Application Of Skin Grafts Research Articles

Use of lyophilized bovine collagen for split-thickness skin graft donor site management

Donor site management after split-thickness skin graft applications can have problems such as late healing and pain. Many dressing methods and medical applications are reported to solve these problems but none of them were ideal. In this study we aimed to promote epithelisation and remove pain earlier with using lyophilized bovine collagen (gelfix spray). According to our results, epithelisation time for the gelfix group was earlier than control group (9.09 days mean and 11.2 days mean for control group ( p < 0.05)). Pain relief was determined by visual analogue pain scale. In the gelfix group, there was pain relief up to 40 h from the operation. There were no differences between groups for scarring 30 and 90 days after surgery.

Transplant Tolerance Associated With a Th1 Response and Not Broken by IL-4, IL-5, and TGF-β Blockade or Th1 Cytokine Administration

Specific transplant tolerance is mediated by CD4 T cells that die unless supported by T-cell derived cytokines and donor antigen. This study examined the role of Th1 and Th2 cytokines in the maintenance of tolerance. Tolerance to fully allogeneic PVG cardiac allografts in DA rats was induced by short-term anti-CD3 monoclonal antibody therapy. Responses of tolerant cells to donor and third party antigen were assessed in vivo by examination of the infiltrate in the heart and application of skin grafts, and in vitro in mixed lymphocyte culture. Cell subsets were stained, induction of cytokine mRNA assayed by reverse-transcriptase polymerase chain reaction and the role of cytokines determined by treating with blocking monoclonal antibody to cytokines or cytokine administration. Tolerated grafts had a T cell and macrophage infiltrate with increased mRNA for Th1 cytokines, interleukin (IL)-2, and interferon (IFN)-gamma but not Th2 cytokines. Peripheral lymphocytes proliferated in mixed lymphocyte culture and expressed Th1 cytokine mRNA. Tolerant hosts accepted PVG and rejected Lewis skin allografts and the lymph nodes draining both these grafts had similar induction of Th1 and Th2 cytokine mRNA. Treatment of tolerant rats with Th1 cytokines IL-2, IFN-gamma, and IL-12p70 or monoclonal antibody that blocked IL-4, IL-5, and transforming growth factor-beta did not prevent acceptance of PVG skin grafts. These studies in a model of tolerance regulated by CD4CD25 T cells demonstrated there was no defect in Th1 responses. Tolerance was due to regulation that was not solely dependent on IL-4, IL-5, or transforming growth factor-beta and was not inactivated or overwhelmed by administration of Th1 cytokines, IL-2, IFN-gamma or IL-12p70.

Digital reconstruction and donor site resurfacing: A two‐flap technique

Use of a great toe pulp flap is one of the methods to repair partial soft-tissue defect of the thumb or other digits. However, the conventional application of free skin grafts to close the donor site may bring donor-site morbidity. The authors present a two-flap technique that a reverse first dorsal metatarsal artery (FDMA) flap resurfaces the defect of the free great toe pulp flap. Six patients with soft-tissue defects of the thumbs or fingers were treated with this technique. Both the pulp and reverse flaps survived uneventfully after reconstruction of the thumbs and fingers. The reverse flap to resurface the donor site on the great toe was sensate and durable. Satisfactory appearance and function were gained in all patients. Results revealed that this technique can be accepted as an alternative method when treating soft tissue defect of the thumb or finger.

Successful Treatment of Burn and Visceral Injury Combined with Full-Thickness Loss of the Abdominal Wall After Blast Injury

A 29-year-old man was admitted to our institution 10 days after he had undergone an urgent exploratory laparotomy at a local army hospital after a terrorist bombing attack. On admission, deep second-degree and third-degree burns involving 25% of the upper and lower extremities were present, together with a 25 x 10-cm abdominal full-thickness blast injury defect on the left side, an infected eviscerated midline incision, and a colostomy on the right side of the abdomen. The patient underwent a second laparotomy, at which time the intraabdominal abscess was drained, and the abdominal cavity was irrigated with saline. A jejunal perforation was found and sutured. The abdominal cavity was left open and covered with a Bogota bag for temporary closure. On postburn day 18, the patient underwent débridment and grafting of the third-degree burns to the left and right arm and right lower extremities. After several débridment sessions (postburn days 16, 18, 20, 22, and 24), an abdominal skin release and reapproximation were performed (postburn day 26). On postburn day 36, split-thickness skin grafts were placed directly on the granulated tissue of the intestines and on a defect in the left flank and iliac regions. Postoperatively, the patient did well. He was discharged on postburn day 78 with all wounds well healed. In our opinion, temporary closure followed by direct application of meshed split-thickness skin grafts to exposed abdominal viscera represents a simple method of reconstruction that can be safely performed, with minimal risk, on critically ill patients.

The Application of Split-Thickness Skin Graft as an Autogenous Arterial Conduit in a Goat (Capra Hircus) Model

Adequate autogenous vein is often the limiting factor in achieving a successful infrainguinal bypass. Attempts have been made to find alternative conduits; however, these alternatives have demonstrated inferior patency rates. We attempt to show that a split-thickness skin graft conduit provides a feasible autogenous arterial conduit. Neoconduits were prepared with an autogenous split-thickness skin graft (STSG) tubularized for a length of 5-6 centimeters with an appropriate caliber match to native artery. The deep dermal side of the graft was randomized to form either the external surface or the luminal surface. The neoconduit was placed as an interposition graft in the left common carotid artery. Grafts were studied in vivo with duplex ultrasonography and ex vivo by histopathology and immunohistochemistry. Feasibility study involved 4 animals with grafts harvested for study at 24 hours (n = 2) and 7 days (n = 2). Two subsequent groups were studied to evaluate 3-month (n = 8) and 6-month (n = 5) patency. All grafts (n = 4) in the feasibility phase of the study were patent at the time of harvest without evidence of aneurysmal degeneration. In the subsequent 8 goats, grafts with the deep dermal side forming the extraluminal surface (n = 4) had a propensity to ulcerate and rupture or to become aneurysmal (75%). The patency rate of these grafts at 6 weeks was 25%. In contrast, grafts with the deep dermal side forming the intraluminal surface (n = 4) demonstrated 75% patency at 6 weeks. Because of these results the remaining goats underwent placement of neoconduits with the deep dermal side forming the luminal surface. These grafts maintained a patency rate of 80% at 6 months. Neoconduits implanted with a diameter greater than 1.5 times the native arterial diameter became aneurysmal. Histopathology demonstrated neointimal formation in all grafts patent for longer than 7 days. Immunohistochemical staining for Factor VIII/von Willebrand's factor (vWF) was reactive in the endoluminal cells of these grafts. Immunohistochemical staining for a-smooth muscle actin demonstrated reactivity in conduits patent for greater than 1 month. Split-thickness skin may provide a feasible source for autogenous conduit in arterial reconstructions and warrants further study. Technical factors affecting patency include orientation of the deep dermal surface of the STSG and the diameter of the neoconduit at the time of implantation.

Effects of different preservation solutions on skin graft epidermal cell viability and graft performance in a rat model

This study sought to evaluate the viable epidermal cell count of skin stored at 4 °C in different media, and to determine the longest time that grafts could be stored and still be used for clinical application of skin grafts. Harvested rat skin grafts were divided into four groups: saline (group 1), Roswell Park Memorial Institute-1640 solution (RPMI) (group 2), University of Wisconsin solution (UW) (group 3), and Histidine–tryptophan–ketoglutarate solution (HTK) (group 4). After the designated storage time (7, 14, 21, 28, or 35 days), grafts were divided into two parts. Skin grafts (3 cm × 3 cm) were then autotransplanted onto full-thickness circular wound beds. Percentages of viable keratinocytes (PVK) declined significantly for skin grafts stored in UW, HTK, and saline solutions (Kruskal–Wallis, P < 0.05), while there was an insignificant decline in the PVK of skin grafts stored in RPMI until the 28th day of storage (Kruskal–Wallis, P > 0.05). Compared with UW, HTK, and saline, grafts stored in RPMI had significantly higher percentages of PCNA at the 14th and 21st days of storage (Mann–Whitney U-test, P < 0.05). Grafts stored in RPMI had significantly lower apoptosis rates than did grafts stored in UW or HTK ( P < 0.05). Based on these results, we conclude that RPMI-1640 provides a better environment for skin grafts by increased quality and survival time of skin grafts, as assessed by both microscopic and macroscopic investigations.

A Novel Technique for Closing Difficult Diabetic Cleft Foot Wounds With Skin Grafting and a Ring-Type External Fixation System

Treatment of central metatarsal head plantar forefoot ulceration with or without associated underlying osteomyelitis and gangrene usually require resection of the associated central metatarsal rays. Despite various modifications of central metatarsal ray resection, the resultant cleft foot deformity represents a significant challenge to the foot and ankle surgeon. In this regard, the authors present a novel approach using a ring-type external fixation system that uses the principles of Ilizarov to narrow the forefoot cleft followed by application of a split-thickness skin graft over the remaining soft-tissue defect. When compared with previously reported techniques, the authors approach allows precise narrowing of the forefoot, postoperative weightsharing, decreased time frame of actual external fixation device application, and rapid healing via split-thickness skin graft application about the remaining cleft foot deformity, which has the added benefit of producing additional scarring and contracture over time during the skin graft maturation process.

Distally Based Lateral and Medial Leg Adipofascial Flaps: Need for Caution with Old, Diabetic Patients

Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients. Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily. The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 x 5 cm to 7 x 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic. Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered.

Malignant melanoma of the hand and foot: Diagnosis and management

Forty-six patients with melanoma of the hand (5) and foot (41) studied prospectively between 1972-84 have been reviewed to determine guidelines for diagnosis and management. The clinical appearance is varied and the lesions are often misdiagnosed as warts or fungal infections. Clinical assessment of tumour thickness on the sole is difficult because of the nature of the plantar skin. Incision rather than excision biopsy is indicated because of the functional consequences of large excisions on the hand and foot. Melanoma of the toe was treated by local metatarsophalangeal amputation. Plantar melanomas were excised with a 3 cm margin. Dorsum melanomas were treated by a selective policy of 1, 2 or 3 cm margins according to clinical assessment of tumour thickness. These policies have resulted in only one case of local recurrence. An in situ Silastic foam mould facilitates immediate application of split skin grafts to irregular areas. The functional results of split skin grafts on sole and heel have been satisfactory. Toe lesions were thickest, dorsum thinnest, sole and heel intermediate. The prognosis related to these groupings of tumour thickness. Simultaneous clinical nodal involvement carried a hopeless prognosis, and most patients developing nodes within 2 years die--unless treated by prophylactic dissection. The role of prophylactic dissection is still not defined, but it is likely that it will be used more frequently in the future. Early diagnosis offers most hope of improving the outlook. Many elderly patients with nodular lesions have had moles for many years. Younger patients are now being seen with thin lesions, even on the toe.

Treatment of anal intraepithelial neoplasia.

The natural history and malignant potential of anal intraepithelial neoplasia (AIN) remain uncertain, making management decisions about such lesions difficult. The management of 70 patients with AIN is described. The majority of lesions encountered were low grade (AIN I and II; 43 of 70) and required no treatment, but eight invasive anal cancers associated with high-grade AIN occurred over the 4-year study period. Three were a result of apparent progression of high-grade lesions; three more invasive lesions were found in areas of AIN III on histological examination. Surgical excision was used to treat 27 patients with AIN III. Treatment of extensive lesions involving the perianal and anal canal epithelium circumferentially in six patients involved excision of the whole of this epithelium and application of split skin grafts.

Investigation of keratinocyte regulation of collagen I synthesis by dermal fibroblasts in a simplein vitromodel

Hypertrophic scarring and skin graft contracture are major causes of morbidity after burn injuries. A prominent feature is excessive fibroplasia with accumulation of increased fibrillar collagen relative to normal scar tissue. The application of split-thickness skin grafts or cultured epithelial autografts to burn wounds is known to reduce scarring and contraction. To investigate further how the keratinocyte influences underlying fibroblast behaviour by examining the influence of keratinocytes on fibroblast collagen synthesis, using a new assay for collagen synthesis never previously applied to skin cell biology. We investigated the influence of the keratinocyte on fibroblast synthesis of type I collagen using an immunoassay for the aminoterminal propeptide of type I collagen (P1NP) in conditioned medium from monocultures and cocultures of keratinocytes and fibroblasts over 14 days. The importance of the physical presence of the keratinocyte was investigated by comparing cocultures of keratinocytes and fibroblasts against fibroblast monocultures with keratinocyte-conditioned medium. Pharmacological agents known to promote fibroblast proliferation [basic fibroblast growth factor (bFGF)], keratinocyte proliferation [insulin-like growth factor (IGF)-1], modify scarring in vivo[tumour necrosis factor (TNF)-alpha] or modify collagen biochemistry [putrescine, estrone, estradiol and beta-aminopropionitrile (beta-APN)] were then investigated for their effect on collagen synthesis in fibroblasts and in keratinocyte/fibroblast cocultures. Keratinocytes in coculture with fibroblasts, and keratinocyte-conditioned medium, both reduced fibroblast P1NP synthesis. Of the pharmacological agents investigated, bFGF, IGF-1, TNF-alpha and beta-APN all increased collagen synthesis both in monocultures of fibroblasts and in cocultures of keratinocytes and fibroblasts. Fibroblast collagen synthesis appears to be downregulated by keratinocyte-derived cytokines. Fibroblast growth factors and proinflammatory cytokines appear to be able partially to overcome this downregulation and to increase collagen synthesis.

Revisiting Vascularized Muscle Flaps for Complicated Sternal Wounds in Children

Surgeons at our center previously reported a case of a 2-month-old infant who underwent closure of an infected sternal wound following open cardiac surgery with debridement followed by closure with bilateral pectoralis muscle flaps and a unilateral rectus abdominis muscle flap. The success of the procedure has spawned refinements in the technique, such as the one described herein. A 2-week-old neonate was evaluated for postoperative sternal dehiscence and instability following open cardiac surgery for severe congenital cardiac anomalies. Management included initial debridement and application of a vacuum-assisted closure (V.A.C.) system (KCI, Oxfordshire, UK). In conjunction with the final V.A.C. dressing change, the patient underwent delay of the left rectus muscle by division of the inferior epigastric pedicle. She subsequently underwent transposition of the left rectus muscle and application of a full-thickness skin graft for coverage of the sternal defect. She has since done well and still requires further invasive cardiac procedures.

A simple in vitro model for investigating epithelial/mesenchymal interactions: keratinocyte inhibition of fibroblast proliferation and fibronectin synthesis

Hypertrophic scarring and graft contracture are major causes of morbidity after burn injuries. It is well established that application of a split-thickness skin graft reduces scarring and contraction, and cultured epithelial autografts have a similar effect. To investigate the influence of keratinocytes on fibroblast proliferation and fibronectin synthesis, we used an in vitro separated co-culture model in which epithelial sheets were cultured above fibroblast monolayers without physical contact. We also investigated the response of fibroblasts to keratinocyte-conditioned medium (KCM) obtained from confluent and subconfluent keratinocyte monolayers. Both cultured epithelial sheets, composed of adherent fully confluent keratinocytes, and their conditioned medium, reduced fibroblast proliferation. However, KCM from subconfluent keratinocytes stimulated fibroblast proliferation at low concentrations while inhibiting it at higher concentrations, indicating that keratinocytes can produce both mitogenic and growth-inhibiting factors for fibroblasts. KCM, but not epithelial sheet co-culture, also inhibited fibroblast fibronectin synthesis. This indicates regulation of fibroblast phenotype by soluble factors released by the keratinocyte and also suggests that there is a dialogue between keratinocytes and fibroblasts with respect to fibronectin production. We conclude that this separated co-culture model is a simple way to study epithelial/mesenchymal communication particularly with respect to the role of the fibroblast in wound healing.

裂こうに対する治療法の工夫 ＶＩ．裂こうに対するＳＳＧ法の適応と工夫

裂こうに対する治療法の工夫 ＶＩ．裂こうに対するＳＳＧ法の適応と工夫

Applied tissue engineering in the closure of severe burns and chronic wounds using cultured human autologous keratinocytes in a natural fibrin matrix.

Whereas in severe burns cultured human epithelial cells may well serve as a life saving method, the true value of tissue-engineered skin products in chronic wound care has yet to be clearly defined. Among other well-known clinical problems, the engraftment rate of commercially available multilayered "sheet grafts" has been shown to vary extremely. Adherence of transplanted cells to the wound bed--especially in the presence of potential wound contamination-- is one of the crucial aspects of this technique. Keratinocyte suspensions in a natural fibrin sealant matrix can potentially treat a variety of skin defects. In acute burn wounds, as well as in chronic wounds the clinical application of this type of tissue-engineered skin substitute demonstrates the capacity of cultured human autologous keratinocytes in a fibrin sealant matrix to adhere to wound beds, attach and spread over the wound resulting in reepithelialization of both acute and chronic wounds. In full thickness burns the combination of this new tool with allogenic dermis is a promising option to achieve complete dermal-epidermal reconstitution by means of tissue engineering and guided tissue repair. When transferring this technique into the treatment of chronic wounds we found an optimal preparation of such recipient wound beds to be crucial to the success. The additional application of continuous negative pressure (vacuum therapy) and preliminary chip skin grafting to optimally prepare the recipient site may be helpful tools to achieve such well-prepared and graftable surfaces. Prospective controlled comparative studies should be designed to further assess the clinical efficacy of this technique.

Management of periocular post burn scarring in the epileptics.

To assess the clinical presentation and management of patients with epilepsy presenting with periocular post burn scarring. Prospective and descriptive study. Department of Ophthalmology, Jinnah Postgraduate Medical Centre, Karachi from September 1999 to September 2002. This study included 23 patients who had epilepsy and presented with periocular post-burn scarring to the eye department for management. All patients had contractures of their lids with variable amounts of corneal scarring and damaged to the eye ball. The surgical procedure performed consisted of release of contracture, horizontal lid shortening and application of free skin graft. There were 18 (78.26%) female and 5 (21.73%) male patients. The age range was from 18 to 45 years with a mean of 28 years. In 17 (73.91%) patients, lid contracture was released to cover their eyeballs. In 6 (26.08%) patients the eyeball was lost due to late presentation. There should be a high index of suspicion in facial burns for ophthalmic damage and early referral to an ophthalmologist should be made to prevent complications. Early release of contracture with application of full or partial thickness skin grafts is advisable.

Factors Affecting Success of Split-Thickness Skin Grafts in the Modern Burn Unit

The use of early tangential excision or excision to fascia of burn wounds has led to the application of split-thickness skin grafts (STSGs) to a variety of graft beds, including dermis, granulation tissue, fat, and fascia. Because insufficient objective data are available on the effect of the graft bed on survival of an STSG, a 2-year review of success rates of STSGs on a variety of graft beds was completed. The success rates of all 599 STSGs applied to dermis, granulation tissue, fat, and fascia in 233 consecutive burn patients (mean total body surface area [TBSA] burned, 14.5%) by one surgeon at a regional burn center over a 2-year period were reviewed. Data were analyzed to compare outcomes of STSGs on the graft beds listed and in low-risk versus high-risk groups of patients (TBSA burned < or = 35% and > 35%; age < or = 18 years and > 18 years; age < or = 55 years and > 55 years; and diabetes mellitus). One-way analysis of variance was used to compare results of STSGs on different graft beds, and tests were used to analyze differences in results of STSGs in low-risk versus high-risk groups (p < 0.05, significant). The mean success rate at 14 days for all 599 STSGs applied in the 233 patients was 90 +/- 22%. The success rate of STSG on the various surfaces ranged from 85% (fascia) to 93% (dermis; granulation), but the differences among the four graft beds were not significant. Total body surface area burned (> 35%), older age (> 55 years), and the presence of diabetes mellitus each had a significant impact on the percentage take of STSGs at 14 days after application. In the hands of an experienced burn surgeon, the recipient bed has no significant impact on the success rate of STSGs at 14 days postgrafting, except in those patients 18 years or younger, in which the mean STSG success rate was significantly greater on granulation tissue compared with fat. TBSA burned > 35%, age > 55 years, and the presence of diabetes mellitus continue to have an adverse impact on the success rate of STSGs at 14 days.

Vacuum Assisted Closure (VAC) dressing for skin graft application following exenteration of the orbit

Vacuum Assisted Closure (VAC) dressing for skin graft application following exenteration of the orbit

Neovaginal reconstruction with the modified McIndoe technique: a review of 32 cases.

The authors reviewed 32 patients who underwent vaginal reconstruction using a modified McIndoe procedure during the past 15 years. This technique consists of the application of split-thickness skin grafts into a new cavity created between the rectum, bladder, and urethra. The grafts are placed previously on a mold of Optosil, which is a silicon-based condensation curing impression material used by dentists. The mold is kept for 3 months 24 hours each day. During the next 3 to 4 weeks it is applied 12 hours per day. Later, according to sexual activity, the mold can be removed completely. In case of no sexual activity it should be used 1 hour per week. Parameters assessed during the follow-up were mold management, grade of pseudomucinous metaplasia of the skin grafts, sensation of the neovagina, neovagina size changes, sexual satisfaction, and complications. Postoperative complications included partial take of skin grafts (N = 3), postoperative anxiety (N = 2), donor site cheloids (N = 1), and neovaginal stricture in 3 patients who used the mold for 1 month only without having any further sexual activity. Patients who managed the mold correctly or who had constant sexual activity obtained satisfactory dimensions of the neovagina in terms of length, diameter, and elasticity.

Necrotizing Fasciitis of the Upper Extremity Resulting From a Water Moccasin Bite

Aeromonas hydrophila infection has been described as the cause of necrotizing fasciitis in patients with suppressed immune systems, burns, or trauma in an aquatic setting. We report a case in which severe necrotizing fasciitis involving hand, arm, chest, and lateral side of trunk, along with toxic shock, developed after the patient was bitten by a venomous snake. Mixed aerobic and anaerobic bacteria, including A hydrophila, were isolated from the wound culture. The patient was treated with antivenom, a diuretic regimen, broad spectrum antibiotics, and 18 separate surgical procedures. After the application of skin grafts, the wound completely healed. This case illustrates that a venomous snakebite may result in infection with A hydrophila and can cause severe necrotizing fasciitis. Early and aggressive surgical intervention should be implemented as soon as the necrotizing fasciitis is diagnosed.