CC BY
3
COMPREHENSIVE TREATMENT OF DEEP FACIAL BURNS. A CLINICAL CASE
Tazhimuratov N.K.1, Makhanov S.A.2, Zhamashev D.K.1, Montaev B.A.2, Khamidolla A.K.1, Zhorabek A.B.1
1 Kazakh-Russian Medical University, Almaty, Kazakhstan
2 Department of Traumatology, City Emergency Hospital, Almaty, Kazakhstan
Abstract
The article summarizes a case from practice, which describes the comprehensive treatment of a patient with a deep contact burn of the face.
Throughout the development of humankind, people have been faced with the need to treat severe wounds, with facial injuries being of particular importance. Ancient sources describe that facial injuries were very common in Ancient India and the countries of the Middle East.
Patient S. was admitted to the Almaty City Emergency Hospital in 2019. She received a thermal injury at home, according to the patient, she lost consciousness while cooking and fell on a burning gas stove burner. Upon admission, the general condition of the patient was severe, due to the injury and the presence of somatic pathology.
The postoperative period was uneventful. Thus, in order to obtain satisfactory results in the surgical treatment of deep burns of the face, one operation is not enough, complex treatment is required, which includes physiotherapy and corrective operations, this is the only way to achieve the optimal, i.e. desired result. The need to develop new recommendations and their practical implementation for the treatment of this pathology will improve the quality and optimize the treatment of victims.
Хат алысатын автор. Беттщ терен кушктерш кешендi емдеу.
Жамашев Д.К. - Дэргер-траемато-
лог ^азацстан-Ресей медициналыц yHueepcumemÍHÍH ага оцытушысы, Клиникалык жагдай
Алматы ц, ^аза^стан
E-mail: dr.darmen@mail.ru
Тажимуратов Н.К.1, Маханов С.А.2, Жамашев Д.К.1, Монтаев Б.А.2, мудвчлчр ¡р/тыгысы Хамидолла А.К.1, Жорабек А.Б.1
Аеторлар MYдделер цацтыгысыныц жоцтыгын мэлiмдейдi
1 Казакстан-Ресей медицина университету Алматы к., Казахстан Туйш сездер: 2 Травматология бeлiмшесi, ^алальщ жедел шугыл кемек керсету ауруханасы,
W бет,операцщ физиотерапия. Алматы к., Казахстан
Ацдатпа
Мацалада бетнц терец жанасу KyOiai бар науцасты кешенд'1 емдеу сипатталган тэжiрибеден алынган жагдай жинацталган.
Адамзаттыц буш дамуы барысында адамдар ерекше мацызды бет жарацаттары бар ауыр жараларды емдеу цажетт^гше тап болып жатады. Ежелгi дереккездерде бет жарацаттары Ежелгi Yндiстан мен Таяу Шыгыста жи болганын сипатталады.
Науцас С. 2019 жылы Алматы цалалыц жедел жэрдем ауруханасына тускен. Ол ушнде термиялыц жарацат алган, науцастыц айтуынша, тамацп'юру кезнде еанен танып, жаныпжатцан газ плитасыныц оттыгына цулаган. Жарацаттануга жэне соматикалыц патологияныц болуына байланысты тускен кездегi жалпы жагдайы ауыр,
Операциядан кей^ кезец бiрцалыпты етт '1. Осылайша, беттц терец KYйiктерiн хирургиялыц емдеуде цанагаттанарлыц нэтиже алу Yшiн б'р операция жетктшз, KYрделi емдеу цажет, оныц шнде физиотерапия жэне тYзету операциялары цажет, тек осылай гана оцтайлы нэтижеге, ягни цалаган нэтижеге цол жетюзуге болады. Осы патологияны емдеу Yшiн жаца усыныстарды эз'рлеу жэне оларды практикалыц енгiзу цажеттiлiгi зардап шеккендерд '1 емдеудц сапасын жацсартуга жэне оцтайландыруга мYмкiндiк беред'1.
https://doi.org/10.35805/BSK2022IV034
Tazhimuratov N.K.
orcid.org/0000-0001-9988-6363 Zhamashev D.K. orcid.org/0000-0002-1887-3665 Montaev B.A. orcid.org/0000-0002-8647-9723
Khamidolla A.K. orcid.org/0000-0002-0017-1358 Zhorabek A.B. orcid.org/0000-0003-4920-6336
Corresponding author. Zhamashev D.K. -Traumatologist, senior lecturer, Kazakhstan-Russian Medical University, Almaty, Kazakhstan E-mail: dr.darmen@mail.ru
Conflict of interest
The authors declare that they have no conflicts of interest
Keywords:
burn, face, operation, physiotherapy
30
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА №73 • 2022
Комплексное лечение глубоких ожогов лица. Клиническийслучай
Тажимуратов Н.К.1, Маханов С.А.2, Жамашев Д.К.1, Монтаев Б.А.2, Хамидолла А.К.1, Жорабек А.Б.1
1 Казахстанско-Российский медицинский университет, г. Алматы, Казахстан
2 Отделение травматологии, Городская больница скорой неотложной помощи, г. Алматы, Казахстан
Автор для корреспонденции. Жамашев Д.К. - Врач-травматолог, старший преподаватель Казахстанско-Российский Медицинский Университет, г. Алматы, Казахстан E-mail: dr.darmen@mail.ru
Аннотация
В статье обобщен случай из практики, в котором описано комплексное лечение больного с глубоким контактным ожогом лица.
На протяжении всего развития человечества люди сталкивались с необходимостью лечения тяжелых ран, при этом особое значение имели травмы лица. Древние источники описывают, что травмы лица были очень распространены в Древней Индии и странах Ближнего Востока.
Больная С. поступила в Алматинскую городскую больницу скорой медицинской помощи в 2019 году. Получила термическую травму дома, со слов больной, во время приготовления пищи потеряла сознание и упала на горящую конфорку газовой плиты. При поступлении общее состояние тяжелое, в связи с травмой и наличием соматической патологии.
Послеоперационный период протекал гладко. Таким образом, для получения удовлетворительных результатов при хирургическом лечении глубоких ожогов лица одной операции недостаточно, требуется комплексное лечение, включающее физиотерапевтические и корригирующие операции, только так можно добиться оптимального, т.е. желаемого результата.. Необходимость разработки новых рекомендаций и их практического внедрения для лечения данной патологии позволит повысить качество и оптимизировать лечение пострадавших.
Конфликт интересов
Авторы заявляют об отсутствии конфликта интересов
Ключевые слова:
ожог, лицо, операция, физиотерапия
Relevance
Throughout the development of humankind, people have been faced with the need to treat severe wounds, with facial injuries being of particular importance. Ancient sources describe that facial injuries were very common in Ancient India and the countries of the Middle East [1, 2]. They caused serious dysfunction of the organs of the face, which largely explains the attempts to develop ways to restore the lost skin. With the development of society, attention to the appearance of a person has grown significantly. Nowadays facial defects, in addition to functional disorders, cause severe emotional distress and inevitable, to a greater or lesser extent, psychological disorders that impede social adaptation. Therefore, in the XXI century treatment of victims with injuries of the maxillofacial region has become of great importance. Limited deep burns of the face account for 2 to 6.3% of the total structure of burn injuries [3, 4]. Currently, in the treatment of victims with deep burns, active surgical tactics are justified regardless of the area of skin damage [5-7]. In most hospitals, the stratification of the severity of the condition of the burnt depends on the area and depth of the burn. Modern methodology requires assessing the severity of the condition and making a decision on the choice of treatment tactics based on the probability of an unfavorable outcome of the disease, i.e., based on the prognosis [3]. Severely burned patients need to perform necrectomy no later than 3 days after the injury, extremely severely burned patients - on the 1st-2nd day with simultaneous autodermoplasty [8]. Subsequently, victims with deep facial burns who were
admitted early after injury should undergo necrectomy as soon as possible. Treatment of deep facial burns is one of the most difficult tasks in combustiology and reconstructive plastic surgery. This is due to the high significance of the face in functional and aesthetic terms [9-10]. The area of the face is equal to 3.12% of the body surface. However, despite the small area, functionally important organs are concentrated in this area of the body [10]. In the treatment of deep burns of the face, the opinions of specialists in the choice of surgical tactics differ. According to the literature data, scar tissue is formed after 6-12 months [12-13]. Therefore, for a long time, surgical treatment of the consequences of facial burns was performed 1 year after the injury, since in the early post-traumatic period the operation was accompanied by profuse blood loss, reduced mobility of fresh scars, eruption of scar-modified flaps with suture material, and the remaining scarring process caused recurrence of deformities [14]. Clarkson objected to early surgical treatment of burn cicatricial deformity in patients, since he believed that the later the operation is performed, the better the result [15]. Thus, V. S. Savchin believes that burn wounds of the face need to be cleansed of necrotic tissues as early as possible and skin autotransplantation, since independent rejection of necrotic tissues, the formation of a granulating surface and skin grafting do not always give satisfactory results, but, on the contrary, cause the formation of gross cicatricial deformities. Even the use of split skin, which is more prone to retraction than full-thickness skin, does notmean leading to gross scarring. Great difficulties arise in the defeat of areas
of the face with mobile tissues and natural openings, in particular the palpebral fissure. Despite the early necrectomy, autodermoplasty with full-thickness skin, the process of scarring from the 3rd week can lead to eversion of the eyelids. Long-term blepharorrhaphy does not give the desired effect. It is almost impossible to keep the eyelid in a straightened state. Retraction of transplanted grafts makes the face mask-like, depriving it of natural expression and facial expressions. Despite all modern methods of surgical treatment, the appearance of a person after reconstructive surgery of the face changes beyond recognition. Attempts to improve cosmetic results become ineffective at some point and should be discontinued. Thus, at present there is no single tactic for the treatment of deep burns of the face, which is the reason for the continuing high frequency of functional, aesthetic disorders, increased disability in such patients. The development and practical implementation of recommendations for the treatment of this pathology will improve the quality and optimize the treatment of victims [16-20]. Case study
Patient S. was admitted to the Almaty City Emergency Hospital in 2019. She received a thermal injury at home, according to the patient, she lost consciousness while cooking and fell on a burning gas stove burner. Upon admission, the general condition of the patient was severe, due to the injury and the presence of somatic pathology.
Locally: the entire left half of the face from the scalp, the left auricle is covered with a dry scab of a dirty gray color, of a dense consistency. Given the severity and nature of the injury, the patient was hospitalized in the intensive care unit.
After relief of shock, she was transferred to the traumatology department. Where general, analgesic, infusion, detoxification therapy and local treatment of wounds by the closed method were carried out, chemical necrolisis was performed with Shnyrev's paste for 2.5 weeks, and necrectomy was performed at the beginning of 3 weeks. At the end of the 4th week, at the beginning of the 5th week, an operation was performed - delayed autodermoplasty on granulating wounds of the face and scalp.
After the operation period proceeded without complications, the first dressing was made after 48 hours, on the dressing: there was a disease of the graft (the edges of the grafts), which were stopped with a solution of dimexide diluted with a solution of furacillin. (Fig. 1-7). On the 10th day, the grafts survived by 99% and the patient was discharged for outpatient aftercare at the place of residence. The patient was followed up for 2 years.The patient after 2 months noted the eversion of the upper eyelid, asymmetry of the face, due to the formation of hypertrophic scars of the upper left eyelid in the postoperative period in the rehabilitation period, physiotherapy was carried out with the drug fermenkol for 6 months.
Figure 1.
The first 48 hours after surgery
32
BECTHMK XMPyPrMM KA3AXCTAHA №73 • 2022
Figure 2.
2 weeks later
After 6 months, in order to eliminate the eversion of the left eyelid, the excision of the scar, blepharoplasty (free autodermoplasty) was performed. The postoperative period was uneventful. Thus, in order to obtain satisfactory results in the surgical treatment of deep burns of the face, one operation is not enough, com-
plex treatment is required, which includes physiotherapy and corrective operations, this is the only way to achieve the optimal, i.e. desired result. The need to develop new recommendations and their practical implementation for the treatment of this pathology will improve the quality and optimize the treatment of victims.
Figure 3.
2 months later
Figure 4.
4 months later
Figure 5.
4 months later
Figure 6.
6 months later
Figure 7.
At present time
34
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА №73 • 2022
Conclusions
To obtain satisfactory results in the surgical treatment of deep burns of the face, one performed operation is not considered to be sufficient , no matter what kind of it is, i.e. primary necrectomy and delayed ne-
References
1. Alekseev A.A., Kudzoev O.A., Sarygin P.V. Rational plastic surgery of local deep burns and frostbite [Racional'najaplasticheskaja hirurgija lokal'nyh glubokih ozhogov i otmorozhenij] // Mat. scientific Conf.: «Actual problems of traumatology and orthopedics». - N.Novgorod, 2001 - p. 69-70
2. Alekseev A.A., Tyurnikov Yu.I. Statistical indicators of burn hospitals in the Russian Federation for 2013 [Statisticheskie pokazateli ozhogovyh stacionarov Rossijskoj Federaciiza 2013 god] // Mat. scientific Conf.: «Burns and disaster medicine». Ufa, 2014 - p. 16-18
3. Ar'ev T.Ja. Thermal damage [Termicheskie porazhenija] //- L. :Medicina, 1966. - p. 704
4. Vihriev B.S., Burmistrov V.M. Thermal damage [Termicheskie porazhenija] // L.: Medicina, 1985. - p. 208
5. Gusak V.K., Fistal' Je.Ja., BarinovJe.F., Shtutin A.A. Thermal subfascial lesions [Termicheskie subfascial'ny eporazhenija] //Doneck, 2000 - p. 181
6. Evteev A.A., Tjurnikov Ju.I. Autodermoplasty failures [Neudachi autodermoplastiki] // M.: RA IL''F, 2011. - p. 160
7. Kichemasov S.H. Skin plasty with flaps with axial blood supply for thermal lesions of the IV degree [Kozhnaja plastika loskutami s osevym krovosnabzheniem pritermicheskih porazhenijah IV stepeni: avtoref. dis. d-ra med. nauk] // L., 1990 - p. 48
8. Kolesnikov I. S., Vihriev B. S. Surgical treatment of deep thermal burns [Operativnoe lechenie glubokih termicheskih ozhogov] //- M.: Medgiz, 1962 - p. 179
9. Maljutina N.B. Comparative evaluation of the effectiveness of various methods of surgical treatment of burned elderly and senile patients [Sravnitel'naja ocenka jeffektivnosti razlichnyh metodov operativnogo lechenija obozhzhennyh pozhilogo i starcheskogo vozrasta]: dis. kand. med. nauk. M., 2002. - p. 134
10. Matveenko A.V., Chmyrev I.V., Petrachkov S.A. Determining the severity of the condition of those burned using coordinate grids of the probability of death [Opredelenie tjazhesti sostojanija obozhzhennyh s pomoshh'ju koordinatnyh setok verojatnosti letal'nogo ishoda ]// Ambulance: Ros. scient.-pract. magazine - St. Petersburg, 2013. -T.14, No. 1. - p. 34-43
11. Porembskij Ja.O., Paramonov B.A., Jablonskij V.G. Burns: a guide for physicians [Ozhogi: rukovodstvodljavrachej] // St. Petersburg: SpetsLit, 2000 - p. 488
crectomy followed by autodermoplasty for granulating wounds.
Comprehensive treatment is required, which includes physiotherapy and corrective surgeries, this is the only way to achieve the desired result.
12. Sokolov V.A. Combined auto-allodermoplasty in the treatment of burnt [Kombinirovannaja auto-allodermoplastika v lecheniiobozhzhennyh] :avtoref. dis. and. med. sc. - SPb.,1995. - p. 22
13. TjurnikovJu.I., Suhov T.H., Evteev A.A. Experience in surgical treatment of patients with critical burns [Opyt hirurgicheskogo lechenija bol'nyh s kriticheskimi ozhogami ] // Mat. scientific Conf.: «Burns and disaster medicine». - Ufa, 2014 - p.204-206
14. Chmyrev I.V. Necrectomy in the burned: Innovative approaches in the provision of specialized medical care [Nekrjektomija u obozhzhennyh: Innovacionnye podhody pri okazanii specializirovannoj medicinskoj pomoshhi]: dis. Dr. med. Sciences. SPb., 2014. - p. 301
15. Shapovalov S.G., Belyh S.G. Surgical treatment of victims of burn injuries in emergency situations [Operativnoe lechenie postradavshih ot ozhogovoj travmy v chrezvychajnyh situacijah] // Bulletin of Pirogov National Medical & Surgical Center. — 2011. - T. 6, № 1. - p. 67-76
16. Shapovalov S.G., Pleshkov A.S., Panov A.V., Melnikova O.A., Sukhoparova E.P., Novitskaya A.A. Organization of medical care for patients on the basis of the burn department. The first experience of using the MEEK methodology in Russia [Organizacija okazanija medicinskoj pomoshhi pacientam na baze ozhogovogo otdelenija. Pervyj opyt primenenija MEEK metodiki v Rossii ] // Mat. scientific Conf.: «Burns and disaster medicine». - Ufa, 2014 - p.79-81
17. Bishara SA, Shady NH, Gunn SW /New technologies for burn wound closure and healing. Review of the literature. Burns 31 (2005): p. 944956
18. Burke JF, Bondoc CC, Quinby WC /Primary burn excision and immediate grafting: a method shortening illness // J. Trauma Vol. 14, № 5(1974): p389 - 395
19. Caldwell FT Jr, Wallace BH, Cone JB /Sequential excision and grafting of the burn injuries of 1507 patients treated between 1967 and 1986: end results and the determinants of death.// J BurnCareRehabil 17(1996): p137-146
20. Cole JK, Engrav LH, Heimbach DM, Gibran NS, Costa BA, Nakamura DY, Moore ML, Blayney CB, Hoover CL/ Early excision and grafting of face and neck burns in patients over 20 years./ Plast Reconstr Surg 109(2002): p1266-1273
