Donor Site Wound Research Articles

Preparative technique of anterolateral thigh flap

To investigate the surgical techniques and methods of anterolateral thigh (myocutaneous) flap. Two hundred and forty-five consecutive free anterolateral thigh (myocutaneous) flaps for reconstruction of the defects of oral and maxillofacial region following the malignant tumors resection from January 2007 to August 2009 were reviewed. The incision was designed in the upper, middle or lower part 3 cm medial of the iliac-patella line according to the thickness of flaps needed. The perforators with suitable vessel diameter and strong pulse were chosen to make flaps with muscular tissue to fill dead space. More than one perforators were taken when large flaps were harvested. The size of the flaps ranged from 4 cm × 4 cm to 10 cm × 25 cm. Eighteen fat flaps were made thinned. Of the 245 flaps harvested, 3 complete necrosis occurred, and the survival rate was 98.8%. Blisters occurred in 8 thinned flaps, but they all survived. All the wounds were closed directly except 5 cases, which needed skin graft because of too large defects of skin. All the skin graft came from the upper part of the wound of donor site. The shape and function were satisfactory after the reconstruction. When anterolateral thigh (myocutaneous) flaps are harvested, the incision should be designed 3 cm medial of the iliac-patella line according to the thickness of flaps needed. It is helpful to find the perforators. All of the lower, middle and upper parts of anterolateral thigh region have cutaneous perforators. The skin defects within 8 cm can be closed directly, while the skin defects more than 8 cm often need skin grafting. The skin grafts can be taken from the upper part of donor site wounds.

Transplantation of the chimerical osteocutaneous perforator flap with superficial circumflex iliac artery for repair of bone and skin defect in limbs

Objective To investigate the applied methods and effects of the chimerical osteocuta-neous perforator flap with superficial circumflex iliac artery for reconstruction of bone and skin defect in limbs. Methods From February 2008 to April 2009, five patients in whom bone and skin defect in limbs were reconstructed with free chimerical osteocutaneous perforator flaps using superficial circumflex iliac vessel, in-cluding 4 males and 1 female with an average age of 31.2 years. Of 5 patients, 2 were used for the recon-struction of composite metacarpal bone and soft-tissue defects, 2 for foot reconstruction, and 1 for fibula re-construction. The area of cutaneous deficiency was about 5 cm×2 cm to 16 cm×5 cm. The size of osseous flaps ranged from 2 cm×1 cm×0.8 cm to 8 cm×2 cm×0.5 cm, and the size of cutaneous flaps ranged from 6 cm×3 cm to 18 cm×6 cm. All the arteries were reconstructed by end-to-end anastomoses between the donor iliac artery and the recipient artery, except one, which was performed using an end-to-side method. The bone flaps were fixed with the aid of plate and screw (4 cases), and Kirschner wire (1 case). Results One hap-pened arterial crisis during the 2-day postoperative period. The other flaps were fully survival by first intention, and all wounds of the donor site healed within 8 to 27 days. All the cases were followed up for 8 to 19 months, the appearance of flaps was satisfactory and no special protection was needed. All bone defects healed during a period time of 3 to 6 months. No patient complained of pain at the donor site. The function of hand prehension was completely recovered, and thumb opposition was partly recovered. Patients who re-ceived repairing of lower limb were able to ambulate with self-weight bearing. Conclusion The chimerical os-teocutaneous superficial circumflex iliac free perforator flap can minimize the donor site complication and is suit-able for the reconstruction of small area of bone defect, especially combined with a large area of soft tissue defect. Key words: Surgical flaps; Bone transplantation; Transplantation, autologous; Microsurgery

Objective scar assessment—A new method using standardized digital imaging and spectral modelling

Introduction Quantitative assessment of scars is needed in clinical practice and in scientific studies. To date, there have been no entirely objective methods available for these purposes. We introduce a new method developed for scar assessment combining standardized digital imaging (SDI) and spectral modelling (SpM). With this method, the estimated concentration changes (ECCs) of haemoglobin and melanin in the scar can be determined quantitatively. Patient and methods : In the current study, 22 skin graft donor site (SGDS) wounds were treated with two alternative dressing materials, Suprathel ® and Mepilex Transfer ®, side by side on the same wound. The SGSD scars were assessed using SDI and SpM. The scars were given subjective ratings by three surgeons using the POSAS and the Vancouver Scar Scale (VSS). The correlations between the ECCs of melanin and haemoglobin and the corresponding subjective ratings were calculated as well as the Intraclass Correlation Coefficient (ICC) of the subjective ratings. Results There was a statistically significant correlation between the ECCs of melanin and haemoglobin and the subjective ratings. A single observer could reliably assess pigmentation with the POSAS scale (ICC = 0.75) but not vascularity (ICC = 0.51). The reliability ratings of the VSS were unacceptably low. Conclusions The ECC values of haemoglobin and melanin give accurate documentation of the scar status. The results also show that the subjective ratings in this study were unreliable especially when interfering pigmentation and increased vascularity were both present at the same time.

Free Gingival Grafts: Graft Shrinkage and Donor‐Site Healing in Smokers and Non‐Smokers

This prospective clinical study aims to evaluate the influence of cigarette smoking on free gingival graft (FGG) healing, by assessing FGG dimensional changes and donor-site wound healing. Twelve non-smokers and 10 smokers treatment planned for FGG to augment keratinized tissue dimensions in the mandibular incisor area completed the study. All subjects received standardized FGG of same dimensions. Probing depth, gingival margin position, clinical attachment level, keratinized tissue (KT) width, gingival thickness, and FGG dimensions (width, length, and area) were assessed and recorded before surgery, and 7, 15, 30, 60, and 90 days postoperatively. The palatal donor area was evaluated for immediate bleeding and complete wound epithelialization. Differences between the two groups (smokers and non-smokers) were statistically analyzed. FGG dimensions changed significantly postoperatively. At 90 days postoperatively, FGG width, length, and area were respectively reduced by 31%, 22%, and 44% in non-smokers and by 44%, 25%, and 58% in smokers (no significant differences between groups; P >0.05). Significant KT increases were observed in both non-smokers and smokers (5.4 and 4.8 mm, respectively). Donor-site immediate bleeding was significantly more prevalent in non-smokers (75%) compared to smokers (30%) (P = 0.04). At 15 days postoperatively, donor-site complete epithelialization was much more prevalent in non-smokers (92%) than in smokers (20%) (P <0.002). Smoking alters FGG donor-site wound healing by reducing immediate bleeding incidence and by delaying epithelialization, although it does not have discernible effects on postoperative FGG dimensional changes.

Donor site wound protein synthesis correlates with length of acute hospitalization in severely burned children

Autografting of burn wounds results in generation of donor site wounds. Here we measured donor site wound protein fractional synthesis rate (FSR) in a burn pediatric population and showed that FSR increases over time postsurgery and correlates with the length of hospital stay (LOS) normalized for total body surface area (TBSA) burn size. 3.9 +/- 1.1 days after the grafting surgery patients participated in a metabolic study consisting of continuous infusion of l-[ring-(2)H(5)]-phenylalanine and donor site wound punch biopsies. Donor site wound protein FSR was 10.4 +/- 7.5%/day. Wound FSR demonstrated linear correlation with the time postsurgery (p<0.05). Multiple regression analysis showed that LOS/TBSA correlated with donor site wound protein FSR and time postsurgery (p<0.001) and the following equation describes the relationship: estimated LOS/TBSA=(FSR-12.95-1.414 x postsurgery day)/(-17.8). This equation predicted that FSR corrected for the postsurgery day when the metabolic study was conducted accounted for 67% of the variability (r(2)=0.673) in the LOS/TBSA. Donor site wound protein FSR correlated to LOS/TBSA of burn patients admitted to the intensive care unit. Measurement of protein deposition in regenerating donor site wound using stable isotope technique provides a quantitative measure of wound healing.

The application of soft silicone foam dressings in the management of middle-thickness skin graft donor site wounds

Objective To determine the effect of Soft Silicone Foam Dressings in the Management of Middle-Thickness Skin Graft Donor Site Wounds.Methods 30 patiants were included in this study.The skins graft donor site wounds were randomly divided into two groups to receive either petrolatum gauze (control group) or Soft Silicone Foam Dressings( Mepilex,therapy group).Outer dressings were changed at 3 days after operation and inner dressings were changed at 5 days after operation.Then dressings were changed every 2 days and observate the wound healing.Results The pain was released obviously in therapy group by 5, 7, 9 days post-operation.Better bacteriostatic effect existed in therapy group with significant difference compared with control group.And There was significant difference between the two groups on the healing rate, with the dry therapy group (97.4 ±5.3) and the control group (80.5±11.2) by 11 days post-operation (P<0.01).Conclusions In the Management of Middle-Thickness Skin Graft Donor Site Wounds, the Application of Soft Silicone Foam Dressings has obvious effect in releasing pain, depressing infection rate and accelerating wound healing. Key words: Soft silicone soam dressings; Skins graft donor site wounds; Healing; Pain

Beneficial Effects of Insulin on Cell Proliferation and Protein Metabolism in Skin Donor Site Wound

Insulin has been demonstrated to accelerate skin wound healing; however, its effects on wound metabolism have not been adequately studied. Adult rabbits were prepared by creation of skin donor site wound on the back, catheterization of the carotid artery and jugular vein, and placement of a nasogastric feeding tube under general anesthesia. The rabbits were given total enteral nutrition thereafter. On day 5 stable isotope tracers were infused to measure the kinetics of protein (reflecting tissue repair) and DNA (reflecting cell proliferation) in the wound. During the isotope tracer infusion, regular human insulin was infused at 2.5 mU/kg per min with concomitant glucose infusion for euglycemia in an insulin group but not in a control group. Plasma insulin concentration was 140±26 μU/mL in the insulin group (n=8), greater (P<0.001) than that of 16±3 μU/mL in the control group (N=8). In the insulin group the fractional synthetic rates of wound protein and DNA were 9.0±1.2 and 5.4±0.5%/day, greater (P < or=0.05) than those of 6.4±0.5 and 4.0±0.6%/day in the control group, respectively. Wound protein fractional breakdown rates were not significantly (P =0.2) different; net protein deposition rate was ~50% greater in the insulin than in the control group, although the difference was not statistically different (P=0.2). Insulin infusion increased wound protein and DNA synthesis, which are anticipated to promote tissue repair and reepithelialization.

The chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery for reconstruction of oromaxillary soft tissue defect

To report the application of the chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery for large and complicated oromaxillary soft tissue defect. Based on the anatomic study of descending branches and cutaneous perforators of lateral circumflex femoral artery, the perforator vessels were found and used as flap pedicle. The perforator flap was made as chimeric flap for repairing the oromaxillary soft tissue defect in 8 cases. The chimeric perforator flaps were divided into three types as anterolateral thigh flaps and anteromedial thigh flaps, anterolateral thigh flaps and rectus femoris perforator flaps, and anterolateral thigh flaps and anterolateral thigh flaps. All the 16 flaps in 8 cases survived completely with no complication. The wounds in donor sites were all primarily closed with no skin graft. The patients were followed up for 1-9 months with good functional and esthetic results. There was no morbidity in donor sites. The chimeric perforator flap has a large tissue volume for large and complicated oromaxillary defect. There is no need for extra donor site and extra blood vessel anastomosis.

Hemicellulose dressing versus rayon dressing in the re-epithelialization of split-thickness skin graft donor sites: a multicenter study

The aim of this study was to compare the effectiveness of a hemicellulose dressing with that of rayon dressing in the healing of split-thickness skin graft donor sites. Twenty-eight patients were selected from five different hospitals and randomized into two groups: hemicellulose dressing group and rayon dressing group. All patients underwent split-thickness skin grafting for various reasons, and the skin graft donor site wounds were covered with hemicellulose dressing ( n = 14) or rayon dressing ( n = 14). The donor site was assessed on postoperative days 1, 7, 14, 21, and 28 for hyperemia, pruritus, pain, exudate level, and adherence of the wound dressing. At the 60-day follow-up visit, the donor site was assessed again for pruritus and pain. Touch-pressure, thermal, and pain sensibility tests were performed preoperatively and on postoperative day 60 together with the assessment of color and texture of the re-epithelialized area. In all patients, re-epithelialization was completed between 14 and 21 days after surgery. There were no significant differences between the two groups with regard to pain, hyperemia, pruritus, exudate, and final appearance (color and texture) of the skin graft donor site. The rayon dressing provided significantly better adherence than the hemicellulose dressing, and both dressings showed similar results with regard to the parameters evaluated when used in the treatment of split-thickness skin graft donor sites.

Supraclavicular Artery Island Flap for Head and Neck Oncologic Reconstruction: Indications, Complications, and Outcomes

The supraclavicular island flap has been used successfully for difficult facial reconstruction cases, providing acceptable results without using microsurgical techniques. The authors use this regional flap in reconstructing various head and neck oncologic defects that normally require traditional regional or free flaps to repair surgical wounds. A pedicled supraclavicular artery flap was used to reconstruct head/neck oncologic defects. Complications and functional outcomes were assessed. Head and neck oncologic patients underwent tumor resection followed by immediate reconstruction using a supraclavicular artery island flap. Ablative defects included neck, tracheal-stomal, mandible, parotid, and pharyngeal walls. All flaps (n = 18) were harvested in less than 1 hour. All ablative wounds and donor sites were closed primarily and did not require additional surgery. Major complications included a complete flap loss when the vascular pedicle was inadvertently divided and pharyngeal leaks. The leaks resolved without surgical intervention, and both patients regained the ability to swallow using their neo-esophagus. Minor complications included donor-site wound dehiscence and cellulitis. None of the patients reported functional donor-site morbidity. This thin flap is easy and quick to harvest, has a reliable pedicle, and has minimal donor-site morbidity. It is now the authors' flap of choice for many common head and neck reconstructive problems. Early experience using the supraclavicular artery island flap suggests that it is an excellent flap option for head and neck oncologic disease patients.

The use of “composite dressing” for covering split-thickness skin graft donor sites

To evaluate the effect of a new dressing method for clean wound coverage, two kinds of dressing materials are combined together to cover nine wounds in nine patients. All the wounds are split-thickness skin graft donor sites located in the anterior thighs. The size of the wounds ranges from 6 cm × 4 cm to 10 cm × 8 cm (42 cm 2 on average). A central fenestration is created in the polyurethane film layer for draining the wound discharge, and a piece of 2.5 cm × 2.5 cm carboxymethyl cellulose dressing is fixed on top of the fenestration for protecting the underlying wound. Dry gauze is used to cover the composite dressing, which is replaced daily. The wound condition is checked and recorded everyday until the patient is discharged. Further management and follow-up for the wound is performed at the outpatient department or by telephone. All wounds healed smoothly on the postoperative 6th to 7th day. No wound infection was noted, including one patient who had diabetes mellitus. Five patients responded to follow-up for at least 5 months and no hypertrophy scar formation was noted. From clinical experiences, we know that this new method is practical and cost-effective for covering small-sized, split-thickness skin graft donor-site wounds.

Acute propranolol infusion stimulates protein synthesis in rabbit skin wound

Propranolol administration has been demonstrated to improve cardiac work, decrease energy expenditure, and attenuate lipolysis in burned patients; however, its effect on wound healing has not been reported. In rabbits, a partial-thickness skin donor site wound was created on the back, and catheters were placed in the carotid artery and jugular vein. A nasogastric feeding tube was placed for enteral feeding. On day 5 after injury, stable isotope tracers were infused to determine protein and DNA kinetics in the wound. Propranolol hydrochloride was injected in 1 group during the tracer infusion to decrease heart rate, and the other group without propranolol injection served as a control. The propranolol infusion decreased heart rate by 21%. The protein fractional synthetic rate in the wound was greater in the propranolol group (8.6 +/- 0.9 vs 6.1 +/- 0.5%/day, P < .05). Wound protein fractional breakdown rates were not significantly different. The rate of protein deposition (synthesis - breakdown) was increased in the propranolol group (5.0 +/- 1.2 vs 2.8 +/- 0.7%/day, P = .07). Wound DNA fractional synthetic rates were comparable. The protein fractional synthetic rate was correlated with percent decrease in heart rate, but expression of the beta-adrenergic receptors and downstream signaling cascades in local wounds were not affected after propranolol treatment. Propranolol infusion increased wound protein synthetic rate and tended to increase wound protein deposition rate, which might be beneficial to wound healing. These changes might reflect a systemic response to the beta-adrenergic blockade.

Inhibition of Multidrug-resistant Acinetobacter baumannii by Nonviral Expression of hCAP-18 in a Bioengineered Human Skin Tissue

When skin is compromised, a cascade of signals initiates the rapid repair of the epidermis to prevent fluid loss and provide defense against invading microbes. During this response, keratinocytes produce host defense peptides (HDPs) that have antimicrobial activity against a diverse set of pathogens. Using nonviral vectors we have genetically modified the novel, nontumorigenic, pathogen-free human keratinocyte progenitor cell line (NIKS) to express the human cathelicidin HDP in a tissue-specific manner. NIKS skin tissue that expresses elevated levels of cathelicidin possesses key histological features of normal epidermis and displays enhanced antimicrobial activity against bacteria in vitro. Moreover, in an in vivo infected burn wound model, this tissue results in a two log reduction in a clinical isolate of multidrug-resistant Acinetobacter baumannii. Taken together, these results suggest that this genetically engineered human tissue could be applied to burns and ulcers to counteract bacterial contamination and prevent infection.

Scrotum reconstruction with the anterolateral (ALT) thigh flap

Scrotum reconstruction is challenging. Both the functional and cosmetic outcome are considered. Many reconstructive methods have been described, from burying the exposed testicles into a subcutaneous pocket to local musculocutaneous or fasciocutaneous flaps. We report our experience of treating three patients for scrotal reconstruction by using the anterolateral thigh island flap. Three patients received scrotum reconstruction with the anterolateral thigh island flap from 2003 to 2007. Two of them had Fournier’s gangrene and one had hidradenitis suppurativa. In two occasions a “true” perforator flap was used and in one a small muscle cuff of the vastus lateralis muscle was also included. All three flaps were successful. One patient had a proximal donor site wound dehiscence due to inadequate drainage. Simple conservative treatment resolved the problem. No patient had any functional donor site morbidity. We conclude that the anterolateral thigh flap is a valuable tool in reconstruction of the scrotum. It should be considered as a sound alternative within the available reconstructive procedures.

Multifunctional In Situ Photopolymerized Semi-Interpenetrating Network System is an Effective Donor Site Dressing: A Cross Comparison Study in a Swine Model

Effective dressings for donor sites or other partial thickness wounds must promote removal of nonviable or necrotic tissue, eradication and prevention of microbial infiltrate, exudate absorbance, and regrowth of healthy epidermis and dermis. There are many commonly used products that facilitate these processes. Established properties of an in situ photopolymerizable semi-interpenetrating network (sIPN) suggest that it is also a viable treatment option. The widely varying material properties suggest that these dressing treatments may elicit different healing responses via different cellular mechanisms. In this study, we sought to resolve the differences in healing between Acticoat, sIPN, nonadherent dressing with Tisseel, and Xeroform dressing treatments in a porcine partial thickness wound model. Donor site wounds were produced on pigs at two cut depths and dressed with Acticoat, sIPN, nonadherent dressing with Tisseel, and Xeroform with alternatively placed autografts to provide a control area between each test site. Pigs were euthanized at 4, 7, 14, and 42 days for macroscopic examination and biopsy collection. Biopsies were analyzed histologically by two blinded observers for cellular densities and regional thicknesses within the tissue. sIPN- and Xeroform-treated wounds were healed by 7 days, and Acticoat- and nonadherent dressing with Tisseel-treated wounds were healed by 14 days. Inflammatory responses were between comparable treatment type across all time periods. Dermal granulation features increased with time but were not significantly different. All dressing treatments elicited wound healing without outstanding toxicity or pathology indicating that sIPN is a comparable and viable treatment for partial thickness wounds.

Clinical experiences of using a cellulose dressing on burns and donor site wounds

These preliminary results suggest this temporary skin substitute reduces pain and achieves comparable healing rates to other dressings. Furthermore, its transparency enables regular inspection of the wound bed for signs of infection.

S147 – Pectoralis Major Flaps: A Workhorse in Today's Free Flap Era

Objectives To study the use, complication rate, and efficacy of pedicled local regional flaps for head and neck reconstruction, and to compare these results with those of microvascular free flap reconstruction. Methods Retrospective analysis of all head and neck oncologic resections requiring flap reconstruction in a tertiary head and neck surgery centre over a 6-year period from 2001–2007. Results In total, 77 operations with flap reconstruction were performed. 44 resections employed pedicled locoregional flaps, comprising 33 pectoralis major, 3 trapezius, 3 cervical rotation, 1 deltopectoral, 1 temporalis muscle, 2 nasolabial, 1 cheek rotation, and 2 bilobed rotation flaps. 2 patients had a combination of 2 regional flaps. There was 1 flap failure. Minor complications occurred in 25% of patients comprising wound seromas (3), wound dehiscence (6), fibrotic band formation (1) and pharyngocutaneous fistula (1). 33 resections employed free flap microvascular reconstructions, comprising 22 free radial forearm, 7 free rectus abdominis, 1 free jejunal, 1 free fibular, and 2 anterolateral thigh flaps. There was 1 flap failure. Minor complications occurred in 33% of patients, comprising donor site wound dehiscence (4), recipient site wound dehiscence or seroma (4), plate extrusion (1), abscess and wound breakdown (2). Conclusions Despite the ready access to free flap reconstruction today, pedicled flaps, especially the pectoralis major flap, remain a major workhorse in head and neck reconstruction. They are hardy, reliable, cost-effective, and can be done in a short operative time. Moreover, for several regions, the functional outcome is no worse than free flap reconstruction.

Repair of soft tissue and bone defects at the distal phalanx with rib graft and the medial plantar flap

Objective To summarize our clinical applications of rib graft and the medial plantar flaps to repair soft tissue and bone defects at the distal phalanx. Methods Five patients (4 males, 1 female) with soft tissue and bone defects on the palmar surface of the distal phalanx underwent microvascular reconstruction with the rib graft and the medial plantar flap. Their ages ranged from 19 to 43 (mean, 31)years. Of them, 3 cases had defects at 2 fingers and the other 2 had defects at 3 fingers. The wound of donor site was closed by a meshed split-thickness skin graft. The vascular pedicles of the flaps were anastomosed end-to-end to the recipient site vessels. Results One ease sustained superficial postoperative infection at the donor site and the wound healed gradually by daily dressing. The flaps survived completely without major complications. Follow-up of 10 to 28 (mean, 19) months revealed satisfactory clinical results. Good appearance was obtained at the donor and recipient sites. Durable, sensate coverage of the defects was achieved in all patients and their 2-point discrimination was 5 to 14 (mean, 8) mm. There was no remarkable donor site morbidity. Conclusions Nourished by the medial plantar artery, the medial plantar flap has a constant and rich vascular anatomy. Its long vascular pedicle makes the flap dissection easy. The technique of rib graft and the medial plantar flap transplant is suitable for repair of the soft tissue and bone defects on the palmar surface of the distal fingers. Key words: Fingers injury; Surgical flaps; Microsurgery

Use of an Acellular Regenerative Tissue Matrix in Combination with Vacuum-assisted Closure Therapy for Treatment of a Diabetic Foot Wound

Diabetic foot ulcers can be difficult to treat for a variety of reasons, and may result in amputation. The use of skin grafts can often be a useful method of achieving wound coverage and subsequent healing of diabetic foot ulcers; however, this method of treatment requires creation of a donor site wound that adds to the patient's overall wound burden. Application of an acellular regenerative tissue matrix may eliminate the need for harvesting a skin graft in order to cover a nonhealing wound. The use of vacuum-assisted wound closure has been shown to promote an environment that enhances wound bed contraction and surface epithelialization. The combination of an acellular regenerative tissue matrix with vacuum-assisted wound closure can be used to promote healing in the management of a nonhealing diabetic foot wound. x.

Workshop: summary of discussions and conclusions

1. Local application of collagen-gentamicin for prevention of sternal wound infection (SWI) is a fairly new concept. Is there reason to present recommendations or precautions regarding its use after summarizing the documentation and clinical experience so far? 2. An objective and reliable registration of all postoperative wound infections constitutes the basis for further improvements and allows the comparison of SWI rates over time and between centres. Is it possible to achieve recommendations for uniform follow-up of postoperative surgical site infections (SSI) after cardiac surgery among centres in the Nordic countries? 3. National registries exist for a number of diagnoses and conditions in Sweden. Is the time ripe for a National Medistinitis Registry? What should be the aim and design of such a registry?