Unlike adult hand burns, pediatric hand burns remain a difficult problem because of the serious risk of hand deformity along with functional impairment due to cicatricial contracture, which results from a patient's rapid growth during childhood. Deciding to perform split-thickness skin grafting or full-thickness skin grafting in the acute phase is always complicated at the time of the burn. Several clinics have suggested that full-thickness skin grafting in an acute pediatric hand burn may cause scarring at the base of the grafting site due to continuous inflammation; hence, a previous study has recommended general wound treatment until the wound remodeling period has ended, and then repair of the cicatricial contracture should be performed [2
]. Additionally, in pediatric cases, it is difficult to determine the depth and range of a burn, and to also reach agreement on post-surgery management.
The take rate of full-thickness skin grafts is lower than split-thickness skin grafts because of edema and inflammatory reactions; therefore, consideration is typically given to preserving the donor skin for further full-thickness grafts. However, a recent long-term analysis of pediatric hand burns confirmed that primary full-thickness skin grafting was superior to split-thickness grafts because it reduced the necessity of secondary reconstruction operations, and even if reconstruction was required, full-thickness skin grafting could also delay the duration [3
]. Therefore, a primary full-thickness skin grafting method and selection of the graft site are important for the preservation of relatively limited donor sites.
To improve the take rate of primary full-thickness skin grafting, surgery should be performed during reduced inflammatory reaction conditions. Surgery performed within 2 to 3 weeks after an injury allows a surgeon to easily determine if the area requires debridement. After 3 weeks, the margin of debridement becomes unclear due to unstable re-epithelization; therefore, because the progress of scar contracture occurs faster in pediatric patients than in adults, postoperative physiotherapy should be performed as soon as possible.
Recently, early excision and skin grafting have been advocated to reduce mortality, duration of illness, and the cost and length of hospital stay. Omar and Hassan [6
] had reported that early excision and skin grafting had better results than delayed grafting such as preservation of hand function and shortened hospital stay. Tambuscio et al. [7
] reported that early surgical treatment can reduce readmission for secondary revisions. However, unlike adults, in pediatric patients, it is difficult to judge the exact depth and range of excision within 5 days post-burn; even if the operation is performed, graft loss still occurs frequently. A decision well in advance is needed on the preservation of relatively limited skins from donors.
Among the pediatric patients who were treated for acute burn injury without surgery and experienced hand deformation, flexion contracture accounted for 38% of the cases and cicatricial syndactyly accounted for 30% [8
]. As a result of long-term observation in our study, cases involving finger reconstruction of the volar side, excluding the web spaces, showed a markedly low revision rate (4/115, 3.4%) (). Additionally, by performing full-thickness skin grafts, flexion contracture and cicatricial syndactyly did not occur. In other words, primary full-thickness skin grafting is a good indication for volar finger reconstruction, excluding web spaces, regardless of the number of injured fingers.
According to the long-term, 10-year observations on skin grafting such as the study by Chandrasegaram and Harvey [9
], scar release operations were performed in 50% of the split-thickness skin grafts used on the volar area. Therefore, primary full-thickness skin grafting is a good choice from a revision rate perspective, even when web spaces are included (18/65, 27.7%, P=0.045). However, in cases where more than 3 fingers are involved, including each web space, determining the appropriate region of debridement is difficult, and occurrence of scar contracture is high due to partial skin loss. Additionally, in our study, full-thickness skin grafting had to be re-performed during revision due to severe webbing deformity. In other words, primary full-thickness skin grafting is not recommended for burns that encompass more than three fingers that include the web spaces.
As reported by Chandrasegaram and Harvey [9
], when performing split-thickness skin grafting, the dorsal area had a lower post-surgery contracture rate (4/19, 21%) than the palmar area (8/12, 67%). Split-thickness skin grafting on the dorsum of the hand (4/19, 21%) has been acknowledged as having a higher post-surgery contracture rate than full-thickness skin grafting at the same site (2/25, 8%); however, in cases of large burns that lack a donor site or when donor tissue requires preservation for further full-thickness skin grafting, split-thickness skin grafting on the dorsal area can be considered.
Even primary full-thickness skin grafting cannot avoid deformation of the web spaces. According to our study analysis, cases of burns that included the web space had a higher revision rate (20/70, 28.6%). However, even when a linear scar band that interferes with digital abduction occurs, this can be resolved using Z-plasty or V-M plasty without further skin grafting, and the operation period can be delayed until the deformity has essentially ceased [10
The main limitation of full-thickness skin grafting is the resulting color difference. In particular, palmar areas, like the soles, consist of a unique type of epidermis and thus show many differences from inguinal skin in properties including texture and hardness. To overcome this problem, our hospital used the lateral aspect of the inguinal area, which markedly reduced the obvious color differences ().
Outcome of skin harvested from the lateral aspect of the inguinal area
The present study concluded that a maximum positive outcome could be obtained by following the below guidelines (): 1) To increase the take rate, a careful and technical debridement is required, and the operation should be performed when the inflammation reaction has decreased. The maximum skin grafting area must be obtained. 2) In the volar area when finger reconstruction excludes the web spaces, full-thickness skin grafting can be an absolute indication. Full-thickness skin grafting on less than 3 fingers including the web spaces may reduce the subsequent reconstruction rate. 3) In the dorsal area when only the dorsal hand area is burned, primary full-thickness skin grafting may be a good procedure to perform. However, if the donor site is insufficient and the wound is large, split-thickness skin grafting on the dorsal area can be considered. 4) Through regular follow-up, web space deformity that interrupts digital abduction can be resolved using a simple local flap. 5) To overcome the color difference, from an aesthetic point of view, donor skin should be obtained from the lateral aspect of the inguinal area.
Our algorithms for primary FTSG of pediatric hand burns