Treatment of deep partial thickness andindeterminate depth facial burn wounds withwater—jet debridement and a biosynthetic dressing

M. Tenenhaus a, D. Bhavsar a, H.-O. Rennekampff b,*

aDivision of Plastic Surgery, University of California, San Diego, School of Medicine, San Diego, CA, USAbClinic of Plastic, Hand, Reconstructive and Burn Surgery, BG Trauma Center, University of Tubingen,Tubingen, Germany

Injury, Int. J. Care Injured (2007) 38S, S38—S44

www.elsevier.com/locate/injury

KEYWORDSBurns;Face;Debridement;Waterjet;Skin substitutes;Dressings

Summary

Background: Debriding deep thermal injury to face and neck can be particularlychallenging with cold knife techniques. Timely healing, a precondition for minimalscarring, is dependant upon optimal wound bed preparation.Objective: A new water-jet surgical tool (Versajet)TM (Smith & Nephew, Hull, UK) hasbeen designed for wound debridement. Ex vivo histologic analysis of depth ofdebridement on human skin confirmed that predictable and controlled depth ofdebridement could be obtained by adjusting apparatus settings.Methods & Materials: We prospectively studied the versatility of this instrument forthe treatment of deep and indeterminate depth face and neck burns. Wounds werethen covered with either a biosynthetic (Biobrane)TM (Bertek Pharmaceuticals Inc) orcultured biosynthetic dressing (TransCyte).Results: Patient follow-up demonstrated no adverse effects. Placement of biosyn-thetic dressings was compatible with water-jet debridement. Median healing time forwounds covered with biosynthetic dressings was 14 days, and 12 days for those whichreceived the cultured biosynthetic dressing.Conclusion: We have found the water-jet system to be a versatile instrument forsurgical burn debridement with particular advantage in addressing the challengingand delicate contoured regions found in the face and neck. Accurate control ofdebridement depth facilitates wound bed preparation for simultaneous treatmentwith growth promoting biosynthetic dressings.# 2007 Published by Elsevier Ltd.

* Corresponding author.E-mail address: rennekampff.oliver@mh-hannover.de

(H.-O. Rennekampff).

0020–1383/$ — see front matter # 2007 Published by Elsevier Ltd.doi:10.1016/j.injury.2007.10.039

Introduction

The acutely burned face, particularly with deep orindeterminate burns, poses particular challengesfor the surgeon and staff: a delayed excisional

Water-jet debridement and a biosynthetic dressing S39

Table 1 Demographics of patients with burn injuries to the face and neck

Case no. Age/sex Area treated (% TBSA) Depth of burn Time to heal (days) Additional treatment

1 45/m Face, neck, 5% IIb8 9 TransCyte2 32/m Face, neck, 4% IIb8—III8 12 TransCyte, allograft then

autograft to III8 neck3 76/m Face, neck, 5% IIb8 12 TransCyte4 49/m Face, neck, 4% IIb8 8 TransCyte5 80/f Face, 4% IIa8—IIb8 14 Biobrane6 54/m Face, 3% IIa8—IIb8 13 Transcyte7 19/m Face, 4% IIa—IIb8 12 Biobrane8 30/m Face, neck, 5% IIb8 III8 12 TransCyte, allograft then

autograft to III8 neck9 38/m Face, 4% IIa—IIb8 19 Biobrane

10 20/w Face, neck, 3% IIb8 17 TransCyte11 20/m Face, 4% IIa8 14 Biobrane12 37/m Face, 4% IIa—IIb8 18 Biobrane13 34/m Face 4% IIa—IIb8 14 Biobrane

approach provides additional time for accuratewound depth determination and preservation stra-tegies while early excisional strategies will decreaseedema, inflammation, and scarring 2,10.

Debridement of superficial and intermediatedepth partial thickness wounds with classical sharpinstruments like theGoulian orHumbyknife, or deep-faceted curettes, may easily result in the loss of skinappendages critical for timely re-epithelialisation.Sensitive tissue preservation aswell as timely closurehelp to minimise scarring and deformity.

For control of bacteria, biologic dressings providean alternative to topical antimicrobial agents.These optimise the physiologic wound environment,protect the wound from desiccation and promotethe healing process by encouraging the release ofcytokines and growth factors.5,13 Allogenic skin 7 aswell as commercially available biosynthetic dres-

Table 2 Results of ex vivo study on depth of debridement

Setting Observation

1 No macroscopically visible debridement ofepidermis compared to a control non-debrilayers of the epidermis were intact

2 No macroscopically visible debridement ofof the supra-basal epidermis, mainly the st

3 Superficial macroscopically visible debridemdebridement of the supra-basal epidermis lseen with power setting 2.

4 Several areas demonstrated a debridementpath of debridement. Histology revealed codebrided to a depth of approximately 40 m

5 and 6 A similar histologic picture to setting 4. Theof dermis was debrided (Fig. 3c). Skin apperemain intact

7 and 8 Partial debridement of the dermis to a thic9 and 10 Debrided 1/10 (approx 200 microns) of the

tissue could be seen. The surface of the de

sings like BiobraneTM 3,6 and TransCyteTM 4,11 areexcellent adjuncts for wound bed protection, pre-servation and the promotion of epithelialisation inthe treatment of partial thickness injuries. Biobraneis a biosynthetic wound dressing principally com-posed of a porcine collagen-coated nylon mesh.TransCyte is a refined temporary skin substitutecontaining collagen, various cytokines and growthfactors produced by human dermal fibroblast cul-ture on a porcine collagen-coated nylon mesh.These products bio-integrate most favourably whenapplied early before the development of a pseudo-eschar.

Recently, a water—jet debriding tool has beendeveloped for surgical wound debridement andwound bed preparation and has shown particularpromise in the field of cutaneous debridement 8,14.The benefits include controlled and rapid debride-

with the Versajet system

the skin. Histologically, no significant effect on theded skin specimen (Fig. 3a). Basal and supra-basal

the skin. Histology revealed a partial debridementratum corneument path. Histologically, in several cross sections,eaving an intact basal layer (Fig. 3b) similar to that

pattern down to the basement membrane. A clearmplete removal of the epidermis. The dermis wasicrons at this setting.epidermis was completely removed and some degree

ndages, especially the bulb region of the hair shaft,

kness of 80 to 100 microns (Fig. 3d)depth of dermis. In several areas, deeper cuts into thebrided dermis was somewhat irregular (Fig. 3e)

S40 M. Tenenhaus et al.

ment, evacuation of debris as well as the elimina-tion of a sharp hazard from the surgical setting. Thehigh concentration of adnexa in the face seemedparticularly well suited to this application. Indeed,there is a precedent for this approach in the treat-ment of embedded road rash to the face. Wedescribe here our experience of combiningwater—jet debridement and biosynthetic dressingsin the treatment of deep and indeterminate depthburns of the face and neck.

Surgical techniques

The depth of excision and debridement was estab-lished using the Versajet on excised abdomino-plasty specimens. Goulian debrided tissue takenwith a new guarded instrument (#10) was mea-sured for depth of debridement. Biopsies werefixed in 10% formalin, embedded in paraffin, sec-tioned at 7 mm thickness, mounted onto slides, andstained with hematoxylin and eosin and measuredusing micrometry via light microscopy. The thick-ness of the debrided tissue was recorded for eachsample.

Thirteen patients with deep partial thickness orindeterminate depth thermal injuries to the face andneck, as assessed by experienced burn and recon-structive surgeons, were treated with water—jetdebridementandbiologic coverage.Most of theburnswere due to fuel and flame and the appearancesuggested that they were all very deep, justifyingan approach using debridement. After cleansing andsterile draping, debridement was performed withsettings 3 to 4 in the malar region and nose, 5 to 6in the mental and frontal regions, and 2 to 3 in theperiorbital region. The end point of debridementwasbleeding, following removal of devitalised tissue,while maintaining deeper dermis and adnexa. Fatwas not exposed, as would be the case in full thick-ness tangential excision.

After debridement, a temporary synthetic dres-sing was applied. Surgeries took place at the Uni-versity of California, San Diego, School of Medicine,San Diego, California, USA (n = 6) and the BurnCenter, BG Trauma Center, Tubingen, Germany(n = 7) between December 2003 and November2005. Etiology of the burn and time to completeepithelialisation are shown in Table 1.

Figure 1 This patient presented with partial thicknessburn to the face (a) appearance after debridement withthe water jet system and subsequent placement of acultured biologic dressing; note dermal preservation;(b) uneventful healing was observed.

Results of ex vivo experiments ondepth of debridement

Table 2 shows the results of using different Versajetsettings on the abdominoplasty specimens. Deb-

rided tissue specimens from burn wounds excisedwith the Goulian knifemeasured amean thickness of739 � 86 mm (S.E.M.).

Clinical cases

Deep and indeterminate depth thermal burn woundswere effectively and rapidly debrided of pseudo-eschar and debris with the water—jet debridingsystem (Fig. 1a). No complications from excessivetissue excision were noted with the Versajet and nopatients required secondary debridement as a resultof inadequate debridement. Biosynthetic dressingsbio-integrated to the wound bed in all but onepatient (Fig. 1b).

This patient (#12) suffered a flash flame burn tothe face and was placed into Biobrane after Versa-jet debridement. On postoperative day 4, the Bio-brane was removed as a result of exudative build upbelow the dressing. The patient healed unevent-fully with conventional daily Vaseline gauze treat-

Water-jet debridement and a biosynthetic dressing S41

Figure 2 Patient #10: patient presented with middermal partial thickness burn to the right neck (a), appearance afterdebridement with the water jet system (b) and subsequent placement of a cultured biologic dressing uneventful healingwas observed 17 days after the burn injury (c).

ment. Re-epithelialisation was complete 18 daysafter injury.

Two patients (# 2, #8) who suffered flame burns tothe face and neck required additional subsequentexcision and grafting to a 2 in.-square region on theneck. All skin grafts healed without complications.All other wound sites treated with cultured biosyn-thetic dressings epithelialised within 5—17 days.The median healing time with this approach was12 days. Median healing time in the biosynthetic(Biobrane) group was 14 days (Table 1).

To date, no patients have required scar revision inthe treated areas following removal of the biosyn-thetic dressing.

Debriding facial burns ofindeterminate depth

Full thickness burns and superficial burns pose fewproblems to the surgeon. It is the deeper and inde-terminate depth thermal injuries which are particu-larly challenging. Protractedmanagement strategiescanprolong the inflammatory phase ofwoundhealingand compromise aesthetic and functional results.Conversely, over-aggressive debridement necessi-tates skin graft closure or flap reconstruction withits resultant stigmata.

Water—jet systems were initially introduced ascutting devices for solid organs. 12,15 Over the past 2

S42 M. Tenenhaus et al.

Figure 3 Histological section of human skin showing depth of debridement with a single pass of the water jet system.Control specimen without debridement (A), setting 3 (B), setting 5 (C), setting 7 (D), setting 9 (E); H&E, originalmagnification 40 x.

years, we and others (Granick, personal communi-cation, 2005) have gained significant experiencewith this technique for the treatment of complexwounds, for wound bed preparation in chronicwounds and a similar methodology is employed forthe treatment of road rash, with excellent results.Recently, we 14 and others 8 have employed this toolin the treatment of burn wounds, and the apparatus

has received the CE mark in Europe for debridementpurposes. A high pressure jet stream of saline isoriented parallel to the working plane andcreates a vacuumwhich evacuates debris and tissue.Ex vivo experiments demonstrate that the adjusta-ble power settings of the VersajetTM System giveprecise and controlled debridement of the surgicalplanes of skin while preserving adnexa, critical for

Water-jet debridement and a biosynthetic dressing S43

epithelialisation. Adjustable power settings withprecision and reproducibility are necessary to deb-ride delicate areas like the face where the thicknessof skin and epidermis varies (Fig. 2a—c). The ex vivoresults demonstrate that it is possible to preciselyselect and adjust increments of depth. Eyelids witha total skin thickness of 593 mm and a dermal thick-ness of 138 mm require a much lower debridementsetting than the retroauricular or skin of the mentalregion which averages a total thickness of 2544 mmand a dermal thickness of 1375 mm (Fig. 3).

Standard debridement tools for the face includetheGoulianknife, surgicaldermabrader, curette, andsurgical brush. The commercially available Goulianknife is inexpensive and comes in three differentguardsettings,8,10,12allowingadebridementdepthof 0.8 mm, 1.0 mm, 1.2 mm, respectively. Ourexperimental data demonstrate that a cutting depthof 740 mm spans the anticipated range of this tool. Asa result, accurate debridement of lesser depths isdifficult to control with cold knife techniques. Simi-larly, areas consisting of complex curves and delicateskin like the nasolabial fold, medial canthal, perioraland ocular regions including the eyelids are verydifficult to debride with a Goulian knife.

More superficial debriding tools like the surgicalbrush or curette can be useful when removingpseudo-eschar; however, when deeper dermallayers require debridement, these tools are oftenineffective. The surgical dermabrader has beenadvocated by some for the debridement of theseintermediate depth wounds; however, spin orienta-tion, if not carefully attended to, can trap and tearloosely fixed tissues like those found in the regionsof the eyelids and lips.

Deep and partial thickness burns, especially scaldinjuries, often respond to the application of a bio-synthetic dressing. Rapid adherence and integrationprotects thewound, decreases pain, and significantlypromotes epithelialisation over conventional topicaltherapies 3,4,6,9,11. Demling and DeSanti 1 reported asignificantly reduced healing time with the use of acultured biosynthetic dressing in facial burns whenplaced immediately after the injury. If there is delay,a pseudo-eschar cancomplicate this application. Thisis a proteinaceous exudate which develops on ther-mal injury surfaces treated with topical antimicro-bials. It inhibits epithelialisation, skin graft take andbiosynthetic biointegration. The water—jet rapidlyremoves this layer affording accurate assessment ofthe depth of injury, and develops a wound bed sui-table for the placement of a biosynthetic. Deeperthermal injuries can similarly be successfully deb-rided of non-vital tissue and debris.

This was a small study without surgical controls,and two different biosynthetic dressings were used

as adjuncts to debridement, so no significant con-clusions can be drawn about the healing rate orhealing period of this approach. However, the sur-geons involved have a great deal of experience intreating these injuries and it is their opinion thatthis approach to this type of thermal injury shouldbe investigated more thoroughly.

The water—jet system in its higher power settingrange is a powerful cutting instrument. Full thick-ness eschars, particularly when overlying superfi-cially located fatty collections as seen in the malarregions of the face, require judicious applicationand care in use as with all surgical instruments. Theprecise and clean level of debridement afforded bythis technology makes it easy to determine thedepth of debridement and the viability of the under-lying tissue. Perhaps most importantly, tissue pre-servation and selectivity are improved over coldknife techniques. The benefits of the Versajet sys-tem include controlled depth precision, rapid deb-ridement, evacuation of debris and the eliminationof a sharp hazard from the operating theatre. Con-comitant application of biosynthetic dressings com-plements this approach allowing optimal healing offacial burn wounds with minimal scarring.

Conflict of interest statement

D. Bhasvar has declared no conflict of interest.H. Rennekampff and M. Tenenhaus have declaredthat they serve on an advisory board for Smith &Nephew and have obtained honoraria for presenta-tions by Smith & Nephew.

Acknowledgements

We would like to acknowledge Mrs. M. Meier’s helpwith preparation of the colour pictures, and wewould also like to acknowledge Ms. Jane Uhle’s helpin organisation of the text.

References

1. Demling RH, DeSanti L. Management of partial thicknessfacial burns (comparison of topical antibiotics and bio-engi-neered skin substitutes). Burns 1999;3:256—61.

2. Eldad A, Weinberg A, Breiterman S, et al. Early nonsurgicalremoval of chemically injured tissue enhances wound healingin partial thickness burns. Burns 1998;24:166—72.

3. Gerding RL, Imbembo Al, Fratianne RB. Biosynthetic skinsubstitute vs. 1% silver sulfadiazine for treatment of inpa-tient partial-thickness thermal burns. J Trauma 1988;28:1265—9.

S44 M. Tenenhaus et al.

4. Hansbrough JF. Dermagraft TC for partial thickness burns: aclinical evaluation. J Burn Care Rehabil 1997;1(Part 2):S25—8.

5. Hansbrough JF, Morgan J, Greenleaf G, et al. Development ofa temporary living skin replacement composed of humanneonatal fibroblasts cultured in Biobrane, a synthetic dres-sing material. Surgery 1994;115:633—44.

6. Hansbrough JF, Zapata-Sirvent R, Carroll WJ, et al. Clinicalexperience with Biobrane biosynthetic dressing in the treat-ment of partial thickness burns. Burns 1984;10:415—9.

7. Horch RE, Jeschke MG, Spliker G, et al. Treatment of seconddegree facial burns with allografts–—preliminary results.Burns 2005;31:597—602.

8. Klein MB, Hunter S, Heimbach DM, et al. The Versajet waterdissector: a new tool for tangential excision. J Burn CareRehabil 2005;26:483—7.

9. Kumar RJ, Kimble RM, Boots R, et al. Treatment of partialthickness burns: a prospective randomized trial using Trans-cyteTM. ANZ J Surg 2004;74:622—6.

10. McDonald WS, Deitch EA. Hypertrophic skin grafts in burnpatients: a prospective analysis of variables. J Trauma1987;27:147—50.

11. Noordenbos J, Dore C, Hansbrough JF. Safety and efficacy ofTransCyte for the treatment of partial thickness burns. J BurnCare Rehabil 1999;20:275—81.

12. Piek J, Oertel J, Gaab MR. Waterjet dissection in neurosur-gical procedures: clinical results in 35 patients. J Neurosurg2002;96:690—6.

13. Rennekampff HO, Kiessig V, Loomis W, et al. Growth peptiderelease from biological dressings: a comparison. J Burn CareRehabil 1996;17:522—7.

14. Rennekampff HO, Wisser D, Schaller HE, et al. Debridementof burn wounds with a water jet tool. Burns 2006;32:64—9.

15. Shekarriz B, Shekarriz H, Upadhyay J, et al. Hydro-jet dis-section for laparoscopic nephrectomy: a new technique.Urology 1999;54:964—7.