abstract Some groups have avoided early microsurgical flaps in electrical burns under the pretext of injury to the microvasculature, which could increase vascular thrombosis. However, this option frequently results in amputation of the extremity. This study aims to evaluate the early application of microsurgical flaps for the treatment of electrical burns of extremities. A case series was retrospectively evaluated including patients with electrical trauma in extremities undergoing early microsurgical reconstruction. Data were obtained from medical charts, including age, trauma location, flap type and microvascular anastomosis, the need for other procedures, postoperative complications, the length of hospital stay after the flap surgery, and patient outcomes. Five microsurgical flaps were performed in less than 30 days to trauma, one anterolateral thigh flap to cover skin failure in upper limb, and four radial forearm flaps to cover failure in feet. The patient ages had a mean of 25.8 years (from 12 to 42 years). The microsurgical procedure occurred from 21 to 27 days after the burn, with a mean of 24.2 days. Hospital discharge had a mean of 26.6 days (from 19 to 35 days after the surgery). Only one patient required reintervention for re-anastomosis. All patients had a good flap viability, avoiding amputation of the affected extremity and with a proper preservation of function. The early application of microsurgical flaps for patients with electrical burns of extremities may provide adequate, sturdy, and stable skin coverage, contributing to the treatment of noble structures exposed and avoiding amputation of the extremities. Electric trauma can yield since extensive tissue damage to inapparent nervous lesions. Tissue damage is secondary to thermal burn and electroporation, central events of the pathophysiology of electric trauma, which add up to varying degrees. Such lesions are more frequent at the “points of contact”, known as points of “entrance” and “exit”.1 The thermal burn of tissues occurs by the passage of electric current, which causes heat generation and cell death. The extent of electrical burn is related to the magnitude, frequency, and duration of the electrical current and the tissue resistance. The electroporation injury is secondary to the produced electric field and mainly affects the cell membrane. It is known that the cell membrane loses its anatomical structure and function when exposed to potencies of 600–800 mV. Cells with large areas such as neurons and muscle cells are more susceptible to injury. The intensity of the damage depends on the electric field, pulse duration, and current amperage. Regarding the electric trauma caused by high-voltage current (above 1000 V), it is believed that the injury ensues in two phases: immediate and late (or progressive). The progressive tissue injury occurs over the hours after the immediate injury.2 In deep burns with exposure of noble structures (vessels, bones, and nerves), the adequate skin cover would be a flap, locoregional, distant, or microsurgical. The main indications of microsurgical flaps in electrical trauma are for reconstruction of the extremities of the upper and lower limbs, because of the scarcity of local tissues, and because of the destruction of the remaining tissue options secondary to the electric burn.3 Because of the injury of the microvasculature caused by the electric trauma, many studies propose to avoid the indication of microsurgical flaps early under the pretext of causing more complications and the risk of triggering anastomosis thrombosis.4–6 The purpose of this study is analyzing the early application of microsurgical flaps in the electric trauma of extremities in two referral centers for burn treatment. METHODS It is a retrospective case series of patients with electrical injuries of the extremities in which reconstruction with microsurgical flaps was performed earlier (less than 30 days after the burn event) for cutaneous, soft tissue, and bone coverage. The study was conducted in two burn treatment units: Ribeirão Preto Medical School (University of São Paulo, Brazil) and Institute of Medical Assistance of the State Public Servant (São Paulo, Brazil), from 2009 to 2016. Data were obtained from the patient’s medical charts, including age, trauma location, flap and microvascular anastomosis type, flap reoperation, postoperative complications, the length of hospital stay, and patient evolution. The microvascular anastomosis was performed using a separated suture for arterial and venous anastomosis using a Zeiss OPMI Vario microscope at Ribeirão Preto Medical School and a Möller-Wedel Hi-R 700 microscope at Institute of Medical Assistance of the State Public Servant. Postoperative monitoring of the flaps was performed using conventional methods of clinical evaluation (color, temperature, perfusion time, and scarring bleeding pattern) and comparative test of the glycemia between the flap blood and the peripheral blood. The glycemia test was performed by simple puncture of the flaps and measurement with simple commercially available portable devices. RESULTS In this period, five microsurgical flaps were performed for cutaneous, soft tissue, and bone coverage of five patients with electric trauma of the extremities. The patients’ ages ranged from 12 to 42 years, with a mean of 25.8 ± 12.01 years (Table 1). Table 1. Patient characteristics, affected areas, and microsurgical flaps performed Patient Age/Sex Affected Areas Day Postburn in Which the Flap Was Harvested Microsurgical Flap Hospital Length of Stay (days) After Flap Surgery 1 34/M Medial and dorsal side of both feet 23 Radial antebrachial 31 2 20/M Lateral and dorsal side of the right foot 27 Radial antebrachial 25 3 42/M Medial and dorsal side of the left foot 26 Radial antebrachial 19 4 12/M Right forearm 21 Anterolateral thigh 23 5 21/M Plantar area of the right forefoot. 24 Radial antebrachial 35 Patient Age/Sex Affected Areas Day Postburn in Which the Flap Was Harvested Microsurgical Flap Hospital Length of Stay (days) After Flap Surgery 1 34/M Medial and dorsal side of both feet 23 Radial antebrachial 31 2 20/M Lateral and dorsal side of the right foot 27 Radial antebrachial 25 3 42/M Medial and dorsal side of the left foot 26 Radial antebrachial 19 4 12/M Right forearm 21 Anterolateral thigh 23 5 21/M Plantar area of the right forefoot. 24 Radial antebrachial 35 M, male. View Large Table 1. Patient characteristics, affected areas, and microsurgical flaps performed Patient Age/Sex Affected Areas Day Postburn in Which the Flap Was Harvested Microsurgical Flap Hospital Length of Stay (days) After Flap Surgery 1 34/M Medial and dorsal side of both feet 23 Radial antebrachial 31 2 20/M Lateral and dorsal side of the right foot 27 Radial antebrachial 25 3 42/M Medial and dorsal side of the left foot 26 Radial antebrachial 19 4 12/M Right forearm 21 Anterolateral thigh 23 5 21/M Plantar area of the right forefoot. 24 Radial antebrachial 35 Patient Age/Sex Affected Areas Day Postburn in Which the Flap Was Harvested Microsurgical Flap Hospital Length of Stay (days) After Flap Surgery 1 34/M Medial and dorsal side of both feet 23 Radial antebrachial 31 2 20/M Lateral and dorsal side of the right foot 27 Radial antebrachial 25 3 42/M Medial and dorsal side of the left foot 26 Radial antebrachial 19 4 12/M Right forearm 21 Anterolateral thigh 23 5 21/M Plantar area of the right forefoot. 24 Radial antebrachial 35 M, male. View Large Four radial antebrachial flaps were performed (one of which was splitted), and one anterolateral thigh flap was carried out. The microsurgical procedure was performed between 21 and 27 days after the burn event, with a mean of 24.2 ± 2.39 days. All anastomosis, arterial and venous, were performed end-to-end. Regarding the postoperative complications, two patients had a partial wound dehiscence, which was re-sutured. Besides, one other patient had postoperative flap congestion, and he needed to be reoperated to remake the venous anastomosis caused by venous thrombosis. Hospital discharge occurred between 19 and 35 days after the flap surgery, with a mean of 26.6 ± 6.39 days. We present below the five patients treated with early microsurgical flaps. Patient 1 A 34-year-old man treated at the Ribeirão Preto Medical School, a victim of high-voltage electric trauma with the entrance point on the right hand and the exit points on the medial and dorsal side of both feet. Destruction of local tissue caused cutaneous necrosis and extensive muscle exposure. After debridement of devitalized tissues, due to the absence of local tissues for reconstruction, wound closure was achieved by a left radial antebrachial microsurgical flap, which was performed on the 23rd postburn day. The flap was splitted to cover the failure of both feet with anastomosis in dorsalis pedis artery and vein, with an anterograde flow flap in the right foot and a reverse flow flap in the left foot. After 16 hours postoperatively, the clinical evaluation revealed congestion of the right foot flap, probably due to venous anastomosis thrombosis. Emergency surgical exploration was performed and confirmed this diagnosis, so the venous anastomosis was remade. There was a good postoperative evolution with hospital discharge at 31 days after the flap surgery. In a successive outpatient evaluation, the cutaneous cover remained stable, with a good adaptation to the footwear and without impairment to ambulation (Figure 1). Figure 1. View largeDownload slide Patient 1, a 34-year-old man. (A) Defect on the medial face of both feet after debridement, with muscle exposure and loss of skin cover. (B) Planning of the radial antebrachial flap. (C) Dissection of the flap. (D) and (E) Dissected radial antebrachial flap. (F) Twelve months postoperative. Figure 1. View largeDownload slide Patient 1, a 34-year-old man. (A) Defect on the medial face of both feet after debridement, with muscle exposure and loss of skin cover. (B) Planning of the radial antebrachial flap. (C) Dissection of the flap. (D) and (E) Dissected radial antebrachial flap. (F) Twelve months postoperative. Patient 2 A 20-year-old man attended at the Ribeirão Preto Medical School, a victim of high-voltage electric trauma with the entry points on the palmar face of both hands and the exit point on the lateral and dorsal side of the right foot. There was local tissue destruction with extensive necrosis including bone exposure of the diaphysis and distal epiphysis from the fifth metatarsal. Due to the absence of local flap options and the risk of limb amputation, as an attempt to preserve the foot, the coverage of the defect was performed with a left radial antebrachial microsurgical flap, performed on the 27th day after burning. Hospital discharge occurred 25 days after the flap surgery, with good flap viability. The outpatient evaluation revealed a stable flap, with adequate foot support and no slippage. However, the patient maintained difficulty in dorsiflexion and lateral rotation of the foot. This patient has been followed up with a rehabilitation team (physiotherapy and occupational therapy), with an excellent adaptive and functional gain for daily activities (Figure 2). Figure 2. View largeDownload slide Patient 2, a 20-year-old man. (A) Defect on the lateral and anterior face of the right foot, with osteomuscular and tendon exposure, and skin loss. (B) Defect after debridement. (C) Planning of the radial antebrachial flap. (D) Immediate postoperative with the flap positioned. (E) Thirty-six days after surgery. (F) Six months postoperative. Figure 2. View largeDownload slide Patient 2, a 20-year-old man. (A) Defect on the lateral and anterior face of the right foot, with osteomuscular and tendon exposure, and skin loss. (B) Defect after debridement. (C) Planning of the radial antebrachial flap. (D) Immediate postoperative with the flap positioned. (E) Thirty-six days after surgery. (F) Six months postoperative. Patient 3 A 42-year-old man treated at the Institute of Medical Assistance of the State Public Servant, a victim of high-voltage electric trauma with the entry point on the right foot and the exit point on the medial and dorsal side of the left foot. Local tissue destruction included cutaneous necrosis, osteoarticular and tendinous exposition of the hallux and the metatarsophalangeal joint. After debridement of the devitalized tissues, because of the risk of possible hallux amputation and due to the scarcity of local tissues, coverage with a radial antebrachial microsurgical flap was performed 26 days after the burn. The patient was discharged 19 days after the flap surgery with good flap viability. Postoperatively, the cutaneous coverage provided by the flap remained stable, without wounds, with good shoe adaptation and minimum ambulation impairment. The only functional sequel evidenced was a deficit in the right hallux extension, without prejudice to daily activities (Figure 3). Figure 3. View largeDownload slide Patient 3, a 42-year-old man. (A) Defect on the medial and anterior right foot after debridement, with osteoarticular and tendon exposure, and loss of cutaneous coverage. (B) Radial antebrachial flap after its dissection. (C) Radial antebrachial flap with its vascular pedicle. (D) and (E) Flap positioned over the defect, after vascular anastomosis, entirely covering the area of tendinous and osteoarticular exposure. (F) Twelve months postoperative. Figure 3. View largeDownload slide Patient 3, a 42-year-old man. (A) Defect on the medial and anterior right foot after debridement, with osteoarticular and tendon exposure, and loss of cutaneous coverage. (B) Radial antebrachial flap after its dissection. (C) Radial antebrachial flap with its vascular pedicle. (D) and (E) Flap positioned over the defect, after vascular anastomosis, entirely covering the area of tendinous and osteoarticular exposure. (F) Twelve months postoperative. Patient 4 A 12-year-old teenager attended at the Institute of Medical Assistance of the State Public Servant, a victim of high-voltage electric trauma with the entry point on the right forearm and the exit point on the lower left limb. Local tissue destruction was extensive, with bone exposure of the proximal third of the ulna, and muscle-tendinous exposure of the distal forearm. From the beginning, a functional deficit of ulnar nerve territory was noticed, as well as a deficit of flexion of the fingers caused by the destruction of the flexor apparatus. Due to the extensive destruction of the local flap options, because the imminent risk of limb amputation, and as an attempt to salvage the right upper limb, the wound coverage was performed with an anterolateral thigh microsurgical flap associated with split-thickness skin graft, 21 days after burning. The patient was discharged 23 days after the flap surgery. On the postoperative period, the coverage persisted adequate, but the patient remained with functional sequelae, motivating reconstruction of the ulnar nerve with a graft from the sural nerve and reconstruction of the digital flexor tendons with fascia lata. Two years after surgery, the patient had a satisfactory functional gain and continues to be followed up by a team of physiotherapists, occupational therapists, and plastic surgeons (Figure 4). Figure 4. View largeDownload slide Patient 4, a 12-year-old teenager. (A) and (B) Defect in the right upper limb after debridement, with osteoarticular and tendinous exposure, and loss of cutaneous coverage. (C) Anterolateral thigh flap dissected. (D) and (E) Flap positioned over the defect, after vascular anastomosis, entirely covering the area of noble tissue exposure. (F) Three months postoperative, demonstrating a proper contour. Figure 4. View largeDownload slide Patient 4, a 12-year-old teenager. (A) and (B) Defect in the right upper limb after debridement, with osteoarticular and tendinous exposure, and loss of cutaneous coverage. (C) Anterolateral thigh flap dissected. (D) and (E) Flap positioned over the defect, after vascular anastomosis, entirely covering the area of noble tissue exposure. (F) Three months postoperative, demonstrating a proper contour. Patient 5 A 21-year-old man, attended at the Ribeirão Preto Medical School, a victim of an electric trauma of 13,000 V with the entry point on the right occipital region and the exit point on the plantar area of the right forefoot. Tissue destruction at the exit point was extensive, with tendon, muscle, and bone surface exposure, involving the region of the head of first to third metatarsals. Concomitant to surgical debridement, negative pressure wound therapy was associated to prepare the wound bed for a subsequent surgical approach. Facing the risk of amputation of the forefoot and the absence of reliable adjacent tissues as a local flap, the coverage of the defect was performed 24 days after burn with radial antebrachial microsurgical flap, associated with nerve anastomosis (radial lateral cutaneous nerve). The patient was discharged 35 days after the flap surgery. After 12 months, the coverage remained adequate with a good sport, without ambulation impairment. It was also observed a gradual gain of cutaneous sensibility, indicating that the axonal growth is taking place on the anastomosed nerve tube (Figure 5). Figure 5. View largeDownload slide Patient 5, a 21-year-old man. (A) Defect on the plantar face of the right forefoot after debridement, with osteoarticular and muscular exposure, and loss of cutaneous coverage. (B) Radial antebrachial flap dissected. (C) Flap with its vascular pedicle (below) and the radial lateral cutaneous nerve (above). (D) Dissection of receptor vessels before anastomosis. (E) Flap positioned over the defect, after tunneling of the vascular pedicle and nerve, and after vascular and nerve anastomosis, entirely covering the area of osteoarticular and muscular exposure. (F) Three months postoperative, with good contour and skin coverage. Figure 5. View largeDownload slide Patient 5, a 21-year-old man. (A) Defect on the plantar face of the right forefoot after debridement, with osteoarticular and muscular exposure, and loss of cutaneous coverage. (B) Radial antebrachial flap dissected. (C) Flap with its vascular pedicle (below) and the radial lateral cutaneous nerve (above). (D) Dissection of receptor vessels before anastomosis. (E) Flap positioned over the defect, after tunneling of the vascular pedicle and nerve, and after vascular and nerve anastomosis, entirely covering the area of osteoarticular and muscular exposure. (F) Three months postoperative, with good contour and skin coverage. DISCUSSION Reconstruction of extremities after electrical trauma, mainly the distal third of the limbs, is defying. There are not good and reliable source of local flaps, as the irrigation and drainage of the distal structures are composed by low diameter terminal vessels. Nevertheless, the electrical trauma incite local destruction of structures, making local flaps sometimes impossible to be harvested as the tissues are unavailable because of the electrical lesion. The first reports of the use of microsurgical flaps in patients with burn are dated from the second half of the 1970s.7 In electrical traumas, microsurgical flaps are used when there are no locoregional flaps available due to an scarcity of tissues (as the case of extremities) or when local tissues have been destroyed by the extent of the burn.3, 7 The main indications of microsurgical flaps in burned patients are 1) preservation or restoration of function, 2) coverage of exposed noble structures (vessels, nerves, bones, tendons, and joints), and 3) salvage of the limb in the imminence of amputation (mainly in electric traumas).8 Several studies have demonstrated the safety of microsurgical reconstruction in victims of electric trauma. For the results to be optimized, it is essential to perform a debridement of the devitalized tissues (until obtaining a viable wound bed), to select the proper recipient vessels, and to have an experienced and trained team in microsurgery.4, 7, 9–11 Surgical debridement of the wound bed and adequate recipient vessels are crucial in electrical burns. It is important to emphasize that in electrical burns, the vascular injury could be progressive, tissue damage is not superficial, and it does not have a constant depth, as occurs in thermal burns. As the electric trauma can cause damage distant from the necrotic area, rigorous debridement should be performed on the recipient’s vessels, aiming to do the vascular anastomosis far from the trauma zone.12 Monitoring of free flaps after surgery is vitally important, especially in the first few hours because the timing of reoperation can determine flap salvage or loss. The most appalling and common complication is the vascular thrombosis. Objective methods for monitoring (such as spectral imaging and intraparenchymatous venous pressure) are of unfeasible in our center and difficult to reproduce. Our group has observed that in cases of venous thrombosis, the glucose measurements were significantly reduced compared with well-vascularized flaps. This method consists in simple puncture and measurement of glycemia with simple commercial devices easily available.13 We do not replace the detailed clinical evaluation method. Our purpose with this technique is to offer one more information that would contribute to the decision to reoperate or to intervene early. There are insufficient data on the literature about the ideal period for performing the microsurgical flap in electrical traumas. Baumeister et al correlated the loss of the microsurgical flap in electrical burns with the early accomplishment of the procedure. This same group showed fewer complications with reconstruction after 45 days. It is speculated that definitive reconstruction should be delayed, after stabilization of the vascular lesion.8 Although there is an unproven risk of flap loss, early reconstruction is justified in situations of noble tissue exposure of extremities. This approach may prevent amputation and ensure limb salvage, as reported in our series of five patients.3 The approach with early microsurgical reconstruction adopted in this study showed good results. The primary objective was functional restoration, limiting deformities, and loss of function that could limit daily activities. In the cases presented, the microsurgical flaps provided adequate, resistant, and stable skin coverage with proper tissue contour, collaborating to avoid the amputation of the extremity committed by the electric trauma. CONCLUSION The early application of microsurgical flaps for patients with electrical burns of extremities may provide adequate, sturdy, and stable skin coverage, contributing to the treatment of noble structures exposed and avoiding amputation of the extremities. We consider that microsurgical flaps are a good option for skin coverage in patients with electrical burns of the extremities, and they can be performed early after proper planning. REFERENCES 1. Lee RC , Astumian RD . The physicochemical basis for thermal and non-thermal ‘burn’ injuries . Burns 1996 ; 22 : 509 – 19 . Google Scholar Crossref Search ADS PubMed 2. Daniel RK , Ballard PA , Heroux P , Zelt RG , Howard CR . High-voltage electrical injury: acute pathophysiology . J Hand Surg Am 1988 ; 13 : 44 – 49 . Google Scholar Crossref Search ADS PubMed 3. Ofer N , Baumeister S , Megerle K , Germann G , Sauerbier M . Current concepts of microvascular reconstruction for limb salvage in electrical burn injuries . J Plast Reconstr Aesthet Surg 2007 ; 60 : 724 – 30 . Google Scholar Crossref Search ADS PubMed 4. Karabekmez FE , Duymaz A , Tosun Z , Keskin M , Savaci N . Early and late term microsurgical free flap reconstruction and risks in high voltage electrical injury . Acta Med Mediterr 2013 ; 29 : 711 – 6 . 5. Oni G , Saint-Cyr M , Mojallal A . Free tissue transfer in acute burns . J Reconstr Microsurg 2012 ; 28 : 77 – 84 . Google Scholar Crossref Search ADS PubMed 6. Saint-Cyr M , Daigle JP . Early free tissue transfer for extremity reconstruction following high-voltage electrical burn injuries . J Reconstr Microsurg 2008 ; 24 : 259 – 66 . Google Scholar Crossref Search ADS PubMed 7. Ibrahim AE , Skoracki R , Goverman JG , et al. Microsurgery in the burn population - a review of the literature . Ann Burns Fire Disasters . 2015 ; 28 : 39 – 45 . Google Scholar PubMed 8. Baumeister S , Köller M , Dragu A , Germann G , Sauerbier M . Principles of microvascular reconstruction in burn and electrical burn injuries . Burns 2005 ; 31 : 92 – 98 . Google Scholar Crossref Search ADS PubMed 9. Esses SI , Peters WJ . Electrical burns; pathophysiology and complications . Can J Surg 1981 ; 24 : 11 – 14 . Google Scholar PubMed 10. Nazerani S , Sohrabi M , Shirali A , Nazerani T . Early coverage of upper extremity electrical injury wounds . Trauma Mon 2012 ; 17 : 333 – 36 . Google Scholar Crossref Search ADS PubMed 11. Coltro PS , Ferreira MC , Batista BP , Nakamoto HA , Milcheski DA , Tuma Júnior P . Role of plastic surgery on the treatment complex wounds . Rev Col Bras Cir 2011 ; 38 : 381 – 86 . Google Scholar Crossref Search ADS PubMed 12. Koul AR , Patil RK , Philip VK . Early use of microvascular free tissue transfer in the management of electrical injuries . Burns 2008 ; 34 : 681 – 87 . Google Scholar Crossref Search ADS PubMed 13. Millan LS , Ishida LC , Choi EM , Giacchetto EC , Wei TH , Mattar R , Jr , Ferreira MC . Detection of venous thrombosis in free flaps by measurement of capillary blood glucose . Rev Bras Cir Plast 2012 ; 27 : 523 – 6 . Google Scholar Crossref Search ADS © American Burn Association 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Early Application of Microsurgical Flaps in the Electric Burns of Extremities: A Two Institutional Case Series
JO - Journal of Burn Care & Research
DO - 10.1093/jbcr/irx010
DA - 2018-10-23
UR - https://www.deepdyve.com/lp/oxford-university-press/early-application-of-microsurgical-flaps-in-the-electric-burns-of-O9sdvTkRu7
SP - 1037
VL - 39
IS - 6
DP - DeepDyve
ER -