burns 40 (2014) 1415–1420
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Letter to the Editor A practical solution to a potentially expensive problem Excision of a burn eschar is best done with a manoeuvrable and technically reliable instrument. Commonly used dermatomes include Zimmer, Paget, Davies, etc. and the cordless battery operated HumecaW D42 & D80 dermatomes (Fig. 1). We acquired the latter but had to modify the power supply from battery driven to an electronic motor devise (done by the manufacturers in the Netherlands). This became necessary following the unfortunate autoclaving of the expensive HumecaW dermatome batteries on two occasions (Fig. 2).
The HumecaW dermatome remains unchanged, except for the replacement of the rechargeable batteries with an electrical driven motor, which fits both the D42 & D80 models (Figs. 3 and 4). This has safeguarded long-term functionality of the dermatome in a setting of frequent and inexperienced staff changes and limited resources.
Fig. 3 – HumecaW dermatomes with electronic motor.
Fig. 1 – HumecaW D42 & D80 dermatomes.
Fig. 2 – HumecaW dermatome & battery with warning.
Fig. 4 – Electronic HumecaW dermatome.
1416
burns 40 (2014) 1415–1420
Reference 1. Humeca1 dermatome catalogue.
Acknowledgement The authors want to thank Professor Alp Numanoglu, Head of Department: Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa. Gertruida van Niekerk* Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa Heinz Rode Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa *Corresponding author at: Department of Paediatric Surgery, 6th Floor ICH Building, Red Cross War Memorial Children’s Hospital, Klipfontein Road, Rondebosch 7700, South Africa. Tel.: +27 21 6585012/823344377 E-mail address: [email protected] (G.Niekerk) http://dx.doi.org/10.1016/j.burns.2014.05.012 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Letter to the Editor The hand knife: A forgotten tool in plastic surgery training
Dear Sir, Split thickness skin grafts are one of the most commonly performed procedures in Plastic Surgery Departments. They can either be harvested using a powered dermatome or the more traditional method, which involves the use of a hand knife. The latter technique has fallen out of favor mainly due to lack of training, fear of medico-legal implications and technical challenges. We feel that both techniques should be learnt with the hand knife having many advantages over its powered counterpart. In our department we use a Watson Knife and hold it closer to the blade rather than solely by the handle. This provides better stability compared to the more traditional methods previously described [1]. Adjusting the wheel on the Watson knife can modify the thickness of the graft. Either a 15 blade can be used to measure the thickness of the graft or visual inspection from the operator whilst lifting up the hand knife to the theater light [2]. An assistant places tension over the donor site which is covered with Aquacel gel # and the hand knife is introduced at a 458 angle to the skin. Essentially the same technique adopted when using a powered dermatome. Small oscillating movements are
made advancing the hand knife forward to harvest the skin graft. One can determine the thickness of the graft simply by examining the translucency of the graft and thus halt or adjust if appearances suggest too thick a skin graft [3]. The hand knife also has numerous advantages over the power dermatome. It is easily portable unlike the larger power dermatomes. This is particularly useful when many plastic surgery units in the United Kingdom have peripheral local operating lists as they follow a ‘hub and spoke’ model of care. The hand knife is ideal for harvesting thin grafts for skin cancer defects in the pretibial region and smaller 1–2% burns that can be managed under local anesthesia. It is also more cost effective and saves on the overuse of the power dermatome. Encouraging the use of the hand knife will also help refine the skillset of the residents in the department particularly when it comes to tangential excision of large burns. To the best of our knowledge there are no studies in the literature that have examined the donor site outcomes of powered versus hand knife skin graft harvest. Some surgeons have stated that the ‘Saw Toothing’ of donor site edge when using a hand knife aids in blending of the donor site with adjacent virgin skin thereby providing a superior scar outcome at the donor site [4]. We believe that it is just as easy to take a full thickness skin graft, or have delayed wound healing at the donor site with a powered dermatome. It is therefore important to consent patients with regards to these possible complications that can occur with either technique. As Tehrani etal. state surgeons should use whichever instrument they feel will in their hands provide the optimum result and not be directed by anecdotal opinions [4]. Both techniques are best learnt on training models, and following careful safety checks to prevent taking full thickness skin grafts. In 2006 Tehrani etal. in postal survey of British Plastic Surgeons found that 44% of Senior House Officers were not confident in using a Hand Knife. This figure is most likely much higher at present as training has significantly changed since that time. The MDU and MPS were also contacted in their study and no specific cases of negligence were attributed to the use of the hand knife over the powered dermatome. In summary Plastic surgeons should learn both techniques, and indeed learning how to use a hand knife appropriately is an extremely useful skill to master.
Conflicts of interest None.
Funding None.
references
[1] Barret JP. The small burn. In: Barret-Nerin JP, Herndon DN, editors. Principles and practice of burn surgery. New York: Marcel Dekker; 2005. p. 209.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Letter to the Editor A practical solution to a potentially expensive problem Excision of a burn eschar is best done with a manoeuvrable and technically reliable instrument. Commonly used dermatomes include Zimmer, Paget, Davies, etc. and the cordless battery operated HumecaW D42 & D80 dermatomes (Fig. 1). We acquired the latter but had to modify the power supply from battery driven to an electronic motor devise (done by the manufacturers in the Netherlands). This became necessary following the unfortunate autoclaving of the expensive HumecaW dermatome batteries on two occasions (Fig. 2).
The HumecaW dermatome remains unchanged, except for the replacement of the rechargeable batteries with an electrical driven motor, which fits both the D42 & D80 models (Figs. 3 and 4). This has safeguarded long-term functionality of the dermatome in a setting of frequent and inexperienced staff changes and limited resources.
Fig. 3 – HumecaW dermatomes with electronic motor.
Fig. 1 – HumecaW D42 & D80 dermatomes.
Fig. 2 – HumecaW dermatome & battery with warning.
Fig. 4 – Electronic HumecaW dermatome.
1416
burns 40 (2014) 1415–1420
Reference 1. Humeca1 dermatome catalogue.
Acknowledgement The authors want to thank Professor Alp Numanoglu, Head of Department: Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa. Gertruida van Niekerk* Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa Heinz Rode Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa *Corresponding author at: Department of Paediatric Surgery, 6th Floor ICH Building, Red Cross War Memorial Children’s Hospital, Klipfontein Road, Rondebosch 7700, South Africa. Tel.: +27 21 6585012/823344377 E-mail address: [email protected] (G.Niekerk) http://dx.doi.org/10.1016/j.burns.2014.05.012 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Letter to the Editor The hand knife: A forgotten tool in plastic surgery training
Dear Sir, Split thickness skin grafts are one of the most commonly performed procedures in Plastic Surgery Departments. They can either be harvested using a powered dermatome or the more traditional method, which involves the use of a hand knife. The latter technique has fallen out of favor mainly due to lack of training, fear of medico-legal implications and technical challenges. We feel that both techniques should be learnt with the hand knife having many advantages over its powered counterpart. In our department we use a Watson Knife and hold it closer to the blade rather than solely by the handle. This provides better stability compared to the more traditional methods previously described [1]. Adjusting the wheel on the Watson knife can modify the thickness of the graft. Either a 15 blade can be used to measure the thickness of the graft or visual inspection from the operator whilst lifting up the hand knife to the theater light [2]. An assistant places tension over the donor site which is covered with Aquacel gel # and the hand knife is introduced at a 458 angle to the skin. Essentially the same technique adopted when using a powered dermatome. Small oscillating movements are
made advancing the hand knife forward to harvest the skin graft. One can determine the thickness of the graft simply by examining the translucency of the graft and thus halt or adjust if appearances suggest too thick a skin graft [3]. The hand knife also has numerous advantages over the power dermatome. It is easily portable unlike the larger power dermatomes. This is particularly useful when many plastic surgery units in the United Kingdom have peripheral local operating lists as they follow a ‘hub and spoke’ model of care. The hand knife is ideal for harvesting thin grafts for skin cancer defects in the pretibial region and smaller 1–2% burns that can be managed under local anesthesia. It is also more cost effective and saves on the overuse of the power dermatome. Encouraging the use of the hand knife will also help refine the skillset of the residents in the department particularly when it comes to tangential excision of large burns. To the best of our knowledge there are no studies in the literature that have examined the donor site outcomes of powered versus hand knife skin graft harvest. Some surgeons have stated that the ‘Saw Toothing’ of donor site edge when using a hand knife aids in blending of the donor site with adjacent virgin skin thereby providing a superior scar outcome at the donor site [4]. We believe that it is just as easy to take a full thickness skin graft, or have delayed wound healing at the donor site with a powered dermatome. It is therefore important to consent patients with regards to these possible complications that can occur with either technique. As Tehrani etal. state surgeons should use whichever instrument they feel will in their hands provide the optimum result and not be directed by anecdotal opinions [4]. Both techniques are best learnt on training models, and following careful safety checks to prevent taking full thickness skin grafts. In 2006 Tehrani etal. in postal survey of British Plastic Surgeons found that 44% of Senior House Officers were not confident in using a Hand Knife. This figure is most likely much higher at present as training has significantly changed since that time. The MDU and MPS were also contacted in their study and no specific cases of negligence were attributed to the use of the hand knife over the powered dermatome. In summary Plastic surgeons should learn both techniques, and indeed learning how to use a hand knife appropriately is an extremely useful skill to master.
Conflicts of interest None.
Funding None.
references
[1] Barret JP. The small burn. In: Barret-Nerin JP, Herndon DN, editors. Principles and practice of burn surgery. New York: Marcel Dekker; 2005. p. 209.
