Using Biobrane: Techniques to Make Life Easier

TECHNIQUE 1

This has successfully been used in our burns unit for many years. The wound bed is meticulously cleaned and prepared according to the guidelines developed in the consensus meeting⁵ and reiterated in our previous work⁴ and then Tincture of Benzoin (Friar's Balsam) is applied to the clean skin around the wound edge to make it “tacky.” The sheet of Hypafix (BSN Medical GmBH, Hamburg, Germany) is folded and then cut to form ribbons approximately 3- to 4 cm wide. A sheet of Biobrane is applied to the wound bed and a wide strip of Hypafix is first cut to size and then stuck to one side of the Biobrane (Fig 1) and then used to anchor it to the normal skin surrounding the burn wound edge (Fig 2). The Biobrane is then stretched across the wound by pulling against the anchored edge and trimmed to size. The free edge of Biobrane opposite the fixed edge is “picked up” with a strip of Hypafix, ensuring that half of the adhesive surface of Hypafix is still free and is then used to pull the Biobrane over the wound (Figs 3a and 3b). The free edge of the Hypafix is then secured to the intact skin beyond the burn wound. We recommend that the Hypafix be not applied to the burn wound itself, as exudate from this area makes adherence difficult. The remaining 2 edges are then similarly stretched, trimmed, and secured with Hypafix.

Figure 1. Prior to application, the free edge of the Biobrane is “picked up” by a strip of Hypafix.

Figure 2. This facilitates single user application to, for example, the posterior flanks.

Figure 3. (a) and (b) The opposite edge can be similarly placed under tension prior to adhesion by the tape.

This technique allows rapid application of Biobrane to a wound in any position which can be performed by a single operator. The Hypafix tape used is inexpensive, provides secure fixation, and does not cause discomfort to the patient upon removal. The adhesive qualities of Hypafix also do not seem to degrade with sterilization. We recommend this technique as a fast and reliable method of applying Biobrane to burn wounds.

TECHNIQUE 2

Passive flexion of the wrist on the operating table produces extension of the metacarpophalangeal joints of the hand via the “passive” tenodesis release effect.

In burns surgery, Biobrane gloves are used within the first 24 hours to cover clean partial-thickness burn wounds of the hand. The glove promotes early movement of the burned hand and helps create a barrier from infection. However, the insertion of the fingers into the thin adherent material of the Biobrane glove can create difficulty for the single surgeon. Described below is the application of the tenodesis release to produce passive finger extension and allow single-handed application of the Biobrane glove for the anesthetized patient.

The tenodesis effect is based on the principle of developing and using passive tension in a 2 (or more) joint contractile structure by moving one of the joints to produce movement at another of the joints. It has been used to substitute for lost function (creating a functional grip in paralysis), in tenodesis surgery of the hand, in the use of dynamic hand splints, to test for integrity of the extensor tendons of the hand (tenodesis test), and as the foundation of self-defence moves to disenable grasp of a weapon.

Active wrist flexion stretches the extensor digitorum communis. The tension created pulls the fingers into extension (Fig 4a). A similar but converse action results in the tenodesis grasp effect, in which wrist extension results in finger flexion (Fig 4b). With the application of the tenodesis effect during surgery, finger extension is maintained without individual manipulation of the digits, leaving one hand completely free to apply the glove to the burned hand (Fig 5). Once the digits are in their respective glove fingers, traction on the axial seams allows smooth apposition all the way down to the Web spaces. At this point, traction on the “gauntlet” part of the glove (the wrist and forearm component) causes further smooth apposition, and Hypafix tapes can be used to close the open forearm seam and fix the proximal end in place.

Figure 4. (a) Tenodesis “release” with wrist flexion and (b) tenodesis “grasp” with wrist extension.

Figure 5. Using tenodesis release to aid application of a Biobrane glove.

CONCLUSION

Extensive use of any technology encourages the development of “short-cuts” and manoeuvres designed to facilitate, and thus expedite, procedures. Although surgeons may arrive at these techniques spontaneously with time, it behoves us to share information that makes all of our surgical lives easier.

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