Debridement of linear burns especially on the trunk and abdomen can be challenging. Some currently used methods are technically difficult and potentially hazardous to the surgeon or the assistant. We propose a simple and effective method of linear burn debridement using towel clips. A pair of strong towel clips can be used to grasp the area of the burn at either end producing a tenting effect and therefore facilitating debridement of difficult areas. This technique provides a simple, precise and safe method of linear burn debridement.
Debridement of full thickness burns is now standard of care. It improves survival, decreases length of hospital stay and reduced expenditure in burned patients of all ages. Tangential excision as described by Janzekovic, remains the common technique [1]. Tangential excision removes necrotic tissue, but preserves as much of the underlying viable tissue as possible. The technique involves removal of successive layers of dead tissue till viable, healthy, bleeding tissues is reached. Haemostasis of the excised area is done and the raw area is then skin grafted. Skin grafts are usually reasonably adherent by the fourth day [2]. Tangential excision is advantageous in that, it preserves body contour but causes more blood loss. This is in contrast to fascial level excision which causes a contour defect but less blood loss.
A number of different instruments have been used to perform tangential excision including Rosenberg knife, Goulian knife, Watson knife and powered dermatome [3]. All these instruments have a broad front and this makes it particularly difficult to debride linear burn wounds, especially if they lie on flat body surfaces and body concavities. Some surgeons debride linear burns by pinching the tissue and shaving the summit of the pinched surface. This is however technically difficult and potentially hazardous to the surgeon or the assistant. There is considerable risk of acquiring blood-borne infection, in particular hepatitis B virus (HBV), hepatitis C virus (HCV) and the human immunodeficiency virus (HIV). The risk of acquiring HBV from one percutaneous exposure is up to 10 times higher than that for HCV, and up to 100 times greater than that for HIV [4]. The role of universal precautions is always stressed, but linear burn debridement presents a particular problem. How can one perform the shave in a safe, controlled manner without endangering personnel to sharps injury? We use towel clips in a simple maneouver, to alleviate the problem of linear burn shave.
2. Technique
A strong pair of sharp-ended towel clips are used. The area of linear burn is strongly grasped at its very edge, by one towel clip taking a firm grip of the dermis. The towel clip is sharp and does not damage normal tissue. Strong traction on the towel clip is applied and countertraction with another towel clip or swab is used on the other side of the linear burn. The effect of this maneouver is to produce a ‘tenting effect’ on the linear burn (Fig. 1). The tented area can then be pinched on either side and presents a raised, bulbous area. Debridement can then be carried out quite easily, in a precise manner (Fig. 2). The technique finds particular use on the back and anterior abdominal wall where the surface is flat and difficult to debride.
Fig. 2. The tented area is then debrided safely and precisely without damage to adjacent healthy skin.
The merits of the technique include less secondary damage, with debridement more confined to the linear burn itself. The procedure is safe as it keeps the hands out of the way and thus avoids inadvertent sharps injury.
References
[1]. [1]Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma. 1970;10:1103–1108. MEDLINE
[2]. [2]McGregor IA. Fundamental techniques of plastic surgery. Churchill: Livingstone; 1989;.
[3]. [3]Muller MJ, Ralston D, Herndon DN. Operative wound management. In: Herndon D editors. Total burn care. 2nd ed.. 2002;.
[4]. [4]Recommendations of the expert advisory group on AIDS and the advisory group on Hepatitis. Guidance for clinical health care workers: protection against infection with blood-borne viruses. UK Health Departments, 2000.
Department of Burns, Plastic and Reconstructive Surgery, Whiston Hospital, Prescot, Merseyside L35 5DR, United Kingdom
Correspondence to: Flat 59, The Symphony, 2 Stowell Street, Liverpool, Merseyside L7 7DL, United Kingdom. Tel.: +44 7888 687680.
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