BURN CARE AND PREVENTION JOURNAL

KEY WORDS: Nonperforated graft, Plasma technology, Skin burn, Wound treatment

To improve adhesion and fixation of skin grafts on the wound surface, most clinics use suture material or metal staples.¹ Other groups have used glue to connect skin layers during surgical operations.² In studying the effects of low-temperature argon plasma (LTAP) in our clinic, we observed increased adhesion and fixation of split skin grafts on granulated burn wounds under the influence of LTAP. Over the past 3 decades, the effects of low-temperature plasma have been actively studied with the aim of optimizing the wound healing process.^3-5
The active plasma particles that affect tissues are nitrites, nitrates, nitric oxide, ozone, and others. According to previous studies, this physical method of treating burn wounds simultaneously reduces microbial invasion and decreases the severity of the inflammatory response.^6,7 Low-temperature argon plasma has a warming effect on the skin, which in turn stimulates the production of endogenous nitric oxide, enhancing local blood flow. Enhanced microcirculation improves the transport of nutrients, oxygen, and blood cells, counteracting hypoxia, as confirmed by laser Doppler flowmetry.⁸ According to the current scientific literature available to us, no published evidence is available on the application of LTAP in promoting the adhesion and fixation of split grafts. An effect of argon plasma that necessitates evaluation is improved adhesion of transplanted skin grafts to the surface of the burn wound. Therefore, we evaluated the effects of LTAP treatment on the wound surfaces and transplanted skin grafts to improve adhesion and fixation of skin grafts.

MATERIALS AND METHODS

We evaluated treatment outcomes of 41 patients with deep burns requiring split-thickness skin grafts. All patients were treated at the Department of Thermal Injuries of the State Budgetary Institution “St. Petersburg Research Institute of Emergency Medicine named after I.I. Dzhanelidze” between September 2023 and September 2024. We studied the results of intraoperative treatment of split skin grafts on recipient wound surface with LTAP for the purpose of adhesion and fixation of grafts. We examined results at 3 and 7 days after surgery. We recorded the following: the extent of skin graft engraftment, the presence of hematomas, and the frequency of lysis or suppuration. We also studied the results of engraftment of nonperforated grafts in functionally important areas of the hand, foot, and large joints. Intraoperative treatment with LTAP was applied to skin grafts covering up to 5% of the total body surface area. Intraoperative treatment of transplanted skin grafts was performed on an area of up to 5% of the body surface area, which was due to technical capabilities and practical necessity (transplant of nonperforated skin grafts required significant donor resources).
Patients were distributed as follows: 16 (39.02%) were female and 25 (60.98%) were male. The average age of patients was 40.76 years. According to the etiology, 35 patients had injuries caused by flames, 4 by hot water, and 2 by contact with a hot object. Total body surface area damage in patients was 19.51%, including 4.63% of deep burns. The period for performing skin grafting using LTAP was 22.29 days.
The use of LTAP on the wound was conducted by using the plasma-arc surgical unit “Plasmoran” (Moscow, Russia), where argon according to GOST 10157-79 was used as the working gas. The distance from the plasma torch nozzle to the skin graft was 8 to 9 cm for short-term exposure (up to 2 seconds) of plasma flow to the graft and underlying tissues in temperatures ranging from 55 to 66 °C. Under this operating mode, the graft remained viable, and the underlying tissue, together with the wound exudate, formed an adhesive layer that ensured fixation of the skin graft on the wound surface.
Treatment with LTAP was performed on the entire surface of the transplanted nonperforated skin grafts on the upper limbs in 26 patients (63.42%) and on the lower limbs in 15 patients (36.58%). All wound surfaces were visually equally ready for skin grafting. A control area of up to 50 cm2 was selected at random. Because the control and study areas were examined on the same patient, we excluded the influence of the vascular factors in elderly people on the course of the wound process, as all stages of treatment were monitored in the same person.
The efficiency of the proposed method of increasing adhesion and fixation of nonperforated skin grafts in functionally important zones was assessed on a 10-point scale (depending on the percentage of engrafted grafts, the area of blister formation, and lysis manifestations) as follows: 100 points meant all grafts engrafted, 9 meant 90%, 8 meant 80%, and so forth. Over a period of 7 days, we examined the following phenomena during dressing changes: (1) dislocation of grafts, (2) blistering and hematoma formation under the graft, and (3) lysis. In the control area, the graft was fixed with interrupted sutures to prevent dislocation.
For statistical analyses of data, we used the Mann-Whitney 2-sample distribution with normal distribution (Mann-Whitney U test [Wilcoxon rank sum]). For comparative analysis by duration of surgical intervention, 41 case histories of patients with similar skin grafts performed on the same area and localization were retrospectively selected. Written consent had been obtained from patients, and the study was conducted according to the principles of the Declaration of Helsinki.

When we analyzed the score characteristics of each study and control area, we found no differences in the phenomenon of skin graft transplant dislocation between the study and control areas (P = .326; P [x ≤Z] = .163). The Z test showed -0.981 (which was in the 95% CI of -1.96 to 1.96). U score showed 740.5, which was in the 95% acceptance region.
When score characteristics were compared for the formation of hematomas and blisters, differences between the study and control areas were significant. The grafts treated with LTAP had lower formation of blisters and hematomas (P < .001; P [x ≤Z] = .999). The Z test was 3.1813, which was outside the 95% CI of -1.96 to 1.96. U score was 1168, also outside the 95% CI. In numerical terms, the formation of hematomas and seromas was 13.6% less frequently observed in the study area.
Manifestations of graft lysis in the control and study areas were not significantly different (P = .155; P [x ≤Z] = .078). The Z test showed -1.4214, within the 95% CI of -1.96 to 1.96. U score showed 696.5, which was in the 95% acceptance region.
For duration of the operation, a digital equivalent was calculated based only on those areas where nonperforated grafts were used and where fixation with interrupted sutures was required in functionally important areas, which was successfully replaced by LTAP treatment. The result was a 35% reduction in the duration of surgical intervention, with average duration of 130 versus 84.5 minutes.
The use of LTAP made it possible to achieve a number of positive technical results during surgery by using nonperforated grafts on functionally important areas of burn wounds (hands, feet, large joints). First, the processing of skin graft transplants on the wound surface allowed fixation to be achieved of free split grafts on the recipient’s granulated surface, which reduced the duration of the surgical operation by 35%, as it was not necessary to apply fixing sutures around the perimeter of the graft. Second, because of fixation of the nonperforated graft, no hematomas or blisters formed under it.
As a clinical example, a 34-year-old patient (patient M) was treated in the thermal injury department with the diagnosis of 18% (6%) second to third degree burns of the lower extremities. On day 18, the patient received skin graft transplant of nonperforated grafts on granulating wounds on the dorsal surface of the feet and the ankle joint area, followed by treatment of the grafts with LTAP (Figure 1). The result of the operation (10 points after 7 days) is shown in (Figure 2).

The use of plasma technology significantly reduced the frequency of hematoma and seroma formation under transplanted grafts, which was demonstrated by greater graft adhesion to the wound surface as a result of the plasma action and the absence of trauma to the recipient bed during the application of fixation sutures to the graft. This method of fixing nonperforated grafts is appropriate for thin and medium-thickness grafts (up to 0.5 mm), allowing adhesion of the graft to the bottom of the wound surface. In thick and full-thickness grafts, the thickness of the graft tissue would prevent the plasma jet from acting on the wound bed, so the graft is not fixed to the bottom of the wound. Prolonged exposure of the graft to the plasma jet could also result in thermal damage to grafts thicker than 0.5 mm. The most significant finding from a practical health care perspective was a 35% reduction in the duration of surgery compared with skin grafts in other patients, where the grafts were fixed with interrupted sutures.

The use of LTAP allows for adhesion and fixation of skin grafts on the wound surface, with significant reduction in duration of the surgical operation.

Volume: 5 Issue: 1 March 2025

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