will result in severe scarring and disfigurement, often very difficult to correct with plastic surgery.
The treatment for advanced burns in a burn center consists of cleansing the areas, debridement and removal of dead tissue in what is often a painful process because of the live skin remaining next to the dead skin, vigorous fluid and electrolyte replacement, antibiotic therapy, and a very strong psychosocial support program.
The skin is the largest organ in our bodies and, if you didn't already know it, it is a vital organ, keeping infection out of your body and keeping fluids, heat, and chemicals inside. Loss of even a small amount of skin can, therefore, be very dangerous, requiring intensive treatment. In spite of this many burn patients die. The problem is more severe in children because they can deteriorate very quickly and don't have the body “reserves” of fluid to withstand such a major insult.
Often, the survivability of a burn patient is dependent upon two factors: the percentage of the body burned and the amount of second and third degree burns. The following diagram shows the percentage of body surface areas and is used by a doctor in determining these factors.
RULE OF NINES
| REGION | PER CENT |
| HEAD AND NECK | 9 |
| UPPER EXTREMITIES (ARMS) | 18 (9 X 2) |
| LOWER EXTREMITIES (LEGS) | 18 (9 X 2) |
| FRONT OF BODY | 18 |
| BACK OF BODY | 18 |
| GROIN (PERINEUM OR GENITALIA) | 1 |
| TOTAL | 100 |
DIAGRAM 2
Also important is whether the patient has sustained lung damage, thermal or heat damage, and whether there is damage to the kidneys. Underlying other conditions, such as diabetes mellitus, heart disease, kidney disease, and lung problems, such as emphysema from smoking as well as advanced age and poor general physical condition, may cause an increase in the mortality rate.
Burn care is a very complex problem of management, and my best comment is to insist that any significant burn should be treated in a burn center by specialists. It's better to take all burn victims to the experts at once, rather than a day or two after the incident when complications have already started. It is no longer a condition that a family doctor or general surgeon can manage with anywhere near the acuity of specially trained nurses and doctors in a burn facility with the needed isolation units, debridement tanks, special large holding tanks for bathing and debriding, and specially trained anesthesiologists to control the pain management. The plastic surgery required for even the most basic reconstruction is beyond the expertise of the average plastic surgeon.
When confronted by a severe burn think only BURN CENTER!
Chapter 24
SUTURES, STAPLES, AND DRAINS
Sutures, staples, and drains, I contend,
Are all a means to a surgical end.
And to dispel any bizarre surgical rumors,
They're just to close wounds and drain evil humors.
The choices we have to close wounds are as varied
As the tomb you can choose if you want to be buried.
You can suture the skin with nylon or silk,
Or use something else of a polymer ilk.
And of drains, there are plenty for blood or infection,
You'll find in the hospital a massive collection.
The only big choice is just when to use 'em,
And how to place 'em and not to abuse 'em.
The first question many of my patients have before elective or emergency surgery is: “Will there be a big scar?” It's almost as if it doesn't matter what goes on below the skin level.
Vanity, Vanity—the touchstone of humanity!
Well, let's move on. In the past one hundred years we have developed all kinds of suture materials, each with its own particular advantages and disadvantages. Some are nonabsorbable, like the old silk and wire to the newer Prolene, nylon, Nurolon, polypropylene, Ti-Cron, and other chemical polymers, while others are absorbable, which means they dissolve in the body's tissue anywhere from a few weeks to a few months after usage. Among the absorbable sutures are the old catgut, which comes in plain or chromated varieties, to the newer synthetic materials like polyglycolic acid (PDS) sutures and vicryl. Some sutures used on the skin have to be removed, while others used just under the skin in the subcuticular layer, are placed like hem stitches and never have to be removed; they eventually dissolve. Nowadays, the thread comes attached to the needle, and it's very rare that the nurse has to thread a needle for the surgeon. This saves time and, because the thread is amazingly fitted into the back end of the needle, the atraumatic needle, the hole made while suturing is exactly the diameter of the needle itself.
For suturing the fascia, the strong structure holding in your abdomen, and for suturing tendons and heavy structures, we use heavy suture material, whereas for delicate structures like facial skin, children's skin or blood vessels we use finer material that leaves less scarring. Sutures are graded numerically from the very thick #2 to the very fine, thinner than a human hair, 100 used for some types of eye surgery.
Using too weak a suture material may result in wound breakdown, and the surgeon must take the overall wound healing into consideration as we have discussed in Chapter 21. When an area is under tension, the sutures need to be left in longer; when there is no tension and a more plastic closure is desired, the sutures may be taken out earlier and replaced with paper strips called Steri-Strips to hold the wound together without leaving suture marks.
There are several types of wound closures as illustrated. Simple sutures are for the run of the mill closures, mattress sutures for coapting the skin edges a little more securely, and retention sutures for holding large areas together with huge sutures that can be loosened or tightened as needed. There are subcuticular sutures and Steri-Strips as mentioned above. In deep wounds, such as the abdominal wall, a layered closure is performed as shown in Diagram 3.
Now let's move on to drains. Why do we use them? The simple answer is just as it sounds, to drain something out of a wound, whether it is blood, serum from a seroma, bile, infection, pus, or the expectation that there will be an infection or pus. Examples are as follows: with a ruptured appendix, many surgeons will place a drain in the area of the rupture to drain off debris and infected material with the expectation that pus will form and need to get out of the body. With some extensive cancer surgeries, there may be large raw areas that may drain small but steady amounts of serum or blood for a short time. After certain plastic surgery, such as breast implants, reduction mammoplasties, or mastectomies, tube drains may be placed to assure an absolutely dry operative field and prevent formation of hematomas or seromas. These may be JacksonPratt drains, Davol sump drains, or Hemovacs. Sometimes, the surgeon will
