Graft Donor Site Research Articles

Cover Image

The cover image is based on the Original Article Histologic Assessment and Gene Expression Analysis of Intraoral Soft Tissue Graft Donor Sites by Sandra Stuhr et al., https://doi.org/10.1111/jcpe.13843.image

Fasciocutaneous Free Tissue Transfer in Limb Salvage: Prior Flap as a Split-thickness Skin Graft Donor Site.

Free flap surgery for limb salvage has become the surgical standard for reconstruction of bone and soft tissue with success rates and flap survivals of 94%-95%. The soft tissue defect dictates the technique of coverage. In many cases, multiple techniques of soft tissue coverage are necessary, ranging from myocutaneous and fasciocutaneous free flaps to split-thickness skin grafts (STSGs). It has been shown that fasciocutaneous free flaps are not inferior to muscle flaps in treatment of lower leg limb salvage. Although a complete flap loss is rare, it is not uncommon to have partial flap necrosis, wound dehiscence, or secondary soft tissue defects, necessitating further minor reconstruction, which we call "touch up" skin grafts. In many of these secondary procedures, split thickness skin grafts are sufficient. We have been using the skin portion of the fasciocutaneous free flap as a donor site for harvesting STSGs for quite some time without disadvantages. We believe that minimizing additional donor site morbidity is of great importance. The free tissue transfer is insensate and readily available at the site of injury, making prepping and draping simple as well as cosmetically acceptable, as the transferred free tissue, unfortunately, is rarely a perfect fit. The associated pain, discomfort, and scar of an additional donor site can be avoided. In our case series, we did not experience any flap loss, infections, or complications. Thus, harvesting an STSG from a fasciocutaneous free flap seems to be a feasible option to be considered in limb salvage.

Histological assessment and gene expression analysis of intra-oral soft tissue graft donor sites.

To determine the structural and gene expression features of different intra-oral soft tissue donor sites (i.e., anterior palate, posterior palate, maxillary tuberosity and retromolar pad). Standardized mucosal tissue punch biopsies were collected from at least one donor site per subject. Histological processing was performed to determine tissue morphometry and quantify collagen composition. Site-specific gene distribution was mapped using targeted gene expression analysis and validated using real time polymerase chain reaction (qPCR). A total of 50 samples from 37 subjects were harvested. Epithelial thickness did not differ between sites. However, lamina propria was thicker in the maxillary tuberosity (2.55 ± 0.92 mm) and retromolar pad (1.98 ± 0.71 mm) than in the lateral palate. Type I collagen was the predominant structural protein in the lamina propria (75.06%-80.21%). Genes involving collagen maturation and extracellular matrix regulation were highly expressed in the maxillary tuberosity and retromolar pad, while lipogenesis-associated genes were markedly expressed in the lateral palate. The retromolar pad showed the most distinct gene expression profile, and the anterior and posterior palate displayed similar transcription profiles. Tissue samples harvested from the anterior and posterior palate differed morphologically from those from the maxillary tuberosity and retromolar pad. Each intra-oral site showed a unique gene expression profile, which might impact their biological behaviour and outcomes of soft tissue augmentation procedures.

Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction With Pedicular Hamstrings Tendon Graft, Single-Strand Gracilis for ALL and Single Blind Femoral Tunnel

Combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALL r) is a common procedure to treat rotational instability and to prevent ACL graft failure. Recent studies have described numerous combined reconstruction techniques to obtain the most anatomical procedure with the least graft donor site morbidity and the best clinical results.Hamstring (HG) grafts are the most popular graft in literature. Leaving pedicle HG can preserve enough blood supply to improve tendon-bone healing with additional mechanical fixation of the graft on the tibial side. A single femoral tunnel reduces bone loss and prevents convergence of 2 femoral tunnels. We describe an original ACL and ALL reconstruction technique that preserves hamstring tibial insertion with a single blind femoral tunnel.

The Efficacy of Regeneration Oil and Almond Oil on Split-Thickness Skin Graft Donor Sites: A Single-Blinded Randomized Controlled Trial.

Essential oils are a complementary treatment and can play an important role in scar care. The aim of this study was to evaluate and compare the efficacy of a new essential oil (regeneration oil) with a control group on scar quality in healed split-thickness skin graft donor sites. A single-center blinded randomized controlled study was performed on 30 patients with healed split-thickness skin graft donor site. The patients were randomly allocated into blended regeneration oil (n = 14) and pure almond oil (n = 16) groups. Application of the assigned oil occurred twice a day for 6 months. Scarring (Patient and Observer Scar Assessment Scale), itching (ITCH Assessment Scale) and scar discoloration (colorimetry) of the donor sites were assessed after 1, 3 and 6 months. We found no statistically significant differences between the groups in any applied parameter. We observed comparable outcomes (scar quality, itchiness, colorit) in healed split-thickness skin graft donor sites for both oils. Regeneration oil and control oil presented comparable results regarding scar quality, itchiness and colorit in healed split-thickness skin graft donor sites after 6 months of application. Both oils are suitable for skin/scar care in split-thickness skin graft donor sites.

Clinical outcomes and resource utilisation in patients with major burns treated with NovoSorb® BTM

IntroductionPatients with major burns can undergo temporary coverage while skin graft donor sites heal, where dermal templates have an emerging role. The aim of this study was to evaluate the clinical outcomes and resource utilisation in patients with major burns treated with a bilayer biodegradable synthetic matrix (NovoSorb BTM). MethodThis retrospective cohort study included patients admitted to the Royal Brisbane and Women’s Hospital Adult Burn Unit with burns to at least 40 % TBSA who survived their acute admission. Patients treated from July 2017 to June 2022 with BTM were compared with patients with similar injuries treated using cadaveric allograft as temporising full thickness wound coverage between January 2013 and June 2017. Outcomes measures included number of operations, total operative time, hospital and intensive care unit (ICU) length of stay (LOS), cadaveric allograft and BTM use, and blood product use. Unadjusted comparisons were made with Wilcoxon Rank-Sum tests and Fisher’s exact tests. Multivariate linear regression was used to adjust for the effect of TBSA on each outcome. ResultsFifty-five patients were included (78 % male), 22 of whom were treated with BTM. We found no significant differences in age, sex, or TBSA between groups. One patient had half of the BTM removed due to infection and replaced with allograft. Patients treated with BTM had significantly less operative theatre time (median 1361.5 min [BTM] vs 1768 min [no BTM], P = 0.044). Number of operations, allograft use, hospital and ICU LOS, and blood product use were similar between groups. Adjusted models accounting for TBSA supported unadjusted models. ConclusionResource utilisation and clinical outcomes were similar in patients with at least 40 % TBSA treated with BTM and those who were treated with allograft before the introduction of BTM. Patients treated with BTM had significantly less total operative time and no difference in number of operations, allograft use and ICU LOS.

295 Topical Tranexamic Acid in Burn Surgery – A Randomized Controlled Trial

Abstract Introduction Early excision and grafting of large burn wounds can result in considerable bleeding. Systemic use of tranexamic acid (TXA) generally reduces surgical bleeding by 30-40%, but its safety in burn surgery has not been studied. Topical use may provide a sufficient wound concentration with negligible risk of systemic adverse events. However, it is unclear whether topical use may delay wound re-epithelialization. This pilot double-blinded randomized controlled trial aimed to evaluate the therapeutic potential of topical TXA for reducing blood loss and the effect on wound re-epithelialization in burn surgery. Methods Between Jan 2021 – April 2022, burn patients at a single national burn center who needed at least two separate donor sites for split-thickness skin grafting were included. In total, 36 wound pairs in similar anatomical areas were made in 23 patients. Donor sites were infiltrated with tumescence containing epinephrine before harvesting. Paired wounds were randomized to topical application of standard epinephrine solution, with or without added TXA 25 mg/ml, before coverage with vaseline and dry gauze. Endpoints were time to re-epithelialization and surrogate bleeding estimates defined as net weight gain of dressings per cm2 wound area, bloodstain area per wound area, and visual rating of the amount of blood in dressings on the first postoperative day. Results There was no difference in healing time between wounds. The results trended towards less increase in dressing weight gain per cm2 of wound area in the TXA group, though not significant (p=0.12). However, when dividing the results in two at the median bleeding volume, there was a significant reduction in bleeding in the high-bleed group (p=0.012). Similar observations were made for the other two bleeding endpoints, but the differences did not reach statistical significance. Conclusions Moistening a superficial wound surface with TXA 25 mg/ml does not impair wound re-epithelialization. Topical TXA may reduce bleeding from graft donor sites with low risk of systemic complications. Applicability of Research to Practice This pilot study suggests that topical TXA is of value in reducing bleeding in burn surgery without delaying donor site healing. The effect may be larger in wounds not prepared with epinephrine infiltration. More research is warranted regarding the optimal mode of topical drug delivery and systemic concentrations after topical application in burns. Furthermore, it remains to investigate whether topical TXA affects graft take.

Research progress on autologous vascularized graft bone implant repair for maxillofacial bone defect

Maxillofacial bone defect can seriously affect the patient's appearance, mastication, deglutition and speech function. At present, autologous bone grafting combined with implant repair is an effective method for reconstruction of maxillofacial bone defects. Due to the differences in density, nutrition, immunity and other aspects of bone graft at different donor sites, there may be a potential impact on implant repair. In this paper, the biological characteristics of vascularized autologous bone used in maxillofacial bone defect repair were reviewed, and the risk factors of implantation on the bone graft were discussed. It provides support for clinicians in the selection of bone graft donor site and the design of prosthesis.

Biological aspects to enhance fracture healing.

The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss. Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth. Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft. Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties. Recombinant bone morphogenetic proteins can provide an osteoinductive stimulus; however, their licencing is limited and larger studies are required to clarify their role. For recalcitricant non-unions or high-risk cases, the use of composite graft combining the above techniques provides the highest chances of successfully achieving bony union.

Quality and quantity of bone at intraoral graft donor sites in type 2 diabetic patients versus healthy controls: A cone-beam computed tomography study

Objectives: This study aimed to compare the quality and quantity of bone at intraoral autogenous graft donor sites in type II diabetes mellitus (DM) patients versus healthy controls using cone-beam computed tomography (CBCT). Materials and methods: This case-control study was conducted on CBCT scans of 50 DM patients and 50 healthy controls between 20-70 years. Maximum height, width, length, and volume of harvestable bone at the symphysis, ramus, palate, and tuberosity were measured bilaterally. The Hounsfield unit (HU) was also calculated to assess bone quality. The two groups were compared regarding the quality and quantity of harvestable bone using an independent t-test. The effect of confounders was analyzed by the regression model (alpha = 0.05). Results: DM patients had significantly lower harvestable bone volume at the symphysis, ramus, and tuberosity than healthy controls (p < 0.001) but this difference was not significant at the palate (p = 0.957). Also, bone quality was significantly lower at the symphysis, ramus, palate, and tuberosity in DM patients (p < 0.001). Conclusion: Diabetic patients had significantly lower bone quality and quantity at intraoral graft donor sites than healthy controls. Mandibular symphysis had higher bone volume and density than ramus, palate, and tuberosity for graft harvesting in diabetic patients.

Is the retroauricular region a suitable donor site for full-thickness skin grafting in the era of mask wearing?

During the coronavirus disease 2019 (COVID-19) pandemic, the everyday use of face masks massively increased to prevent the spread of infection. Many people complain of ear pain and erosion when wearing a mask for extended periods of time. If prolonged mask usage is uncomfortable for ordinary people, a question arises-how much more inconvenient must mask wearing be for patients with a full-thickness skin graft (FTSG) donor site in the retroauricular region? Herein, we evaluated complications related to face mask use in 27 patients with a retroauricular FTSG donor site, with the goal of clarifying whether the retroauricular region is still an appropriate FTSG donor site in the context of the COVID-19 pandemic. Complications in 27 patients treated by FTSGs harvested from the retroauricular region from 2019 to 2021 were investigated. A questionnaire comparing the normal and the operated sides was administered. Pain, itching, soreness, deformity, and symmetry were further investigated. Pain and itching were the only observed complications. The operated side was slightly more painful than the normal side in four patients (14.8%), and four patients (14.8%) reported itching on the operated side. However, all patients who experienced complications stated that the pain or itching did not interfere with mask wearing. Most symptomatic patients were older than 60 years of age (23.8%, p=0.185) and wore masks for longer periods of time (28.5%, p=0.326). Few retroauricular donor site-related complications occurred, and none of these complications caused inconvenience in daily life. Therefore, in the COVID-19 pandemic, the use of the retroauricular region as an FTSG donor site remains appropriate.

Effect of Nano Fat Graft on the Healing of Donor Site of Split Thickness Skin Graft

Effect of Nano Fat Graft on the Healing of Donor Site of Split Thickness Skin Graft

Three-Dimensional Evaluation of Autogenous Ramus Block Graft Donor Site and Its Relation to Mandibular Canal.

Sufficient bone volume is necessary for placing a dental implant in an ideal position. To restore severely insufficient bone volume, autogenous block graft procedures with various intraoral donor sites are presented in the literature. The aims of this retrospective study are to present the dimensions and volume of the potential ramus block graft site, and to evaluate possible effect of mandibular canal diameter and its position in relation to mandibular ramus block graft volume. Two-hundred cone-beam computed tomography (CBCT) images were evaluated. The maximum length, width, height, and volume of the potential ramus block graft site, mandibular canal diameter, mandibular canal-mandibular basis distance, and mandibular canal-crest distance were measured. Mandibular canal diameter, mandibular canal-crest distance, and mandibular canal-mandibular basis distance were 3.139 ± 0.446 mm, 15.376 ± 2.562, and 7.834 ± 1.285 mm, respectively. In addition, the dimensions of the potential ramus block graft sites were measured 11.156 ± 2.297 mm × 10.390 ± 3.420 mm × 8.816 ± 1.720 mm (height × length × width). Moreover, the potential ramus bone block volume was calculated as 1.076 ± 0.398 cm3. While a positive correlation was detected between mandibular canal-crest distance and the potential ramus block graft volume (r = .160, P = .025), a negative correlation was found between mandibular canal-mandibular basis distance and the potential ramus block graft volume (r = -.020, P = .001). Mandibular ramus is one of the predictable intraoral donor sites for bone augmentation procedures. However, ramus has some volumetric limitations related to its neighboring anatomic structures. It seems to be important to evaluate lower jaw in a 3-dimensional manner to prevent surgical complications.

Role for platelet rich plasma as an adjuvant therapy in wound healing and burns

Abstract Background Platelet rich plasma (PRP) contains high concentrations of growth factors. Intuitively, these were thought to be of potential benefit in healing of chronic wounds, skin grafts and graft donor sites. This was echoed in retrospective studies and an individual case basis but had not been randomized. Methods A systematic search was carried out by two individuals, independently, on the MEDLINE, EMBASE and COCHRANE databases, according to PRISMA guidelines. All data analysis and statistics was pooled and analysed using the Cochrane RevMan Software. Results Split thickness grafts have been described by numerous authors, but PRP use did not offer a significant advantage in graft take in pooled results (MD 5.83, 95% CI − 0.69 to 12.25, random-effects, p = 0.08). The analysis of included randomized controlled trials has shown favourable split-thickness skin graft donor site healing in the PRP group (MD − 5.55, 95% CI − 7.40 to − 3.69, random-effects, p = < 0.00001) compared to the control group. For carpal tunnel syndrome, the pooled results showed no difference in functional scores vs steroid injections (SMD − 0.68, 95% CI − 1.47 to 0.10, randomeffects, p = 0.09) or indeed splinting groups. Conclusions With the current body of evidence, we conclude that the use of PRP as an adjuvant therapy in skin grafts, burns, carpal tunnel surgery or scars cannot be rationalised. A potential use of PRP is in donor site management but the cost of this would be difficult to justify. Level of evidence: Not ratable.

Effect of autologous nano fat graft on the healing of donor site of split thickness graft.

Effect of autologous nano fat graft on the healing of donor site of split thickness graft.

Evaluation of amnion versus calcium alginate as split-thickness skin graft donor site dressing: A randomised controlled trial

Background: Split-thickness skin graft (STSG) covers patient’s primary wound, but, at the expense of a donor-wound which heals by secondary intention. This study evaluated the efficacy of amnion and calcium alginate dressings at STSG donor sites in terms of healing duration, patient comfort and incidence of infection.
 Patients and methods: An open label randomised control trial was conducted during October 2018 to May 2019. Total 60 patients, aged 20-45 years, were randomly allocated to two equal groups. Amnion was applied to 30 donor sites in Group A and calcium alginate in 30 donor sites in Group B. Patients were phone-called on 1st, 3rd and 7th post-operative days and donor site pain scored using numerical rating scale. Donor site was opened on 10th postoperative day and signs of infection assessed. Lastly, the day on which donor site healed, revealing an epithelialized wound, was noted.
 Results: Group A included 30 patients (11 females, 19 males) having mean age of 31.23 years and Group B included 30 patients (12 females, 11 males) having mean age of 31.30 years. Average pain scores on 1st, 3rd and 7th post-operative days were 7.6, 6.6 and 4.4 in Group A and it was 8.2, 6.5 and 4.4 in Group B. Two cases of amnion, 4 of calcium alginate got infected. Average healing duration was 11 days in Group A; and it was 14 days in Group B (p-value = 0.000).
 Conclusion: Amnion shows quicker healing and better pain control than calcium alginate.

A prospective dual-centre intra-individual controlled study for the treatment of burns comparing dermis graft with split-thickness skin auto-graft

To investigate if donor and recipient site morbidity (healing time and cosmesis) could be reduced by a novel, modified split-thickness skin grafting (STSG) technique using a dermal component in the STSG procedure (DG). The STSG technique has been used for 150 years in surgery with limited improvements. Its drawbacks are well known and relate to donor site morbidity and recipient site cosmetic shortcomings (especially mesh patterns, wound contracture, and scarring). The Dermal graft technique (DG) has emerged as an interesting alternative, which reduces donor site morbidity, increases graft yield, and has the potential to avoid the mesh procedure in the STSG procedure due to its elastic properties. A prospective, dual-centre, intra-individual controlled comparison study. Twenty-one patients received both an unmeshed dermis graft and a regular 1:1.5 meshed STSG. Aesthetic and scar assessments were done using The Patient and Observer Scar Assessment Scale (POSAS) and a Cutometer Dual MPA 580 on both donor and recipient sites. These were also examined histologically for remodelling and scar formation. Dermal graft donor sites and the STSG donor sites healed in 8 and 14 days, respectively (p < 0.005). Patient-reported POSAS showed better values for colour for all three measurements, i.e., 3, 6, and 12 months, and the observers rated both vascularity and pigmentation better on these occasions (p < 0.01). At the recipient site, (n = 21) the mesh patterns were avoided as the DG covered the donor site due to its elastic properties and rendered the meshing procedure unnecessary. Scar formation was seen at the dermal donor and recipient sites after 6 months as in the standard scar healing process. The dermis graft technique, besides potentially rendering a larger graft yield, reduced donor site morbidity, as it healed faster than the standard STSG. Due to its elastic properties, the DG procedure eliminated the meshing requirement (when compared to a 1:1.5 meshed STSG). This promising outcome presented for the DG technique needs to be further explored, especially regarding the elasticity of the dermal graft and its ability to reduce mesh patterns.Trial registration: ClinicalTrials.gov Identifier (NCT05189743) 12/01/2022.

Role of Cyclic Negative Pressure Wound Therapy in Thermal Burns

Thermal Burns are a major cause of morbidity. They cause both time and financial burdens on the patient and caregiver. Over the years, there has been drastic improvement in modalities used in the treatment of Thermal Burns. The recent treatment options include the use of negative pressure wound therapy. We would like to share our experience in the management of Thermal burns with Cyclic NPWT. A common treatment for both acute and chronic wounds is negative pressure wound therapy. NPWT is recommended for a range of difficult wounds, and certain research supports its usage in specific burn care procedures. Even though more study is required to fully understand the advantages for burns, NPWT has shown promise as a dressing that supports skin grafts, encourages the integration of bilaminate dermal substitutes, encourages the re-epithelialization of skin graft donor sites, and may even lessen the zone of stasis. Based on indication/application, this article analyses the literature on NPWT in burns and discusses our experience with modified NPWT for major burns.

Longitudinal Evaluation of Biomarkers in Wound Fluids from Venous Leg Ulcers and Split-thickness Skin Graft Donor Site Wounds Treated with a Protease-modulating Wound Dressing.

Venous leg ulcers represent a clinical challenge and impair the quality of life of patients. This study examines impaired wound healing in venous leg ulcers at the molecular level. Protein expression patterns for biomarkers were analysed in venous leg ulcer wound fluids from 57 patients treated with a protease-modulating polyacrylate wound dressing for 12 weeks, and compared with exudates from 10 acute split-thickness wounds. Wound healing improved in the venous leg ulcer wounds: 61.4% of the 57 patients with venous leg ulcer achieved a relative wound area reduction of ≥ 40%, and 50.9% of the total 57 patients achieved a relative wound area reduction of ≥ 60%. Within the first 14 days, abundances of S100A8, S100A9, neutrophil elastase, matrix metalloproteinase-2, and fibronectin in venous leg ulcer exudates decreased significantly and remained stable, yet higher than in acute wounds. Interleukin-1β, tumour necrosis factor alpha, and matrix metalloproteinase-9 abundance ranges were similar in venous leg ulcers and acute wound fluids. Collagen (I) α1 abundance was higher in venous leg ulcer wound fluids and was not significantly regulated. Overall, significant biomarker changes occurred in the first 14 days before a clinically robust healing response in the venous leg ulcer cohort.

Role of topical application of aloe vera for accelerated wound healing of cutaneous burns wound: A case report

Abstract Background: Aloe vera is a cactus plant that thrives in warm areas. Since ancient times, it has been used to treat acute wounds. However, the efficacy of aloe vera for burns and split-thickness skin graft (STSG) donor sites is inconclusive. Materials and Methods: In this study, we have applied pure aloe vera gel extract as an adjunct to dressing second-degree (superficial) burn wounds and assessed the time for complete epithelization Results: The time taken for complete epithelization of the wound was 11 days when compared to the normal (evidence-based) time of 14 days.