MEEK case 2

Micrografting in the treatment of large area full thickness burns

by Prof. Ognian Hadjiiski, MD, Pirogov Emergency Medical Institute, Sofia, Bulgaria.

We present the case of a 16 years old male patient who sustained a 65% TBSA flame burn in the back, chest, arms and legs. He was in thermal shock and had inhaled smoke. The patient was admitted to our centre 14 hours after the accident. On days 3, 5 and 7 we performed early surgical excision of the necrotic tissue in the legs, chest and belly in 32% TBSA, leaving 14% disseminated necrotic tissues. The wound surfaces were covered with micrografts in five surgical steps every third to fifth day. The total donor site area was 14%. The donor sites were large because of the need to change some of the marks in subsequent surgical stages. During treatment the patient developed generalized bacterial infection, which was appropriately treated. On day 79 he was discharged in good health.

The area of the skin autografts performed in one operation was less than 2% TBSA and the blood loss from the donor sites was no more than 300-400 ml. In the third operation on a separate site we left the gauze until day 7-9. We do this only when the grafting is good and there is no local infection or exudation. After removing the gauze we observe initial epithe-lialization between the marks. It is important to bear in mind that in certain conditions removal of the gauze can be postponed. The advantage is that the sterile milieu is left undisturbed, some of the marks remain stable and allograft is not necessarily used to cover the wound surface.

Patiënt with 60% TBSA shortly after accident	Both thighs before surgical necrectomy
Both thighs after surgical necrectomy	Thighs covered with MEEK skin grafts
Micrografts covered with allografts	Detail of skin grafts 5th POD
Final result after 2 years

Discussion

In extensive burns (more than 30% TBSA), whole autografts can be used only in 18% of surgically treated patients and donor sites are limited. If donor sites are used, the treatment continues for several months, with numerous operations - a period during which the patient might develop a severe catabolic syndrome, organ insufficiency and generalized infection, which may be fatal. Until 1996 we followed the Chinese method, but our manual preparation of the marks was not sufficiently accurate. In the MEEK method, the distribution corres-ponds exactly to that planned, whereas with the meshgraft technique the expansion is smaller (20-45%). The MEEK technique combined with allografts ensures better results, especially if removal of the necrotic tissues is performed early. This technique obviates the application of tissue cultures. We believe, like many other researchers, that the MEEK method presents the following advantages:

• simple and effective; possibilities of combination with other methods, e.g. mesh graft and tissue cultures
• small size autografts can be used, which is important in large burn areas
• only small donor site area required, from which it is not obliged to take whole grafts
• the surgical operation is not very traumatic and bleeding from donor sites is limited, owing to the reduced operative volumes
• possibility of large expansion (up to 1:9)
• the gauze, supporting the grafts, helps to place and fix them in points of difficult access, such as the armpit and gluteal fold
• effective distribution equals theoretical distribution, better planning of operative volumes and donor sites
• the operative technique reduces the number of donor site areas, which is important in extensive burns
• easy orientation of the sides (upper side, epidermal; lower side, dermal) of the skin marks because they are fixed to the gauze. At large expansions (over 1:6), especially on second use of donor sites in extensive burns, orientation of the graft sides is very difficult and wrong position leads to failure
• epithelialization between the marks occurs at smaller distances than with all other methods, resulting in fast wound coverage
• the marks rarely drop off during wound dressing. This would compromise the method, as happens when widely spread mesh grafts detach from a wound
• in the event of failure caused by an infectious complication, only some of the marks are affected and the epithelialization process in other sites surrounding other marks continues successfully
• the patients’ faster healing shortens treatment and reduces the cost of hospital stay
• functional results are similar to those with mesh grafts; aesthetic results are better with the MEEK method. There is no great difference between the scars and those observed with other methods.
• one disadvantage is the loss of marks due to their small size, but this in no way affects the method as a choice of treatment.

Conclusion
The MEEK method is suitable in the treatment of burns, especially in large area burns. Its application saves the lives of patients in case other operative methods do not have positive results. The method is also recommended when other methods are impossible (tissue cultures). The late results of the MEEK method are good.