Dr. Derek Bell on the Physical Signs of Adequate Excisional Debridement

Dr. Roselle Crombie, general and burn surgeon from CT Burn Center, Yale New Haven Health System, speaks with Dr. Derek Bell, plastic surgeon and Director of the Kessler Burn Center at University of Rochester Medical Center. Dr. Bell  explains in detail his approach to excision, including why he looks for signs of “paprika” and “glistening corn silk” to evaluate the readiness of a wound bed.

The opinions expressed, and techniques described, herein are general in nature and based on the clinical experience of the presenting physician. Physicians should use their own professional judgment and consider patient-specific factors in treating their own patients.

 Dr. Crombie has a consulting relationship with Integra LifeSciences. Neither Dr. Crombie nor Dr. Bell was compensated for their participation on this podcast.

Visit the Tissue Technologies blog to learn more.

Transcript

Dr. Crombie:

Give a little introduction about who you are, where you are, and how long you've been there. 

Dr. Bell:

So Derek Bell, the University of Rochester. I did my general surgery training at the University of Buffalo and did my plastic surgery training at the University of Virginia. I've been at the University of Rochester for 13 years and have been in the Burn Director role for almost the entirety of that, about 12 and a half years. My practice consists of reconstructive plastic surgery, reconstructive burn surgery, as well as primary burn surgery.

Dr. Crombie:

You've done a lot.

Dr. Bell:

It's busy. It also allows me to learn from my experiences. I tell the residents I've learned a lot along the way of what not to do and I’ve learned from my failures.

Dr. Crombie:

Let’s talk about that. You and I… you’re my contemporary. I’m probably just a few years ahead of you. But I didn’t go into this learning how exactly to approach a debridement, what to do. Think way back to 16, 17 years ago when you were first learning about burn surgery and being inspired by it. What are the things that you did differently then for debridement that you’ve learned along the way?

Dr. Bell:

I have the fortunate experience of having done it from a general surgery standpoint with our Burn Director who was in Vietnam. He was a surgeon in Vietnam. So his perspective on things was a little bit different than what mine is currently. Looking back, it was pretty gruesome. We didn't use tourniquets. We used the Humby and you just kept cutting until it was bleeding aggressively. And then even after that, we weren't really meticulous with hemostasis. Everything got meshed. It was a school of thought that you should put the graft on while it's still aggressively bleeding, because that will help the graft imbibe. And it's drastically different from what I do now and what I train my residents. That there's no purpose in that. It's not safe for the patient. Looking back, being a junior level resident, those are the residents that are from the burn cases, you don't really know the difference. And then having transitioned through into plastic surgery training and see how they approached it with tourniquets, meticulous hemostasis, which helped to mitigate problems with graft take.

Dr. Crombie:

What is something that you learned early on in your career in terms of your excision and looking at the wound that you have changed in your practice now from where you started in the beginning?

Dr. Bell:

When I'm explaining it to the residents, and they're like, "What are you looking at? How do you know it's ready for autografting versus allografting or some other graft," or how you make a decision using ADM? A lot of it has to do with the wound bed. It's not really so much what I'm going to put on it, but it's the preparation of the wound bed. For me, I take into consideration factors other than just the burn itself like the age of the patient, the nutritional status of the patient, the mechanism of the burn injury.

For example, if the patient has a contact burn for a prolonged period of time, like they have an extremity caught in a hot press or something like that, I know that even though I take a patient in the operating room, I excise it to what appears to be grossly healthy tissue and bleeding aggressively, that that's probably going to continue to evolve with time. So that's a patient that I would not autograft initially, but I would excise with the anticipation that they're going to need re-excision.

I try to excise as superficially as possible. I think that there is a lot of benefit to maintaining that deep dermis. I'm not aware of any studies on this, but I think that if you retain some of that deep dermis, it helps to mitigate future scarring. But it's really, for me, it's a lot of like looking at the wound bed, seeing what the color is, taking into consideration the mechanism of the burn injury, and seeing what's red versus kind of beige and not quite deep enough in terms of excision.

And also for me, and this is probably the longest part of my case, is the hemostasis, which is safe for the patient. It helps them minimize whatever graft you're putting on there, minimizing graft loss, but also allows me for an opportunity to go back and look again before putting a graft on to make sure that the wound bed is really optimized regardless of what the graft choice is.

Dr. Crombie:

What specific color are you talking about? What texture are you talking about that you would tell them that you would look at, that would make you think, "I got to do more," or, "I'm good." Or, "I shouldn't graft now. I should wait."

Dr. Bell:

I tell the residents, "What we want to see is perfect punctate bleeding." And what it should look like is a wound bed that is sprinkled with paprika, and if it doesn't have that appearance with that stipple bleeding, like when you let a tourniquet down, for example, that's not deep enough. That's what I'm looking for. Again, I try to retain as much of the deep dermis as possible, but if it requires further excision, that's what we do. I'm not of the school of thought that we should excise everybody down to fat all the time.

Of course, there may be some problems with that with patients that have some deep epidermal elements that may be retained underneath the dermis like hair follicles, which in that circumstance, if you're putting a sheet graft on those patients can cause problems later with inclusion, like little mini-inclusions or milia from occluding the sebaceous glands, that retain sebaceous glands-

Dr. Crombie:

So say it’s beyond the dermis and there's no dermal elements and you're looking at just the fat bed. How do I decide this is good fat, this is bad fat? I can graft, I can not graft?"

Dr. Bell:

It should be of the appearance of like glistening corn silk is what the fat should look like in my opinion to be graftable. If it's not, then we excise further. I also do not do fascial excisions straight away unless the patient absolutely needs it. But I will try to maintain as much of the fat as possible. If I were to graft these patients straight away, if they had fascial excisions it could cause a lot of problems with contracture and mobility issues.

Dr. Crombie:

So say you're down to the anterior tibialis. What are you looking for specifically at the level of the fascia, and what are looking for at the level of the bone that you would say, "I’ve got to keep going," or, "This is ready for me to put something on."

Dr. Bell:

In that circumstance, if it was a primary excision, I would probably stop there to see what is going to take an allograft in that circumstance. When excising down to the muscular fascia, you can kind of see little capillaries in the peritenon or the periosteum, and if they're red, I know it's probably going to be okay. Granted, those may convert with time or if they become desiccated, but that's when I stop in those circumstances.

Dr. Crombie:

What about the bone? How do you look at the bone?

Dr. Bell:

So the bone's a big challenge. So obviously, if we are not careful and excise healthy periosteum that could have been grafted, dealing with the bone is a huge problem.

Dr. Crombie:

How do you debride your bone? 

Dr. Bell:

It depends on the location. So every patient's a little bit different in terms of what bone is exposed. If it's a metacarpal, it would be treated differently than the pretibial area. I would start by using a diamond tipped bur and using an ADM on those type of wounds to see if I could get that to take and then proceed forward with skin grafting. Sometimes those will granulate over with time. Some of those patients require flap coverage. If it's distal third, those patients may need a free flap or a soleus. Fortunately from my training, I've learned techniques to provide flap coverage for differing areas of the hands and extremities, but everybody's a little bit different.

Dr. Crombie:

What are the basic tenets of excision that's kind of stayed with you from your training that's consistent now? 

Dr. Bell:

Be very delicate and thoughtful with your excision and just when excising, excise the tissue as thin as possible and keep excising until you get down to the right level. Because I think over excision is detrimental and you can't really put it back. Some of these residents are a little bit heavy handed when they don't know how to use a weck blade. It's like, just barely kiss the tissue. You can always keep taking slices like prosciutto.

Dr. Crombie:

You've got a 60 to 80 percenter. When do you take him to the operating room, how long are you there for, positioning…

Dr. Bell:

I take in consideration the mechanism of the burn. So if it's flash burn or something like that in a young male that throws gasoline on a fire, even though some of those areas may look bad, I know that many of those may go on to heal. So I'd be conservative in that regard and maybe debride some areas. Generally I would take those patients to the operating room within a couple of days, unless they're continuing to demarcate. Again, taking into consideration the mechanism of injury. So if it's a scald burn, for example, with water, I know that given the age of the patient or co-morbidities, a lot of that will probably go on to heal. So that's a patient that I may wait longer before excising, but if something gets pretty obvious within a couple of days...

In regard to prioritization of which areas to begin with, I tell the residents, "I look at the patient, I see what's burned, that's the first thing I do." Second thing I do... This is not the ABCs. I look at the burn, see what's burned. The second thing I do is look at potential donor sites and I start planning immediately when I first see that patient in terms of what I have for donor sites, what is going to have to be grafted, and how to do so without burning through my donor sites, either using really super thin grafts, meshing widely. Depending on what other areas are involved, for example, the face.

So I'm not going to mesh your graft in the face. I know that that's going to consume a lot of split thickness graft with an ADM plus or minus. I want to save the absolute best donor sites for the face, eyelids. I'm going to use groin creases if possible or other areas axillary fold for full thickness grafts on the eyelids. And then in regard to what to prioritize, I usually do the deepest areas first. I don't necessarily do the most cosmetically important areas first. I do the areas that I think are going to first and foremost save the patient's life, and then I prioritize the cosmesis and functional outcomes secondarily.

Dr. Crombie:

You do pediatrics as well. What are your thought processes on how you approach debridement for, say an eight month old versus your sixty year old that you were describing that had a scald burn in the shower. 

Dr. Bell:

Again, it depends on the mechanism of injury.

Dr. Crombie:

So typically scald, right?

Dr. Bell:

Yeah. Yeah. And doing the obvious deeper areas first.

Dr. Crombie:

When you look at the wound bed, how do you personally decide whether or not somebody needs an ADM versus just they're able to be grafted? 

Dr. Bell:

I take a lot of consideration into the patient's propensity to have problems with scarring. So a young Asian female is going to be a high likelihood to scar. So that's somebody that I may do an ADM in depending on the depth of the burn as well. If there's some deep dermis remaining, I may just skin graft that type of patient. But if it does require excision into the subdermal fat without any residual dermis, then I'll put an ADM on that patient. Of course, we're taking into consideration how laborious this is going to be right with prolonged time before we can autografy them, but I explain to the parents, a lot of effort up front may help to alleviate a lot of future problems. So those are the type of patients that I would use an ADM on.

Dr. Crombie:

Got it. Versus grafting.

Dr. Bell:

Versus grafting.

Dr. Crombie:

When you're thinking about challenges that we have as burn surgeons kind of moving forward in today's day and age, I mean we've had a pandemic, we've had resources that are not available to us. What are the things that trouble you looking at how our specialty is moving forward?

Dr. Bell:

I think we made great advances with skin grafting, ADMs. The challenges that I see currently are staffing issues in the OR and on the floors. But that's like our second pandemic if you will.

And I think that one of the biggest challenges that we have going forward is getting residents and medical students interested in being burn surgeons. Now they don't have requirements in doing burns as part of their curriculum. It's hard to provide them exposure and justify providing exposure to them when it's not necessary Residents should have mandatory burn exposure.

Dr. Crombie:

For plastics as well, right?

Dr. Bell:

Yeah. They only have to do two cases in plastics. You do that in an hour of your entire training.

Dr. Crombie:

Right. 

Dr. Bell:

But I think the problem is getting people interested, exposed and excited about burns, because it obviously has a tremendous impact on our society. But if you don't have that exposure, then you're not going to go into it.

Dr. Crombie:

How did you choose to go into burns? You were so horrified by the guy that was in Vietnam as a general surgery resident…

Dr. Bell:

Well, those cases were kind of exciting. They were exciting as a resident. It's like a trauma scene. There was blood all over the place, skin is flying, you're whipping the skin off the blade.

I didn't foresee myself being a burn surgeon. You don't know how lucky you are until you look back. Fortunate experiences in your life, and you try to make the most of them. So having done a lot of burn during general surgery and then going out and doing my plastics fellowship and also taking care of all the burns at the University of Virginia where general surgery did not, I had a lot of exposure to burn. When I came to the University of Rochester, there was a need for somebody to take care of the burn patients, and being the young, eager academic plastic surgeon I was, I was like, "Yeah, I'll do it. I'll do anything. I'll do it all."

And I quickly came to realize that it's really powerful what an impact we have on people's lives, and not only saving lives, but saving livelihoods was something that is so potentially instantaneously devastating to somebody's life, and that we have the capacity to help mitigate that with a thoughtful approach to their care in minimizing scarring, minimizing their physical scarring, their psychological scarring. 

I have a box under my desk and when I'm having a lousy day or when people come to me and they ask me this question, "Why did you decide to do burn," I pull this box out and I pull out these letters I've received from patients. And I just grab one, open it, read it, put it back. 

It helps me reset that metronome sometimes when you're having a lousy day or when you're trying to explain to somebody. The hundreds of letters I've received. I don't get letters from people saying, "Hey, thanks for fixing my broken hand," or, "Thanks for doing my breast reduction," or whatever. It's, "Thanks for giving me another Christmas with Mike.”

Dr. Crombie:

Right. That's awesome. My God, thank you. That's so impactful. I mean, I think you're speaking to exactly why we all went into burn surgery quite frankly, because even in the smallest of burns, you change that person's life. See them get better and view themselves, and put them back in function.

Dr. Bell:

When I'm talking to medical students and I press them a bit, and I say to them, "Over the course of the period of time that you're going to spend with me or on our service, I want you to answer a question: Why don't you want to be a burn surgeon?"

I have many patients I'm friends with that have my phone number. Some people think that we, as surgeons, don't have continuity of care, I've known these people for 13 years, and I will know them my entire life.