Elsevier

Burns

Volume 41, Issue 2, March 2015, Pages 257-264
Burns

Comparing outcomes of sheet grafting with 1:1 mesh grafting in patients with thermal burns: A randomized trial

https://doi.org/10.1016/j.burns.2014.07.023Get rights and content

Abstract

Background

In many units, the standard mesh ratio is 1.5:1, but in our unit we have a 1:1 mesher, which does not expand the skin but provides regular fenestrations. There is some evidence that the unexpanded 1.5:1 meshed graft compares favourably with sheet grafts from a cosmetic perspective whilst reducing the risk of graft failure secondary to a subgraft haematoma, but none comparing the 1:1 meshed graft with the sheet graft.

We conducted a randomized trial to compare surgical outcomes in unfenestrated sheet grafts with 1:1 meshed grafts.

Methods

All patients aged ≥16 years undergoing skin grafts with either a sheet or a 1:1 mesh for burn reconstruction were included. Patients on steroids, those with conditions that impair healing, and burns >20% were excluded. Patients were randomized into the sheet grafting or mesh graft using a computer-generated allocation system. The mean percentage of graft loss was assessed by a Visitrak overlay system. At 3–4 months, 7–8 months and at 1 year, photos were taken for scar assessment using the Vancouver Scar Score (VSS).

Results

Out of 72 patients, 48 patients (24 sheet vs. 24 mesh) completed the trial at 12 months. The mean age was 58 years (range 21–90). There was no total loss of graft in either group. The mean percentage of graft loss due to haematoma formation was higher in the sheet graft group (10%) compared to the 1:1 mesh group (6%) (P < 0.062). The VSS score was 5 in both groups at 12 months. There was no significant difference in scar quality between the treatment groups.

Conclusion

These results show that the 1:1 mesh graft is superior to the sheet graft with regard to graft loss, although this result is not statistically significant. There are comparable findings in terms of cosmetic perspective at 12 months post-operatively in both arms of the trial.

Introduction

Skin grafts can be used either as sheet grafts or as fenestrated grafts by passing them through a mechanical meshing device. Sheet grafts are traditionally seen as the gold standard for resurfacing burn wounds of up to 20% total burnt surface area (TBSA) as they avoid the potentially poor cosmesis of the fenestrated graft. The philosophy of many burn units has also been to use sheet grafts for cosmetically sensitive areas such as the face and hand. This advantage comes at a cost, as small areas under the sheet graft can collect haematoma and thus result in partial graft loss, which in turn leads to scarring. Sheet grafts also come at a price to the donor site: there is a belief that one should not trade a large donor-site scar with poorer cosmesis for a more cosmetic skin graft [1]. Each interstice on the meshed graft could be considered an individual wound and has to heal by secondary intention. Therefore, the wider the mesh the larger the wound has to heal by secondary intention, thereby resulting in further scarring [2]. By contrast, sheet grafts fully cover a wound, bring a rapid end to the inflammatory phase and lead to less scarring.

Techniques such as meshing were developed to allow expansion of the graft so that larger surfaces in the burn patient could be covered [3] using less donor sites. The fenestrations also allow for drainage of haematomas or seromas and also allow better conformity to the irregular wound, which together ensures good graft take. However, when expanded, each fenestration leaves behind a scar, which can be disfiguring for the patient and may increase time to healing. This is particularly true when higher settings of the mechanical meshing devices are used. Expansions of up to nine times are sometimes essential in the patient with burns with limited donor sites.

Although at our unit the standard mesh ratio is 1.5:1, we also have a 1:1 mesher (Brennen mesher), which does not allow significant expansion of the skin but provides the positive qualities of regular fenestrations. We felt that such a mesh ratio would compare favourably with sheet grafts from a cosmetic perspective whilst reducing the risk of graft failure secondary to a subgraft haematoma. We therefore conducted a single-centre randomized trial to compare surgical outcomes in unfenestrated sheet grafts with 1:1 meshed grafts.

Section snippets

Methods and materials

Institutional and ethical board approval was obtained for the trial. Patients were not recruited into the trial without signed informed consent. To ensure consistency of approach, the trial was undertaken at one burn centre in the Queen Victoria Hospital, East Grinstead, UK. The two senior authors PMG and BSD also ensured consistency of follow-up appointments, assessments and wound dressings. Post-operative dressings and compressive therapy followed a standardized protocol between the two

Results

The mean age of our 72 patients recruited into the trial was 58 years (range 20–90). Of the patients, 35 were female and 37 were male (Table 2). Three patients died before completion of the trial (not related to the burn injury). Thirty-seven patients were randomized into the 1:1 mesh arm of the trial. Thirty-five patients were randomized into the sheet graft arm of the trial. All of the burns were full thickness and were most commonly located at the extremities (Table 3). In the 1:1 mesh arm

Discussion

Our findings in this trial challenge the traditional thoughts that sheet grafting in burns is both aesthetically and functionally superior to the 1:1 mesh technique in burns of up to 20%. The VSS, which was the primary end point of this study, was initially lower in the earlier months of the trial in the 1:1 mesh group. This could be attributed to the reduction of subgraft haematoma and seroma in the 1:1 mesh group, which would most likely bear its mark earlier in the study, thereby resulting

Conclusions

These results show that the 1:1 mesh compares favourably in terms of cosmetic appearances with the sheet graft at 12 months, and that with appropriate technique both give good results. The 1:1 mesh is of particular use in areas of difficult haemostasis or graft take. The 1:1 mesh grafts also obviate much of the close monitoring needed for early haematomas or seromas in sheet grafts.

Conflict of interest statement

The authors of this study have no conflicts of interest to declare.

References (19)

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