Hyperpigmentation after surgery for a deep dermal burn of the dorsum of the hand: partial-thickness debridement followed by medium split-thickness skin grafting vs full-thickness debridement followed by thick split-thickness skin grafting
© The Author(s) 2016
Received: 20 October 2015
Accepted: 31 March 2016
Published: 5 May 2016
Early excision and skin grafting are commonly used to treat deep dermal burns (DDBs) of the dorsum of the hand. Partial-thickness debridement (PTD) is one of the most commonly used procedures for the excision of burned tissue of the dorsum of the hand. In contrast, full-thickness debridement (FTD) has also been reported. However, it is unclear whether PTD or FTD is better.
In this hospital-based retrospective study, we compared the outcomes of PTD followed by a medium split-thickness skin graft (STSG) with FTD followed by a thick STSG to treat a DDB of the dorsum of the hand in Japanese patients. To evaluate postoperative pigmentation of the skin graft, quantitative analyses were performed using the red, green, and blue (RGB) and the hue, saturation, and brightness (HSB) color spaces. We have organized the manuscript in a manner compliant with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
Data from 11 patients were analyzed. Six hands (five patients) received grafts in the PTD group and eight hands (six patients) received grafts in the FTD group. Graft take was significantly better in the FTD group (median 98 %, interquartile range 95–99) than in the PTD group (median 90 %, interquartile range 85–90) (P < 0.01). Quantitative skin color analyses in both the RGB and HSB color spaces showed that postoperative grafted skin was significantly darker than the adjacent control area in the PTD group, but not in the FTD group.
There is a possibility that FTD followed by a thick STSG is an option that can reduce the risk of hyperpigmentation after surgery for DDB of the dorsum of the hand in Japanese patients. Further investigation is needed to clarify whether the FTD or the thick STSG or both are the factor for the control of hyperpigmentation.
KeywordsHand burn Hyperpigmentation Skin graft
Early excision and skin grafting are commonly used to treat deep dermal burns (DDBs) of the dorsum of the hand [1, 2]. However, postoperative pigmentation of grafted skin is a major problem, especially in colored people [3–6]. Because the hand is one of the most frequently exposed regions of the human body in everyday life, its appearance is strongly associated with one’s body image, which can affect the quality of life [7, 8]. Asian people are more prone to develop pigmentation than Caucasians because of differences in the physiological properties of their skin, especially in terms of melanocyte function and melanosome regulation [9–12].
In addition to race, differences in operative procedures can also affect postoperative pigmentation . To optimize skin graft take, adequate debridement is essential . With regard to the depth of debridement, partial-thickness debridement (PTD) (i.e., tangential excision, using punctiform hemorrhage as an indicator of the required depth of debridement) is one of the most commonly used procedures for excision of burned tissue of the dorsum of the hand . In contrast, there have been reports of full-thickness debridement (FTD) performed using a tourniquet while exposing the pearly yellowish-white underlying tissue of the dermis and using it as an indicator of the required depth of debridement . However, for deep dermal burns of the dorsum of the hand, it is unclear whether PTD or FTD is better, especially in terms of esthetic outcomes.
Our primary objective in this study was to compare the risks and benefits in Japanese patients, especially in terms of esthetic outcomes, of the two methods of surgery for deep dermal burns of the dorsum of the hand: (1) PTD followed by a medium split-thickness skin graft (STSG) and (2) FTD followed by a thick STSG.
Study design, setting, and ethics
We performed a hospital-based, retrospective cohort study comprised of Japanese patients who had received either a PTD (PTD group) or a FTD (FTD group). The study protocol was approved by the Ethical Committee of Chiba University (approval number 1673). Written consent was not required because patient records were anonymized and were de-identified prior to analysis. All studies were performed according to the guidelines of the Declaration of Helsinki. We have organized the manuscript in a manner compliant with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
Patient selection and study protocol
Patients aged 15 years or older who underwent skin graft surgery for a deep dermal burn of the dorsum of the hand at Chiba University Hospital in Japan and related hospitals in Japan between December 2007 and September 2010 were identified retrospectively from the operative register. We performed FTD followed by a thick STSG harvested from the dorsum of the trunk from May 2009. In the latter 17 months of the study period (from May 2009 to September 2010), all patients who underwent surgery for deep dermal burns of the hand were treated by FTD followed by a thick STSG. As a historical control, in the preceding 17 months of the study period (between December 2007 and April 2009), all patients who underwent surgery for a deep dermal burn of the hand were treated by PTD followed by a medium STSG. Patients judged by a senior plastic surgeon to have third-degree burns of the dorsum of the hand, based on preoperative photographs, were excluded.
Modified Vancouver Scar Scale
Materials to evaluate esthetic quality of the hand
Quantitative analyses in the RGB color space
In the red, green, and blue (RGB) color space, the color of each pixel was defined by a combination of levels of three color components as follows: red intensity, green intensity, and blue intensity . RGB 3D histograms, in a three-axes rectangular Cartesian coordinate system, were obtained using Color Inspector 3D software .
Levels of each of the three color components (red, green, and blue) were expressed on an 8-bit scale (256 integer value levels from 0 to 255). The meanings of the values are as follows: red intensity (0–255; 0, black; 255, red); green intensity (0–255; 0, black; 255, green); and blue intensity (0–255; 0, black; 255, blue).
Histograms and the weighted mean intensity values of each of the color components (red, green, and blue) were obtained (Fig. 4). Differences (Δ) in the color intensity of each color component between the skin graft area and the control area were defined as follows: Δred intensity = mean red value of skin graft − mean red value of control area; Δgreen intensity = mean green value of skin graft − mean green value of control area; Δblue intensity = mean blue value of skin graft − mean blue value of control area.
Quantitative analyses in the HSB color space
In the hue, saturation, and brightness (HSB) color space, the color of each pixel was defined as a combination of three color components: hue, saturation, and brightness . HSB 3D histograms in a cylindrical coordinates system and two-dimensional (2D) histograms were obtained in the same way as those in the RGB color space (Fig. 5).
Continuous variables are presented as median (interquartile range). Continuous variables were compared with Mann-Whitney U test. Categorical variables were compared with Fisher’s exact probability test. All P values quoted are two-tailed. P values less than 0.05 were considered to indicate statistical significance. Statistical analyses were conducted using SPSS software (version 13.0J; SPSS, Chicago, IL).
Partial-thickness (n = 5)
Full-thickness (n = 6)
Fitzpatrick skin type, n
Cause of burn, n
Burn area, %TBSA
Inhalation injury, n
There were no significant differences between the PTD group and the FTD group for age, gender, Fitzpatrick skin type, and cause of burn. There were no significant differences in burn area between the PTD group and the FTD [14 (10 − 41) vs 17 (11 − 24)%TBSA; P < 0.66].
Extent of burn surgery
Characteristics of burn surgery
Partial-thickness (n = 5)
Full-thickness (n = 6)
Hands operated on, n
Time from burn to surgery, days
Preoperative hemoglobin, g/dL
Duration of surgery, min
Duration of surgery per excision, min/%TBSA
Duration of tourniquet, min
Blood loss, g
Blood loss per %excision, g/%TBSA
Blood loss per %excision and %harvest, g/%TBSA
RCC-LR per %excision (units/%TBSA)
Graft thickness (×1/1000 in)
Donor site (number of harvests)
Dorsum of the trunk
Partial-thickness (n = 6)a
Full-thickness (n = 8)a
Time from operation to start of active motion exercise, days
Graft take 7 days postoperatively, %
Donor site epithelialization, days
Modified Vancouver Scar Scale of donor site
Hypertrophic scar of hand, n
Epidermal cyst, n
Hand esthetic outcomes
This is the first study that has directly compared the esthetic outcome of PTD followed by medium STSG and FTD followed by thick STSG as a treatment for a deep dermal burn of the dorsum of the hand. Hyperpigmentation is caused by the excessive accumulation of melanin, and hyperpigmented skin looks darker than skin with normal pigmentation [21–23]. Our study suggested that a thick graft from the dorsal trunk after FTD is an option that can reduce the risk of hyperpigmentation after surgery for burns of the dorsum of the hand in Japanese patients. In our study, graft take and the appearance of the hand were significantly better in the FTD group compared with those in the PTD group. There were no differences in function between the two groups. We considered that the reduced pigmentation in the FTD group compared with the PTD group was caused by the composite effect of sufficient debridement, dorsal trunk donor site, and the thickness of the skin graft.
Graft take was significantly better in the FTD group in our study. We suggest that this was mainly caused by sufficient debridement [13, 24]. There are fewer reports about full-thickness debridement for surgery of a deep dermal burn of the dorsum of the hand than there are for tangential excisions [1, 2, 14, 15, 25–27]. Our treatment strategy in the FTD group is fundamentally in line with a report by Gurfinkel et al. . Improved graft take in the FTD group might have caused less pigmentation of the graft. We think that FTD combined with usage of a tourniquet makes it easier to remove burned tissue completely. Gurfinkel et al. reported that, in a histological analysis, 21.8 % (32 of 146) of samples of tangentially excised (i.e., partial thickness debridement) burn eschars that were clinically deemed to have reached a required depth of debridement did not reach viable tissue . A newly developed water jet hydrosurgical system (Versajet®) may be a workable option to achieve sufficient PTD under a near-bloodless field without a tourniquet; however, we have had no experience with this system [20, 28–32].
In our study, other possible factors that might have influenced the pigmentation of skin grafts were the differences in skin graft donor site and graft thickness . In the PTD group, the lateral thigh or abdomen was used as the donor site for the medium skin graft, whereas the dorsal trunk was used as the donor site for the thick skin graft in the FTD group.
There were significantly more days to donor site epithelialization in the FTD group in our study. A very thin STSG to the donor site following thick skin graft harvest may resolve the prolonged healing problem of the thick skin graft harvested site . To avoid thick STSG harvest, a combination of debridement and collagen-elastin matrix (Matriderm®) as a dermal substitute, followed by a thin STSG, as reported by Haslik et al., can be chosen; however, we have had no experience with the method .
In the color space analyses of our study, the skin graft in the PTD group was significantly darker than it was in the FTD group. Analysis of the accumulation of melanin in the skin using RGB color channels, or other color channels, generated from a conventional color photographic image, has been reported by several authors [18–20, 36, 37]. People of Asian race show stronger pigmentation reactions than do Caucasians because of differences in genetic background and therefore skin physiology [4, 9–12, 38]. The strong pigmentation of medium split-thickness skin grafts observed in our study is consistent with the preceding reports . Tsukada reported that, using electron microscopy, it can be seen that changes in transfer, formation, distribution, degradation pattern, and the size of melanosomes in keratinocytes cause hyperpigmentation of skin grafts in Japanese people .
The main limitation of this study is the small sample size, which can cause a type 2 statistical error. The retrospective nature of the study makes it difficult to infer causality. Multiple factors, such as depth of debridement, donor site, and the graft thickness, are affecting the outcome. Our study cannot differentiate the effects of each of these factors. The generalizability of our results is unknown because the study only included Japanese patients in a limited number of hospitals.
FTD followed by a thick STSG from the dorsal trunk may be an option that can reduce the risk of hyperpigmentation after surgery for burns of the dorsum of the hand in Japanese patients. Further investigation is needed to clarify whether the FTD or the thick STSG or both are the factor for the control of hyperpigmentation.
percentage of total body surface area
deep dermal burns
hue, saturation, and brightness
red, green, and blue
Strengthening the Reporting of Observational Studies in Epidemiology
split-thickness skin graft
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