Surgeons share how they evaluate whether a wound bed is ready for either an acellular dermal matrix or a skin graft
Listen below as Dr. Roselle Crombie, general and burn surgeon from CT Burn Center, Yale New Haven Health System, speaks with Dr. Paul Glat, Director of the Burn Unit at St. Christopher’s Hospital for Children, about the unique challenges of pediatric burn care, including scar management techniques and finding the right depth of excision.
Deep Cuts is a multimedia series on excision, in which surgeons from a variety of specialties discuss excisional debridement, one of the cornerstones of successful wound reconstruction. In Season 1, burn surgeons from across the country—and from a variety of backgrounds—share the challenges and their best practices for optimizing wound bed preparation.
The opinions expressed, and techniques described, herein are general in nature and based on the clinical experience of the presenting physician. Physicians should use their own professional judgment and consider patient-specific factors in treating their own patients.
Drs. Crombie and Glat are paid consultants of Integra LifeSciences, but they have not been compensated for their participation on this podcast.
Complete transcript of this episode:
We have Dr. Paul Glat here, esteemed pediatric burn surgeon. If you could just give a little brief summary of who you are, where you are and how long you’ve been doing this.
I’ve been a pediatric burn surgeon for 25 years, based out of St. Christopher’s Hospital in Philadelphia. I, along with Dr. Burkey, manage the unit, and we take care of kids from birth till 21.
Some of the questions that we have about debridement are different in kids, right?
Anything you do in a child becomes a bigger deal because you can’t just do something at the bedside very easily in a child. They generally would need some sort of anesthetic or sedation. So all sorts of things become just more complicated and you’re dealing with the child and a parent and all of those issues related to that. Things that are simple and painless are really things that we look to do. And if we can avoid the operating room, that’s always been a goal of ours as well.
Think back to when you were first becoming a burn surgeon. What are the things that you do now that you kind of learned over time specifically in the child’s wound bed about debridement?
When we started, we didn’t know much about anything other than surgical debridement. When I took over, just fortuitously, our hospital happened to be using a lot of enzymatic debridement. So I didn’t know much about that, and that became one of the initial mainstay treatments for us to not only would it start to debride a deep partial or indeterminate depth burn where we didn’t really know how deep it was or if it would need surgery or not. It was therapeutically helping, but it also helped us to diagnose the depth of that burn without any fancy equipment. Because if it cleaned up in a day or two, then it was likely to clean up and heal and not need surgery. And if it didn’t, then we could make that trip to the OR faster.
Could you think back to a failure that may have taught you something about the way that you debride a child versus what you do now?
We’re much more concerned about preserving dermis now. Typically, we were used to adults so we would use an instrument that would not excise the entire skin. And before we know it in a child we were in a full thickness situation. So being a little more gentle and a little more conservative and slower, which led us to do things like enzymes.
Now we do a lot of Versajet rather than sharp debridement if we can avoid it, because it’s a little more selective and a little more slow and gentle. Takes more time, but we think it’s worth preserving as much dermis as possible. A.) to potentially prevent the need for an autograft, but B.) just to give that child the best chance of healing.
Got it, and then just in terms of the techniques of debridement in a child. You mentioned a couple things, I think is slow and more conservative. What else… if you were teaching a fellow the differences between an adult burn and a child’s burn about debridement?
Pediatric burns are almost a little easier in some ways. So the debridement part can be a little more challenging because you’re through into the deeper tissues more quickly. But if you do need to debride a full-thickness burn, we have a little more flexibility because we don’t have to excise down to fascia. Kids graft will sometimes take on fat, where in an adult, that wouldn’t happen.
So we’re a little more conservative in that regard as well. We don’t always do very deep excisions. We’ll leave some fat behind and typically the grafts will survive a little more vascularity. We also don’t have to deal with comorbidities such as diabetes and vascular disease and those sort of things. It’s a little more of a pure way of looking at it. We are not dealing with those interesting complications.
So you mentioned the anesthesia piece of it, dealing with the parents… When you talk about like a large pediatric burn, so 80% or 90%-ers coming to you and Dr. Burkey, what would you sort of convey to the fellow about how do you make a decision about timing to go to the OR and how long you’re there with a child?
Blood loss is more complicated in children. It’s hard to get away with a debridement of any size without the need for a blood transfusion, but we’re very cautious about preparing for the transfusion, making sure we have blood because their reserve is so limited. Using tourniquets and tumescence and things like that, which you do in adults as well, but can be even more important in a child.
Not that adult surgeons are cavalier, but we have to think a little bit more about some of those things as well. Certainly getting all of that dead tissue off a little bit more quickly is a priority because the kids can get sick and can tank pretty quickly. So being aggressive, being prepared that you may have to go to the OR every day for a week or two, until you get all of that dead skin off is really critical. They just don’t tolerate some of those things that a larger person may tolerate.
If biofilm comes up, what are your sort of strategies?
Biofilm is not a huge problem in the acute burn. Obviously the tissue is burned and there’s not bacteria initially and then it starts to grow. This is usually something we’ll see a week or two down the road. And sometimes it’s diagnosed with a biopsy. Sometimes it’s just diagnosed because your grafts or your allograft are not taking, it’s more of a clinical judgment kind of thing. But the wound may just not look the same, not as robust, not as beefy red and those grafts just may just not take. And then we get a little more concerned that there’s something less typical going on.
How do you decide when you’re looking at a kid’s wound bed when it’s ready for either an autograft or a secondary dermal substitute? My second question to that is, when do you use one or the other in a kid?
I think wound bed preparation in general adult or pediatric is the biggest variable in any chronic wound or acute wound burn wound. There’s such a variety in skillsets and different training and all of that. And especially in chronic wounds, which we’re not really talking about today, just there’s so many people debriding and everyone does it a little differently. So I think making sure all the visible dead tissue is gone and sometimes that’s just clinical judgment.
Getting a good, healthy, bleeding wound bed is certainly important. And then depending on how long that process takes and how large an area and how sick or not sick the child is, we may decide to do some allograft as a temporary covering.
Or if we think maybe it’s a contaminated wound, let’s say it’s a road rash versus a sure thermal burn, get that allograft on test to the wound bed before we use that precious autograft. That again, children have even less donor sites than adults…
…so we don’t want to waste donor site or expensive skin substitutes.
When you think about our specialty and we’re trying to train the next generation behind, there’s so much variation in how we approach and teach debridement. What are sort of some of the thought processes from you, in terms of how would you teach your new fellow or your new junior faculty?
I think they’re similar to adults in that obviously superficial burns will heal they don’t need much actual debridement. You don’t have to think too much about it. Full-thickness injuries clearly are surgical problem. It’s sort of those middle depth burns that have multiple options and challenges for debridement starting with enzymatic, starting with you know again, just expectant care in some situations.
And then getting a little more aggressive, but not using a scalpel per se, but using hydro-dissection or Versajet is one that we use quite a bit, again because of that selective nature. And just trying to kind of preserve as much dermis as possible. So getting the wound bed clean, but preserving as much healthy tissue as possible will give the child the best outcome.
How would you discuss the things that you’re thinking about when you’re debriding like a neonate, like a nine month old and then the more preschool type of child?
When you’re dealing with smaller children, again, you can get away with less can be more in many ways. They tend to scar better. Even if we end up not doing a split-thickness skin graft, let’s say it’s a child’s palm, those are always so challenging. And there’s always a big rush to graft the hand. I think in the children, we can really wait longer. We can do enzymatic debridement. We can do skin substitutes. We use a lot of amnion type products, which help to promote the patient to heal on their own. Splinting.
And very often in those types of situations, we can get away without the need for a skin graft. Whereas in an older adult, they may just need to be grafted very quickly. So some of the more expectant, observational-type of treatments can be better.
In some cases, you just have to bite the bullet and do it. But I think like palmar burns, facial burns where sometimes the graft can look worse than a resultant scar. So again, kids have that healing potential that some adults just may not have. And with new technologies like lasers and scar management, a lot of them can avoid a skin graft. If they need one, they get one down on the road when they’re not sick and in the hospital.
So that was a baby. In terms of like a toddler and the elementary age kids…
Toddlers, we deal a lot with reintroduction into the family, back into school, sort of figuring out how long can we keep them out and how quickly can we then reintegrate them back into their lives. It’s not that different than job reintegration in an adult. But many of our adult patients have other things going on and may not be working. And that may not be a concern. For kids we want to get them out of the hospital faster. We deal with a lot post-traumatic stress issues so we sedate a lot. We have a lot of child life, distraction therapy, things like that.
Toddler age kids are already facile with their iPhone and their iPad. You can really get a lot done that way with them. But on the other hand, we want to not prolong the ultimate closure of the wound by doing too conservative of things. We watch a few days and then we can kind of make that decision.
We don’t have obviously a lot of peds, but we do have some peds. And one of the things I always struggle with is how do you decide when to excise a deeper second-degree burn. Because it’s going to be cosmetically and functionally better versus just exactly what you’re saying, the expectant management. I distinctly remember we had a patient where the families were physicians and they just didn’t want their kid to have an operation, a two-year-old on the dorsum of the foot.
Then subsequently, as you can imagine, what happened is the scar happened. And then as the child grew, the scar had a contracture and it started to deform the bones around it. So clearly that particular case probably should have been excised and grafted before.
In a child, some of it’s just experience. If it looks like it’s going to heal in under three weeks, then we’re not going to rush that kid to surgery. Again, three weeks of daily dressing changes, isn’t great either, but there are skin substitutes and things where you can watch it and see them once a week.
If they don’t heal, sometimes the result in graft is much smaller than you ordinarily would’ve done. Or many times they’ll heal with minimal to no scarring. So I use that 17 to 21 day cut off. Some of it’s just being used to looking at what happens with enzymatic debridement and how quickly it’s happening. And if it’s just not happening then they get a graft.
That makes sense. Because it’s going to be a lot smaller of an area that you’re grafting.
And then we’re a little more aggressive with things like amnion tissues and other biologically active matrices which are expensive, but you can cover a lot of area with a graft and a child total body surface area wise much with one piece compared to what that piece would do in an adult. So in many ways, in the hand, face, other strategic areas, those types of grafts can buy some time and or avoid the graft completely.
Got it. Do you think differently about the face versus the hands versus like a leg?
Totally. The face and hands get very specialized attention where avoiding the graft is sometimes more critical than rushing to do the graft. Whereas on the trunk where we’re not across a joint or a thigh, you’re not too worried about the scar. The goal is to get that patient out of the hospital and back to life a little quicker.
Say you’ve had kid that got burned as a 50% or as a toddler, what are the things that you typically see down the line in terms of their scarring and contracture that either that you have to deal with then or would you manage it slightly differently in the beginning?
If you’re concerned about significant scarring, then you want to try to avoid that from the start. So those patients where especially neck, axilla, those areas where scarring can be so difficult, you can get them healed primarily or very quickly with the graft to avoid that. Great.
If not, I think some of the problems with children are that they are still growing. So adults aren’t growing, whereas a child ultimately if they have a scar across a joint, you may have to release that scar multiple times during the first 18 years of their life.
The goal is to really try to first avoid that, do whatever sort of scar management techniques will keep that scar nice and soft so that it will grow with the patient, whether it’s laser or pressure garments even for up to two years in kids, we’ll do that sometimes. And then being more aggressive with lasers and things like that. But ultimately then doing the fewest number of procedures to get them to adulthood. We try to wait until these growth spurts happen and then wait a little longer so we may not have to do it that second or third extra time after that.
When you do the release and you’re looking at the wound bed, is it something that you’re going to put allograft on, autograft on, or secondary dermal substitutes?
It depends on the size of the area. I mean, ideally we’d love to have full-thickness skin grafts to use everywhere, but that’s not practical. But if there’s small burns on the hands or contractures on a finger, then those are available.
Palmar burns, we’ve been very aggressive using glabrous skin grafting from the foot, which has really turned out quite nicely. It’s really a deeper dermal graft that has a great color match. So that works terrifically well in those situations. If they’re larger areas, most often we’ll typically use some sort of dermal substitute.
Because providing that dermis allows it to stretch and grow with growth spurts and those sort of things. So we’re pretty aggressive with doing that rather than just another split thickness graft. We usually use an allograft per say, but a dermal substitute does help.
What are the challenges that you foresee for pediatric burn surgeons and teaching them. What are the challenges that we’re going to have to address and work on?
We’re in this society where everyone wants everything to be fixed immediately, and we have to deal with those expectations. And again, we’re dealing with a patient and with a parent or two parents or in our hospital, lots of complicated family dynamics. Whether it’s child abuse and they end up in a foster health system, which is not ideal. Those are big challenges for us and trying to navigate through that.
Dealing with all of these different products that are coming out has become a challenge. They’re expensive. There’s so many of them, which I guess we all find the ones that we prefer. But how do you present those things to families and be a good steward for financial responsibility, but also what’s best for the patient? But we’ve always been a practice where we like to try new things and see what may improve on the outcomes that we already have, which are pretty good, but to try to even get better.
I think people are afraid of pediatric care and most institutions, if they don’t do it, they send them out and you just don’t get that experience. I think it’s not something to be afraid of. I think it’s something that there are people who can help us with it. We work very well with our pediatric intensivists and our whole team, which is social workers and therapists.
Therapy is really, even more important in kids. The child life is really a big part of getting them through the hospital stay and after. So don’t be afraid of it. You know, respect it. Use the people around you to help. We didn’t train as pediatric surgeons, but we take care of pediatric burns. So we learn in fellowships and on the job, but also use the expertise around you.
In This Category
Venous ulcers, the most common type of chronic lower extremity ulcers, can be painful and debilitating for patients. Reoccurrence rates are high: More than 90% of patients with a venous leg ulcer will experience one recurrence, and one-third will experience four or more over their lifetimes. Venous ulcers are also associated with devastatingly high healthcare costs.
The Economic Toll of Venous Ulcers
There has been a steady increase in the costs associated with these non-healing wounds. In 2009, the total costs to treat ulcers was estimated to be upwards of $3.5 billion. By 2014, just five years later, that burden was estimated at $14.9 billion.
The annual per-patient cost to treat a venous ulcer is estimated at $10,563, according to a study published in the Journal of Vascular Surgery. When it’s a chronic, nonhealing ulcer, the cost rises to nearly $34,000 or more than $2,800 per venous ulcer patient per month. The Journal of Vascular Surgery study found that when venous ulcers were treated with surgical intervention, costs rose to $19,503, but recurrence rates dropped from an average of 34% to just 5%.
In addition to the direct costs, chronic venous ulcers burden economic productivity by resulting in the loss of 4.6 million work days per year. There are also outpatient and inpatient facility costs as well as those that cover visiting nurse services and dressing supplies.
Venous Ulcers: Who’s at Risk?
Venous ulcers most often occur in patients over age 55 as well as in patients with family history of chronic venous insufficiency. Other risk factors include higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis and venous reflux in deep veins.
These ulcers most often affect the lower extremities, particularly near the ankle bone. If they persist more than three months, are larger than 3.9 inches, or the patient has lower limb arterial disease, advanced age, and elevated body mass index, a poor prognosis is expected.
Social and Psychological Impacts
Patients who do develop venous ulcers may suffer social and psychological effects in addition to physical symptoms. For example, a venous leg ulcer that’s oozing fluid and odors might cause a patient to avoid social situations that can lead to embarrassment.
Pain and difficulty getting around may also keep patients isolated, which negatively affects their wellbeing. Compression bandaging and changes in footwear might also impact a patient’s appearance, which could negatively affect their body image. But if they choose to stop those treatment options, their physical symptoms will only deteriorate.
Decrease Risk of Venous Ulcers
When a patient develops a venous ulcer, it can be painful, inhibit mobility and negatively affect their quality of life. Even with treatment, there is a high rate of recurrence, especially if the underlying condition is left untreated. To decrease risk for developing venous ulcers, patients can adopt the following habits in order to ensure good blood flow in their legs, according to Johns Hopkins Medicine:
- Avoid smoking
- Lose weight if you’re overweight or obese
- Stay at your ideal weight
- Get plenty of regular exercise
- Move around often
- Raise (elevate) your legs for a short time, especially if you’ve been standing all day
- Wear compression stockings