Full-thickness Skin Loss Research Articles

Creation of a Bioengineered Skin Flap Scaffold with a Perfusable Vascular Pedicle.

Full-thickness skin loss is a challenging problem due to limited reconstructive options, demanding 75 million surgical procedures annually in the United States. Autologous skin grafting is the gold standard treatment, but results in donor-site morbidity and poor aesthetics. Numerous skin substitutes are available on the market to date, however, none truly functions as full-thickness skin due to lack of a vascular network. The creation of an autologous full-thickness skin analogue with a vascular pedicle would result in a paradigm shift in the management of wounds and in reconstruction of full-thickness skin defects. To create a clinically relevant foundation, we generated an acellular skin flap scaffold (SFS) with a perfusable vascular pedicle of clinically relevant size by perfusion decellularization of porcine fasciocutaneous flaps. We then analyzed the yielded SFS for mechanical properties, biocompatibility, and regenerative potential in vitro and in vivo. Furthermore, we assessed the immunological response using an in vivo model. Finally, we recellularized the vascular compartment of an SFS and reconnected it to a recipient's blood supply to test for perfusability. Perfusion decellularization removed all cellular components with preservation of native extracellular matrix composition and architecture. Biaxial testing revealed preserved mechanical properties. Immunologic response and biocompatibility assessed via implantation and compared with native xenogenic skin and commercially available dermal substitutes revealed rapid neovascularization and complete tissue integration. Composition of infiltrating immune cells showed no evidence of allorejection and resembled the inflammatory phase of wound healing. Implantation into full-thickness skin defects demonstrated good tissue integration and skin regeneration without cicatrization. We have developed a protocol for the generation of an SFS of clinically relevant size, containing a vascular pedicle, which can be utilized for perfusion decellularization and, ultimately, anastomosis to the recipient vascular system after precellularization. The observed favorable immunological response and good tissue integration indicate the substantial regenerative potential of this platform.

Plastic Wrap Versus Occlusive Dressings for the Management of Skin Ulcers: Comparison of Two Symmetrical Wounds in Two Individual Patients

To compare the efficacy of plastic wrap (typically used for foods) as a dressing material to treat skin ulcers versus occlusive dressings, each dressing was randomly allocated to simultaneously treat two wounds at symmetrical locations in two individual patients. In case 1, two wounds with full-thickness skin loss on the neck were treated. A wound measuring 6.2 cm2 that was treated with plastic wrap healed in 9 weeks. A hydrocellular polyurethane dressing decreased the size of a wound measuring 9.3 cm2 to 3.8 cm2 in 12 weeks. The surface area reduction rate was 0.7 cm2/ week with plastic wrap and 0.5 cm2/week with the hydrocellular polyurethane dressing. In case 2, two shallow skin ulcers in both femoral regions resulting from skin grafting were treated. The plastic wrap dressing was randomly allocated to a wound measuring 25.1 cm2 that healed in 18 weeks. The other wound measuring 18.5 cm2 was treated with hydrocolloid dressing and epithelialized completely in 13 weeks. The healing rate of each treatment was approximately equal at 1.4 cm2/week. No adverse events developed in either case. These results are limited because of the case study design but suggest that the plastic wrap dressing treatment is as effective as the occlusive dressing technique in the treatment of chronic wounds.

Restoration of cutaneous pigmentation by transplantation to mice of isogeneic human melanocytes in dermal-epidermal engineered skin substitutes.

Autologous engineered skin substitutes (ESS) containing melanocytes (hM) may restore pigmentation and photoprotection after grafting to full-thickness skin wounds. In this study, normal hM were isolated from discard skin, propagated with or without tyrosinase inhibitors, cryopreserved, recovered into culture, and added to ESS (ESS-P) before transplantation. ESS-P were incubated in either UCMC160/161 or UCDM1 medium, scored for hM densities, and grafted to mice. The results showed that sufficient hM can be propagated to expand donor tissue by 100-fold; incubation of hM in tyrosinase inhibitors reduced pigment levels but did not change hM recovery after cryopreservation; hM densities in ESS-P were greater after incubation in UCDM1 than UCMC160 medium; hM were localized to the dermal-epidermal junction of ESS-P; and UCDM1 medium promoted earlier pigment distribution and density. These results indicate that hM can be incorporated into ESS-P efficiently to restore cutaneous pigmentation and UV photoprotection after full-thickness skin loss conditions.

Reconstructive surgery for treating pressure ulcers.

The management of pressure ulcers involves several interventions ranging from pressure-relieving measures such as repositioning, to treatments that can include reconstructive surgery. Such surgery may be considered for recalcitrant wounds when full thickness skin loss arises and deeper structures such as muscle fascia and even bone are exposed. The surgery commonly involves wound debridement followed by the addition of new tissue into the wound. Whilst reconstructive surgery is an accepted means of ulcer management, the benefits and harms of surgery compared with non-surgical treatments, or alternative surgical approaches are not clear. To assess the effects of reconstructive surgery for healing pressure ulcers (stage II or above), comparing surgery with no surgery or comparing alternative forms of surgery in any care setting. We searched the following electronic databases to identify reports of relevant randomised clinical trials (searched 26 September 2016): the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. We also searched three clinical trials registers and reference lists of relevant systematic reviews, meta-analyses and health technology assessment reports. Published or unpublished randomised controlled trials that assessed reconstructive surgery in the treatment of pressure ulcers. Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias and extract study data. We did not identify any studies that met the review eligibility criteria nor any registered studies investigating the role of reconstructive surgery in the management of pressure ulcers. Currently there is no randomised evidence that supports or refutes the role of reconstructive surgery in pressure ulcer management. This is a priority area and there is a need to explore this intervention with more rigorous and robust research.

Improved Methods to Produce Tissue-Engineered Skin Substitutes Suitable for the Permanent Closure of Full-Thickness Skin Injuries.

There is a clinical need for skin substitutes to replace full-thickness skin loss. Our group has developed a bilayered skin substitute produced from the patient's own fibroblasts and keratinocytes referred to as Self-Assembled Skin Substitute (SASS). After cell isolation and expansion, the current time required to produce SASS is 45 days. We aimed to optimize the manufacturing process to standardize the production of SASS and to reduce production time. The new approach consisted in seeding keratinocytes on a fibroblast-derived tissue sheet before its detachment from the culture plate. Four days following keratinocyte seeding, the resulting tissue was stacked on two fibroblast-derived tissue sheets and cultured at the air–liquid interface for 10 days. The resulting total production time was 31 days. An alternative method adapted to more contractile fibroblasts was also developed. It consisted in adding a peripheral frame before seeding fibroblasts in the culture plate. SASSs produced by both new methods shared similar histology, contractile behavior in vitro and in vivo evolution after grafting onto mice when compared with SASSs produced by the 45-day standard method. In conclusion, the new approach for the production of high-quality human skin substitutes should allow an earlier autologous grafting for the treatment of severely burned patients.

Management of Extravasation Injuries in Preterm Infants

Extravasation injuries occur in up to 70% of neonates in intensive care, majority being preterm infants. Their fragile and premature anatomy makes prevention and management of extravasation extra difficult compared to those of full-term. With increasing advances of intensive care for preterm infants, the use of intravenous medication and nutrition will increase, thus lead to further potential risk of extravasation injuries, which has serious complications, such as full-thickness skin loss, tissue necrosis and acute limb compartment syndrome, with long-term functional and cosmetic sequelae. There is a current lack of evidence in the literature on the most appropriate therapeutic strategy for this vulnerable patient group. This review aims to highlight our trust regime on the management of extravasation injuries (non-chemotherapeutic) for preterm infants, including injury classification and assessment, and implementation of initial interventions.

Study of stiffness effects of poly(amidoamine)–poly(n-isopropyl acrylamide) hydrogel on wound healing

The mechanical miss-match between the host and an implanted foreign body is one of the primary causes for implantation failure. To enhance the efficacy in wound repair, we developed stiffness-tunable temperature-sensitive hydrogels composed of poly(amidoamine) (PAA)-based poly(n-isopropyl acrylamide) (PNIPAM). PNIPAM-PAA hydrogels with three different stiffness fabricated by varying the concentrations of poly(amidoamine) were chosen for morphology and rheology tests. The degradation rate and cell compatibility of gels were also characterized. The PAA-PNIPAM hydrogels were then tested in a wound healing model of mice with full-thickness skin loss. We found that the stiffness of hydrogels has an impact on the wound healing process mainly by regulating the cell activities in the proliferation phase. PNIPAM-PAA hydrogels with appropriate stiffness reduce scar formation and improve wound healing by promoting myofibroblast transformation, keratinocytes proliferation, extracellular matrix synthesis and remodeling. Moreover, the stiffness of hydrogels impact on the secretion of TGF-β1 and bFGF, which play an important role in skin wound healing. These results suggest that the therapeutic effects of hydrogels in skin wound healing can by regulated by hydrogels’ stiffness.

Preparation and characterization of thermosensitive artificial skin with a Sandwich structure

A thermosensitive artificial skin composed of gelatin–chitosan (Gel–CS) scaffold as dermis and poly(N-isopropyl acrylamide) (PNIPAAm) grafted microporous polyurethane (PU) membrane as epidermis bound together by gelatin was prepared, and its morphological structure, water vapor permeability rate (WVPR) and in vivo biological properties were investigated. The results showed that the as-prepared artificial skin showed a “Sandwich” structure and its WVPR was 804g/m2day, close to those from commercial skin dressings (426–2047g/m2day). The in vivo tests indicated that the “Sandwich” artificial skin could effectively accelerate wound closure in a rat model with full-thickness skin loss and the epidermis could easily peel off after wound healing.

Point prevalence of complex wounds in a defined United Kingdom population.

Complex wounds (superficial-, partial-, or full-thickness skin loss wounds healing by secondary intention) are common; however, there is a lack of high-quality, contemporary epidemiological data. This paper presents point prevalence estimates for complex wounds overall as well as for individual types. A multiservice, cross-sectional survey was undertaken across a United Kingdom city (Leeds, population 751,485) during 2 weeks in spring of 2011. The mean age of people with complex wounds was approximately 70 years, standard deviation 19.41. The point prevalence of complex wounds was 1.47 per 1,000 of the population, 95% confidence interval 1.38 to 1.56. While pressure ulcers and leg ulcers were the most frequent, one in five people in the sample population had a less common wound type. Surveys confined to people with specific types of wound would underestimate the overall impact of complex wounds on the population and health care resources.

A novel model of human skin pressure ulcers in mice.

IntroductionPressure ulcers are a prevalent health problem in today's society. The shortage of suitable animal models limits our understanding and our ability to develop new therapies. This study aims to report on the development of a novel and reproducible human skin pressure ulcer model in mice.Material and MethodsMale non-obese, diabetic, severe combined immunodeficiency mice (n = 22) were engrafted with human skin. A full-thickness skin graft was placed onto 4×3 cm wounds created on the dorsal skin of the mice. Two groups with permanent grafts were studied after 60 days. The control group (n = 6) was focused on the process of engraftment. Evaluations were conducted with photographic assessment, histological analysis and fluorescence in situ hybridization (FISH) techniques. The pressure ulcer group (n = 12) was created using a compression device. A pressure of 150 mmHg for 8 h, with a total of three cycles of compression-release was exerted. Evaluations were conducted with photographic assessment and histological analysis.ResultsSkin grafts in the control group took successfully, as shown by visual assessment, FISH techniques and histological analysis. Pressure ulcers in the second group showed full-thickness skin loss with damage and necrosis of all the epidermal and dermal layers (ulcer stage III) in all cases. Complete repair occurred after 40 days.ConclusionsAn inexpensive, reproducible human skin pressure ulcer model has been developed. This novel model will facilitate the development of new clinically relevant therapeutic strategies that can be tested directly on human skin.

Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis.

To evaluate the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers. The objective was to identify the extent to which these frameworks take account of the setting where the ulcer originated as being the person's home rather than a hospital setting. Pressure ulcers involving full-thickness skin loss are increasingly being regarded as indicators of nursing patient safety failure, requiring investigation using root cause analysis frameworks. Evidence suggests that root cause analysis frameworks developed in hospital settings ignore the unique dimensions of risk in home healthcare settings. A systematic literature review and documentary analysis of frameworks used to investigate community-acquired grade three and four pressure ulcers by home nursing services in England. No published papers were identified for inclusion in the review. Fifteen patient safety investigative frameworks were collected and analysed. Twelve of the retrieved frameworks were intended for the investigation of community-acquired pressure ulcers; seven of which took account of the setting where the ulcer originated as being the patient's home. This study provides evidence to suggest that many of the root cause analysis frameworks used to investigate community-acquired pressure ulcers in England are unsuitable for this purpose. This study provides researchers and practitioners with evidence of the need to develop appropriate home nursing root cause analysis frameworks to investigate community-acquired pressure ulcers.

Scarring, stem cells, scaffolds and skin repair

The treatment of full thickness skin loss, which can be extensive in the case of large burns, continues to represent a challenging clinical entity. This is due to an on-going inability to produce a suitable tissue engineered substrate that can satisfactorily replicate the epidermal and dermal in vivo niches to fulfil both aesthetic and functional demands. The current gold standard treatment of autologous skin grafting is inadequate because of poor textural durability, scarring and associated contracture, and because of a paucity of donor sites in larger burns. Tissue engineering has seen exponential growth in recent years with a number of 'off-the-shelf' dermal and epidermal substitutes now available. Each has its own limitations. In this review, we examine normal wound repair in relation to stem/progenitor cells that are intimately involved in this process within the dermal niche. Endothelial precursors, in particular, are examined closely and their phenotype, morphology and enrichment from multiple sources are described in an attempt to provide some clarity regarding the controversy surrounding their classification and role in vasculogenesis. We also review the role of the next generation of cellularized scaffolds and smart biomaterials that attempt to improve the revascularisation of artificial grafts, the rate of wound healing and the final cosmetic and functional outcome.

Chitosan Dermal Substitute and Chitosan Skin Substitute Contribute to Accelerated Full-Thickness Wound Healing in Irradiated Rats

Wounds with full-thickness skin loss are commonly managed by skin grafting. In the absence of a graft, reepithelialization is imperfect and leads to increased scar formation. Biomaterials can alter wound healing so that it produces more regenerative tissue and fewer scars. This current study use the new chitosan based biomaterial in full-thickness wound with impaired healing on rat model. Wounds were evaluated after being treated with a chitosan dermal substitute, a chitosan skin substitute, or duoderm CGF. Wounds treated with the chitosan skin substitute showed the most re-epithelialization (33.2 ± 2.8%), longest epithelial tongue (1.62 ± 0.13 mm), and shortest migratory tongue distance (7.11 ± 0.25 mm). The scar size of wounds treated with the chitosan dermal substitute (0.13 ± 0.02 cm) and chitosan skin substitute (0.16 ± 0.05 cm) were significantly decreased (P < 0.05) compared with duoderm (0.45 ± 0.11 cm). Human leukocyte antigen (HLA) expression on days 7, 14, and 21 revealed the presence of human hair follicle stem cells and fibroblasts that were incorporated into and surviving in the irradiated wound. We have proven that a chitosan dermal substitute and chitosan skin substitute are suitable for wound healing in full-thickness wounds that are impaired due to radiation.

Collagen hydrogels strengthened by biodegradable meshes are a basis for dermo-epidermal skin grafts intended to reconstitute human skin in a one-step surgical intervention

Extensive full-thickness skin loss, associated with deep burns or other traumata, represents a major clinical problem that is far from being solved. A promising approach to treat large skin defects is the use of tissue-engineered full-thickness skin analogues with nearly normal anatomy and function. In addition to excellent biological properties, such skin substitutes should exhibit optimal structural and mechanical features. This study aimed to test novel dermo-epidermal skin substitutes based on collagen type I hydrogels, physically strengthened by two types of polymeric net-like meshes. One mesh has already been used in clinical trials for treating inguinal hernia; the second one is new but consists of a FDA-approved polymer. Both meshes were integrated into collagen type I hydrogels and dermo-epidermal skin substitutes were generated. Skin substitutes were transplanted onto immuno-incompetent rats and analyzed after distinct time periods. The skin substitutes homogeneously developed into a well-stratified epidermis over the entire surface of the grafts. The epidermis deposited a continuous basement membrane and dermo-epidermal junction, displayed a well-defined basal cell layer, about 10 suprabasal strata and a stratum corneum. Additionally, the dermal component of the grafts was well vascularized.

Military medical revolution

Abstract : The battlefield has seen tremendous revolutions in military medical affairs (RMMAs) as a result of the last decade of continuous combat operations. The advances in deployed and en route combat casualty care are categorized as individual RMMAs shown in Table 1. As with prehospital advances, the basis for many of the RMMAs in the deployed hospital care environment as well as en route care was translated from civilian trauma practice but is realistic and relevant to the battlefield context. As the conflict evolved, the substantive data from the battlefield led to many new paradigms of treatment and evacuation. The successful implementation of many of these battlefield practices was then effectively translated back into the civilian injury care environment as has been typical of medical advances developed subsequent to previous conflicts of antiquity. The RMMAs that occurred during the last 10 years of combat casualty care are in the realm of deployed hospital care and en route care and are discussed in detail in this article.

Complex chemical burns following a mass casualty chemical plant incident: How optimal planning and organisation can make a difference

IntroductionFour employees at a chemical plant sustained extensive chemical burns following the explosion of a pipeline containing 100% sulphuric acid. We describe the management of these patients from the initial ED triage through to discharge from hospital in life and limb threatening chemical burns. MethodsFour patients who sustained chemical burns to the torso and extremities are reviewed. Data was retrieved from patient case notes and operating theatre logbooks. ResultsFour patients sustained chemical burns during the blast and were immediately transferred to a local ED where a prompt referral was made to the burns service. All patients were male aged 25–59 years (mean 46.5). Burn size was 2–50% BSA (mean 22.5). Following RFDS transfer to the state burns service two patients required immediate excisional surgery. In these patients the chemical burn involved full thickness skin loss with extensive underlying muscle and neurovascular damage. One patient required immediate above knee amputation of one leg and fascial burn excision of the other. The other patient required fascial burn excision of both legs followed by Integra placement 24h later. Both patients had prolonged hospital stays due to the complex nature of their injuries requiring multiple trips to theatre and lengthy rehabilitation. The two patients with smaller burns had straightforward surgery and an unremarkable recovery. ConclusionEarly communication following this mass casualty incident allowed for organisation of tertiary services and early radical surgery which was life saving. Management lessons were learnt following this mass casualty chemical burn incident.

Suspected Deep Tissue Injury Evaluated by North Carolina WOC Nurses

The purpose of this prospective exploratory study was to determine the percentage of suspected deep tissue injuries (sDTI) that evolve into full-thickness skin loss, to describe the progression from sDTI to full-thickness skin loss, and to explore associated conditions. The study was conducted by WOC nurses at 6 acute care medical facilities in North Carolina. Inclusion criteria were age 21 years or older and presence of an sDTI lesion. Participating members of the North Carolina WOC Nurse's Group identified 40 patients with a total of 45 sDTI. A 2-part data collection tool was developed by 1 of the investigators and validated by members of the North Carolina WOC Nurse Group; data were collected at the time of initial consult and at a follow-up visit that occurred 1 to 20 days later (average 6 days). Data collected included description of wound appearance as well as information about comorbid and potential risk factors. The sample comprised 40 subjects with 45 sDTI; 3 were lost to follow-up, resulting in a total of 37 subjects with 42 sDTI at the second assessment. Eleven (26%) sDTI developed into full-thickness skin loss, and 7 (17%) evolved from purple/maroon discoloration to thin blisters over dark wound beds. Twenty (48%) did not change between the time of initial consult and the follow-up visit up between 1 and 20 days later. Two lesions healed (1 at 6 days and the other at 8 days). Despite preventive care, 26% of the sDTI evolved into full-thickness lesions at follow-up visit, and 17% evolved into unstageable pressure ulcers. However, 5% healed and 48% remained the same, suggesting that preventive care may be effective for many sDTI lesions.

Nipple-Areola Complex Evaluation in Long Pedicled Breast Reductions with Real-Time Fluorescent Videoangiography

Sir: We read with great interest the viewpoint and abstract entitled “Fluorescent Intraoperative Tissue Angiography with Indocyanine Green: Evaluation of Nipple-Areola Vascularity during Breast Reduction Surgery” by Dr. Murray et al.1 In their article, they state that “although intraoperative surgical decisions were not altered based on these images, they nonetheless supported the surgeon's operative evaluation.” In response to their article, we report a case in which laser-assisted indocyanine green angiography identified a decrease in perfusion to the nipple-areola complex that was not apparent to the surgeon intraoperatively. Laser-assisted indocyanine green angiography ultimately proved to be predictive of partial nipple areola loss, and could have been used to positively alter intraoperative decision-making. We present the clinical course of a 45-year-old woman with darkly pigmented skin tone and large breasts who underwent bilateral reduction mammaplasty. Preoperative measurements revealed sternal notch–to-nipple distances of 41 cm on the right and 43 cm on the left, with inframammary fold–to-nipple distances of 19 cm on the right and 20 cm on the left. A Wise-type skin pattern with a superomedial dermal pedicle was selected. A total of 1638 g of breast tissue was removed from the right breast, and 1620 g was removed from the left breast. Because of the patient's long dermal pedicles (20 cm on the right and 21 cm on the left) and dark nipple-areola complex skin tone, we elected to perform laser-assisted indocyanine green angiography to better assess nipple-areola complex vascularity. Intraoperative angiography showed a completely viable right nipple-areola complex and a partial filling of the left nipple-areola complex, with the superior portion showing poor perfusion (Fig. 1). Clinically (color, capillary refill, and bleeding edges), the patient's nipple-areola complex appeared viable. Based on our clinical experience, we elected to loosely inset the nipples and not perform a free nipple graft. On postoperative day 1, clinical assessment was unremarkable. One week postoperatively, however, the patient developed a superficial skin blister in the exact area of concern mapped by laser-assisted indocyanine green angiography. Throughout the following postoperative period, this area progressed to a full-thickness skin loss along the superior one-fourth of the nipple (Fig. 2). This was treated with local dressings and the patient continued to heal and is now satisfied with her results. Retrospectively, the laser-assisted indocyanine green angiographic information could have altered our intraoperative decision-making, to either débride a portion of the nipple or perform a free nipple graft, for example.Fig. 1.: Intraoperative laser-assisted indocyanine green angiographic image of the left breast.Fig. 2.: Appearance of the left breast 2 weeks postoperatively.We have previously demonstrated the ability of fluorescent intraoperative angiography to predict subclinical ischemia in free tissue transfer, in pedicle flap design, and in mastectomy flap analysis.2–4 Intraoperative evaluation of nipple-areola complexes during breast reduction surgery can be challenging as well, and may offer another opportunity to use this technology. In particular, patients with dark skin tone, smokers, and women with long dermal pedicles would be good candidates to undergo laser-assisted indocyanine green angiography. Traditionally, dermal pedicle length, the volume of the reduction needed, history of smoking, and clinical judgment are factors contributing to nipple-areola complex viability and are sometimes used to determine whether free nipple grafting should be performed. We do not routinely perform intraoperative fluorescent angiography on all of our breast reduction cases. However, in patients with these risk factors, we now consider intraoperative angiography to assist with intraoperative planning. We propose that intraoperative fluorescent videoangiography can be used and may alter the surgeon's operative evaluation during breast reduction surgery in challenging cases where patients are at risk for poor nipple-areola complex perfusion. DISCLOSURE Dr. Samson and Dr. Newman are paid consultants and speakers for Novadaq Technologies, Inc. Dr. Newman is a paid consultant and speaker for LifeCell Corp. Louis S. Brunworth, M.D. Michel C. Samson, M.D. Martin I. Newman, M.D. Department of Plastic Surgery Cleveland Clinic Florida Weston, Fla. Jose R. Ramirez, M.D. Department of General Surgery Cleveland Clinic Cleveland, Ohio

Areola and Nipple-Areola-Sparing Mastectomy for Breast Cancer Treatment and Risk Reduction: Report of an Initial Experience in a Community Hospital Setting

BackgroundThe use of areola-sparing (AS) or nipple-areola-sparing (NAS) mastectomy for the treatment or risk reduction of breast cancer has been the subject of increasing dialogue in the surgical literature over the past decade. We report the initial experience of a large community hospital with AS and NAS mastectomies for both breast cancer treatment and risk reduction.MethodsA retrospective chart review was performed of patients undergoing either AS or NAS mastectomies from November 2004 through September 2009. Data collected included patient sex, age, family history, cancer type and stage, operative surgical details, complications, adjuvant therapies, and follow-up.ResultsForty-three patients underwent 60 AS and NAS mastectomies. Forty-two patients were female and one was male. The average age was 48.7 years (range, 28–76 years). Forty mastectomies were for breast cancer treatment, and 20 were prophylactic mastectomies. The types of cancers treated were as follows: invasive ductal (n = 19), invasive lobular (n = 5), ductal carcinoma-in situ (n = 15), and malignant phyllodes (n = 1). Forty-seven mastectomies (78.3%) were performed by inframammary incisions. All patients underwent immediate reconstruction with either tissue expanders or permanent implants. There was a 5.0% incidence of full-thickness skin, areola, or nipple tissue loss. The average follow-up of the series was 18.5 months (range, 6–62 months). One patient developed Paget’s disease of the areola 34 months after an AS mastectomy (recurrence rate, 2.3%). There were no other instances of local recurrence.ConclusionsAS and NAS mastectomies can be safely performed in the community hospital setting with low complication rates and good short-term results.

A Mathematical Description of the Cell Invasion of Dermal Replacement Scaffolds Strattice® and Integra®

Objective: Rapid vascularization via host cell invasion is key to the viability of scaffolds used as dermal replacement for full-thickness skin loss. Two commercially available products used for this purpose are Integra® and Strattice®. The purpose of this study was to employ, for the first time, a mathematical description of the pattern of host cellular invasion of these commonly used dermal replacements, and to develop a template for the comparative evaluation of dermal replacement scaffolds. Methods: Four 8mm discs of Integra® or Strattice® were implanted subcutaneously on the dorsa of 8 C57/BL6 mice.