this article is a summary of our experience with the treatment of a patient with an extraordinarily large deep burn ( 99.5% tbsa and 23% fourth degree burn ) by using the  microskin autografting and alloskin repeated grafting  method to close the deep burn wound because of scarcity of skin sources of the patient .
the patient has been observed for 2 years , and is able to face the reality of life peacefully with the support of his family .
the salvage rate of large burns has improved steadily in the past 10 years in china . however , in patients with a scarcity of skin sources , treatment of large fourth degree burns remains a great clinical challenge . for extensive severe burn wounds repair
, there are 3 major solutions : meek skin grafting , chinese - originated micro - skin autografting , and transplantation of cultured epidermal cells .
meek skin grafting can expand the donor skin by 39 times , and micro - skin autografting can do this 1015 times larger .
therefore , micro - skin autografting is more suitable for application to severely burned patients who have a scarcity of skin sources .
autologous transplantation of cultured keratinocytes can provide adequate skin sources for wound closure , but the long cultivation time , high cost and rigorous technology requirements limit its application in developing countries .
even though the patient is saved , the patient s quality of life remains an increasing concern , both on the part of clinicians and society .
this article is a summary of our experience with the treatment of a patient with an extraordinarily large deep burn ( 99.5% tbsa and 23% fourth degree burn ) by using the  microskin autografting and alloskin repeated grafting  method to close the wound because of scarcity of skin sources .
the patient was observed for 2 years , and the quality of life is evaluated .
the patient is a 29-year - old male who was seriously burned by molten steel ( about 1,500c ) from the top of the head throughout the body , in an accidental furnace explosion .
thirty hours after fluid resuscitation in a local hospital , he was referred to our hospital , when the patient was conscious and the vital signs were relatively stable . except for a small piece of unburned skin on
the posterior head measuring about 0.5% tbsa , the rest of the scalp and the face suffered deep second degree burns , and the trunk and the 4 extremities were full of black eschar .
when the 4 extremities were incised to reduce tension , muscular eversion and necrosis were seen in part of the median sides of the upper limbs and thighs , and lateral sides of the calves , the left arm being the most serious .
the fingers of both hands and toes of both feet were carbonized , presenting as branch - like dry necrosis ( figure 1 ) .
a diagnosis was made of 99.5% tbsa burn wound , 5.5% deep second degree , 71% third degree and 23% fourth degree , and left eye burn with corneal perforation .
fluid resuscitation , anti - infection therapy , mechanical ventilation , and maintenance of internal environmental stability were continued on admission to protect organ functions .
the patient overcame the shock phase in stable condition . on the 3 day after the injury , escharectomy of the 4 extremities and trunk
was performed , involving 65% tbsa , and the wound was covered with nitrogen - preserved alloskin .
as there was only 0.5% tbsa normal scalp available , we used the  microskin autografting and alloskin repeated grafting 
method to repair the wound as soon as possible for the sake of preventing infection , which included using alloskin to cover and protect the wound temporarily , and repeated microskin grafting to sequentially close the wound . from the 5 day after the injury
, the well preserved scalp skin was dissected 5 times for microskin grafting of the right thigh , right upper arm , left thigh , anterior trunk and posterior trunk , closing about 10% tbsa wound .
the scalp skin was taken 6 times for stamp - like autoskin grafting to close the residual wound surfaces .
the entire course of treatment lasted 120 days , during which 14 operations were done .
most of the wound was healed and repaired ( table 1 ) . as the 4 extremities of the patient sustained large areas of fourth degree burns with muscular necrosis and liquification , infection was likely to occur .
in addition , myoglobin produced by decomposition of the necrosed muscle was liable to impair renal function and seriously threaten the patient s life .
on the basis of careful intra - operative observation , those definitely necrosed tissues were resected without delay by incising the deep fascia and sarcolemma , and the exposed deep tissues were covered with alloskin .
as the muscle of the left upper arm was seriously necrosed , amputation was performed on the 10 day after the injury .
as large amounts of muscle of both calves were necrosed , the tibia was exposed after clearing the necrosed tissue . as we were not able to cover it with flaps
, holes were drilled on the exposed tibia to penetrate the cortex and reach the medulla for the sake of promoting granulation formation in the spaces created by the holes .
when the formed granulation tissue covered the exposed tibia in about 4 months , stamp - like autoskin grafting was performed to close the wound of the right calf ( figure 3 ) .
although the left tibia was covered by granulation tissue , bone marrow infection occurred in the long course of dressing changes .
in addition , the left ankle completely lost its function , and the left foot was deformed due to scar contraction . the lower leg and 1/3 of the upper leg had to be amputated .
the fingers and toes of the patient were also affected by deep burns , for which exposure therapy was used to keep the eschar dry . in about 3 months the eschar was lysed and fell off .
the scars were red and hard , and softened gradually over the course of 2 years .
scars in the perineum and right armpit were adhered due to contraction , for which scar dissolution was performed , and acellular dermal matrix and auto scalp skin were grafted .
the condition was ameliorated to some extent , but the patient was still handicapped by severe dysfunction , presenting as right finger defection and palm contraction , so that the patient lost the grasping , holding and lifting functions .
in addition , further plastic surgery was also difficult for him because there was no supply of quality skin sources from his body .
in the course of treatment , though perceiving the magnitude of his disease , the patient held fast to hope of survival and showed gratitude to the medical staff .
currently , there is no obvious functional damage to the patient s heart , lung , liver , kidney and other organs .
particularly , our patient showed no sign altered thinking , language skills and audition between pre - injury and now .
unfortunately , due to amputation and scar contraction , our patient lost his ability to walk and to hold objects , among other survival skills .
in addition , his left eye suffered severe vision impairment , and post - traumatic stress syndrome sometimes troubled him , such as depression and nightmares .
however , with the support of his family , he preserved the will to live and face reality .
he actively listened to the daily news , watched entertainment tv programs , and showed enthusiasm for life .
this was a rare case of burn injury involving 99.5% of tbsa , including 23% tbas fourth degree burn .
the key to successful treatment of such patients depends on correct management and timely closure of the wound . for repair of large burns ,
most developed western countries use the meek technique of skin expansion , or culture and transplantation of human auto epidermal cells .
although the meek technique has unique advantages of mild scar formation and good functional recovery , expansion of an area of skin is limited , usually to 69 times greater , which may be insufficient for patients with a scarcity of skin sources .
epidermal cell culture is able to produce large areas of cell membranes in vitro in 34 weeks , but survival of the transplanted cell membranes is unstable . in addition , serious scar formation and high cost are problems that limit its routine use in developing countries . knowing that our patient was seriously short of endogenous skin sources , and that the above method was inapplicable to the patient , we made full use of the only remaining 0.5% tbsa normal scalp by means of the  microskin autografting and alloskin repeated grafting  method to repair the wound .
the scalp served as a constant skin source at a mean interval of 10 days .
skin cutisection should not be too deep , otherwise healing of the donor area may be affected .
microskin grafting is a skin transplantation technique of chinese origin , and contributes much to maintaining china s first - class success rate in curing patients with large burns . in the present case
, we used the 0.5%tbsa scalp to expand the skin by 1020 times and close the 510% tbsa wound .
most of the wounds were closed by 5 episodes of microskin grafting , and the rest were treated by autoskin stamp grafts .
wounds that were not covered with autoskin were covered with alloskin to reduce exudation and evaporation , and to prevent infection .
this not only provided favorable conditions for autoskin grafting , but also benefited improvement of the general condition and maintenance of organ functions of the patient .
rejection reaction developed 2030 days after alloskin coverage , for which the alloskin was replaced in time to prevent the wound from exposing .
although the course of treatment of the patient was 4 months , no significant wound infection , disturbance of the internal environment and organ dysfunction occurred .
this should be primarily attributed to timely and effective closure of the wound by use of autoskin and alloskin techniques .
management of fourth degree burns is a huge clinical challenge . for small fourth degree burn areas ,
flap repair is a routine solution , but in this patient , the fourth degree burn area was large and the other areas were also deeply burned , so flap repair was inapplicable . after repeated debridement , we used stamp - like autoskin grafts to close the wound after granulation tissue formation .
the disadvantage was that it needed multiple operations performed over a long period of time .
the quality of life of burn patients has long been a great concern both on the part of clinicians and society .
a survey of delegates at the 39 annual meeting of the british burns association showed that there are no conclusive criteria for abandonment of treatment of severe burn patients .
quality of life of burn patients is related not only to the severity of burn , but is also significantly related to educational backgrounds and family and social support . in china , treatment of severe burn patients
for example , we have successfully saved many patients with greater than 80% tbsa burns , and most of them can take care of themselves and live a high - quality life . on admission of this rare case of severe
burn , the doctors were fully aware of problems that the case might entail even though it was healed , such as deformity due to scar contraction , amputation , and loss of daily living abilities .
although the patient experienced severe disability and dysfunction after healing , he is able to keep calm and face reality peacefully with the support , companionship and attention of his family .
 summarybackgroundtreatment of extraordinarily large deep burns remains a huge clinical challenge.case reportthis article is a summary of our experience with the treatment of a patient with an extraordinarily large deep burn ( 99.5% tbsa and 23% fourth degree burn ) by using the  microskin autografting and alloskin repeated grafting  method to close the deep burn wound because of scarcity of skin sources of the patient.conclusionsthe patient has been observed for 2 years , and is able to face the reality of life peacefully with the support of his family . 
Background
Case Report
Conclusions
Background
Case Report
Discussion
Conlcusions