Elsevier

Burns

Volume 31, Issue 5, August 2005, Pages 578-586
Burns

Should dermal scald burns in children be covered with autologous skin grafts or with allogeneic cultivated keratinocytes?—“The Viennese concept”

https://doi.org/10.1016/j.burns.2005.01.001Get rights and content

Abstract

The treatment of scald burns in children is still under discussion. The aim of the present study was to evaluate an optimised treatment regime for scald burns in children.

Between 1997 and 2002, 124 children underwent surgical intervention due to burn injuries. Thirty-six out of these 124 children were enrolled into the evaluation of our recent treatment protocol. Twenty-two children with scald burns covering an average body surface area (TBSA) of 18.5% were treated by early excision and coverage with allogeneic keratinocytes in case of partial thickness lesions (keratinocyte group).

Fourteen children with a TBSA of 17.2% were treated with autologous skin grafts alone (skin graft group). Both groups were comparable according to age, burn depth and affected TBSA. The complete clinical follow-up examination of at least 17 months was performed in 12 out of 22 children of the keratinocyte group and in 9 out of 14 patients of the comparative group. Visible scar formations were classified according to the Vancouver Scar Scale (VSS) in each patient.

The use of allogeneic keratinocytes led to complete epithelialisation within 12 days in 20 of the 22 cases. No secondary skin grafting procedures had to be done. Skin take rate at the sixth postoperative day was 100% in the skin graft group. Blood transfusions were administered intraoperatively according to the clinical need of the patients by the responsible anaesthesiologist. The mean volume of blood, which had to be transfused was 63.9 ml in the keratinocyte group and significantly lower than the volume of 151.4 ml, which was administered in the skin graft group (p = 0.04).

At follow up the VSS observed in areas covered by keratinocytes was 2.33 on the average and therefore, significantly lower than the VSS of 5.22 in skin grafted areas of the comparative group (p = 0.04).

In children the use of cultivated keratinocytes in partial thickness scald burns is a procedure, which renders constantly reliable results. It minimizes the areas of autologous skin harvesting and reduces the amount of blood transfusions. The fact that less scarring is observed after keratinocyte grafting leads to the conclusion that skin grafting in children should be restricted to scalded areas, which have to be excised to the subcutaneous fat tissue.

Introduction

The use of cultured epidermal autografts for the coverage of burn wounds was introduced by Rheinwald and Green [1] and Gallico et al. [2] in the nineteen seventies. Despite many criticisms, in the hands of many burn surgeons it has become a proven method, which can help to save the life of severely burned patients [3], [4], [5]. Nevertheless, especially in the case of autologous use, there are still persistent problems such as the relatively long culture time. It takes about 3–5 weeks to reach sheet grafts, which are suitable for grafting. Moreover, a significant number of severely burned individuals succumb to their injuries during this culture period. A further persisting problem is the observed lack of stability (blistering) in comparison to with split thickness grafted areas. This instability is mainly based on the lack of rete ridges and hemidesmosomes, which have been shown to need several months for their formation [6]. Therefore, many centres in Europe have started to use either fresh or cryopreserved allografts [7].

Due to the release of growth factors and wound healing mediators, it has been claimed that cultured epidermal allografts have a beneficial effect in the treatment of superficial and partial thickness burns [7], [8], [9].

In the burn unit of the Department of Plastic and Reconstructive Surgery at the Vienna University Hospital a programme of cultivation of human epidermal cells was established in 1995. Since 1997 more than 600 sheets of cultured keratinocytes, 75 cm2 in size, have been produced each year. Beside the coverage of partial thickness burns in the face [10] and hands as well as the coverage of skin graft donor sites, one of the main indications for the use of allogeneic cultivated keratinocytes is the coverage of partial thickness scalds in children [11].

However, the treatment of partial thickness scalds in children is still discussed controversially. Whereas several authors have proposed the early excision of scalds and grafting with skin grafts or biological skin substitutes [12], others have advocated a delay of at least 10 days until definitive coverage in order to minimize the operative trauma and blood loss [13].

In 2001, Yanaga et al. showed that coverage with allogeneic cultivated keratinocytes leads to a faster epithelisation of excised scald wounds in comparison to the treatment without any coverage in children [14]. They also reported of faster epithelisation of donor sites covered with keratinocytes in comparison to those treated conservatively. They demonstrated a milder redness and scar formation in the grafted areas due to earlier wound closure and thereby better functional outcome. According to these findings, the clinical outcome using allogeneic cultivated keratinocytes can be considered to be superior upon conservative or surgical strategies in which no further wound coverage will be achieved.

On the other hand, wound coverage can usually be adequately achieved with split skin grafts in children [13]. In regard to the higher risks in developing hypertropic scar formation and contracture in donor sites as well as in scald wounds, covered with split skin grafts, Lochbuhler and Meuli presented new concepts in paediatric burn care in order to refine the surgical techniques and to improve the clinical outcome in 1992 [15], [16].

Due to the fact that wound coverage with autologous split skin grafts can lead to an acceptable functional and aesthetic outcome, one should compare the clinical results obtained in children, where the wounds were covered with biological skin substitutes with those, who received split skin grafts in order to highlight the advantages of the treatment with cultured allogeneic keratinocytes in scald wounds in children. This retrospective study introduces our concept in treating partial thickness scalds in children and compares follow-up results after the use of allogeneic cultivated keratinocytes to those after skin grafting. The aim of the study was to answer following questions:

  • Does the use of allogeneic cultivated keratinocytes render constant and reliable results in children with partial thickness scalds during a follow-up period of at least 17 months?

  • Is the actual intraoperative blood loss less using allogeneic keratinocytes in comparison to the exclusive use of skin grafts?

  • Is the hospitalisation time reduced by the use of keratinocytes in comparison to the “conventional” skin graft treatment?

  • Is there any impact on scar formation after wound coverage with keratinocytes in comparison to the coverage with skin grafts?

Section snippets

Material and methods

Between 1997 and 2002, 124 children underwent surgical intervention to treat burn injuries in our clinical department. Thirty-six out of these 124 children were included into this study. Inclusion criteria were comparable affected TBSA, burn depth and age (refer to Table 1). All enrolled children were surgically treated by the same experienced operation team. Twenty-two out these 36 children with an average age of 19.2 ± 8.8 months and all with partial thickness scald wounds covering an average

Results

In all children, a complete healing of all excised areas either covered with allogeneic keratinocytes or split skin grafts could be achieved. In the keratinocyte group, the mean volume of blood which had to be transfused intra- and post-operatively was 63.9 ± 83.6 ml and thereby significantly less than the volume of 151.4 ± 154.7 ml transfused in the skin graft group (p = 0.04). Moreover, half of the children of the keratinocyte group got no blood transfusion preoperatively at all, whereas in the

Discussion

The present study is focused on the clinical use of skin grafts and biological skin substitutes for the coverage of scald wounds in children. One objective was to highlight the advantages of the treatment with allogeneic cultivated keratinocytes. In accordance with the results of Yanaga et al. [14] the data obtained clearly demonstrate that the use of allogeneic keratinocytes is a reliable method for the treatment of partial thickness scalds in childhood. In cases of full thickness scalds, in

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