Mesh Graft Transplantation Research Articles

Diagnosis and Treatment of Postthrombotic Syndrome.

After acute treatment of deep vein thrombosis, not only the risk but also associated side effects of postthrombotic syndrome (PTS) are often underestimated.There are essentially two main types of PTS.1. Obstructive type-no sufficient recanalization of the deep vein.2. Refluctive type-sufficient recanalization of the deep vein, but insufficient venous valves in conjunction with venous reflux.A statement regarding deep vein recanalization and venous valve function can be made at the earliest after 6 months.PTS is often diagnosed without appropriate medical history. However, the assessment of the degree of recanalization and venous reflux is paramount to the medical prognosis. In our opinion, beside proximal thrombosis, sufficient recanalization combined with a strong venous reflux, especially in the popliteal vein, works as a powerful predictor for an unfavorable and fast progression of PTS and chronic venous insufficiency. Thus, the obstructive type is prognostically more favorable. For PTS in general, consistent compression therapy represents the first-line treatment option.With concomitant varicosis, one should assess whether the varicose veins represent primary varicosis with reflux or secondary varicosis without reflux. Especially in the presence of venous ulcers, the elimination of concomitant primary varicosis leads to an improved prognosis. Moist wound treatment is considered to be the standard treatment for all wounds undergoing secondary healing. A standardized set of topical therapeutic agents also facilitates the treatment. In individual cases "ulcershaving" and mesh graft transplantation proved to be successful.

Management of a severe soft-tissue infection after varicose vein surgery despite peripheral arterial occlusive disease

SummaryWe describe a 65-year-old male with severe soft tissue infection of both lower legs. He had infected ulcer after stripping of small saphenous vein in tumescent anaesthesia and excision of side branches, and was referred from a foreign clinic. Intraarterial angiography of the pelvic and legs vessels showed severe stenosis in the left deep femoral artery and a tandem stenosis of superficial artery. A hybrid procedure with intraoperative percutaneus angioplasty combined with femoral xenogenic patch as well as local wound treatment with negative pressure wound therapy and subsequent mesh graft transplantation were carried out. We observed complete healing of ulcers within four weeks.

Acne inversa (Hidradenitis suppurativa): A review with a focus on pathogenesis and treatment

Acne inversa (AI) is a disabilitating chronic inflammatory disease with major negative impact on quality of life and significant co-morbidities. This is an important link to insights into immune dysfunction, which stimulated therapeutic approaches like tumor necrosis-α inhibitor therapy. This new off-label drug treatment is particularly beneficial when used in combination with wide excision of inflamed skin and subcutaneous tissue. Retinoids have been reported to be helpful in secondary prevention. The standard of therapy in advanced cases is surgery with wide excisions and healing by secondary intention. This treatment results in significant reduction of complaints and achieves satisfactory body contouring.

Pyoderma gangraenosum als Major-Komplikation bei einer Brustrekonstruktion mit freier Doppel-DIEP-Lappenplastik

Pyoderma gangraenosum (PG) as an idiopathic, ulcerative inflammatory skin disease with varying clinical pictures has an estimated incidence of 0.3/100,000 and is due to the non-specific histology primarily a clinical exclusion diagnosis. The rapid progression, as well as the often fatal course of the pathergy phenomenon after surgical intervention is a therapeutic challenge. With the example of the complicated course of a 47-year-old patient with free DIEP flap for bilateral breast reconstruction due to PG, we want to direct attention to this often underrated disease. For bilateral breast reconstruction, a 47-year-old patient received a double free DIEP flap, which had to be resected on the right due to multiple arterial thromboses. The clinical presumptive diagnosis of a PG arose and an IV steroid therapy was started immediately. After 13 days a further debridement and mesh graft transplantation were performed. Now, the histological examination was for the first time compatible with PG. Under the initiated steroid treatment the wounds could be stabilised and the remaining defects could be covered. After 6-week stay, the patient was finally discharged with healed wound conditions, but an unsatisfactory aesthetic result. If unclear, rapidly progressive ulcers occur in surgical interventions one should always think of pyoderma gangraenosum. In particular, since a surgical intervention can result in an uncontrolled exacerbation due to the pathergy phenomenon. Laboratory parameters and histology are not specific. Under a systemic immunomodulatory therapy, a sequential surgical wound management may accelerate wound healing.

Insufficient and Incomplete Shaving in Chronic Venous Leg Ulcers Leads to a Poor Prognosis of the Skin Graft: A Histomorphological Analysis

Background: The surgical treatment for therapy-resistant venous leg ulcers is shave therapy with mesh graft transplantation. Objective: To demonstrate the need of complete shaving with help of histomorphological criteria. Methods: Biopsies were taken from the bottom and the border of the 28 ulcers and from nonulcer skin nearby. Specimens were analyzed in correlation to the clinical course 6 months after the treatment (healed/nonhealed/recurrent). Results: 10 ulcers healed, 10 were recurrent and 8 nonhealed. Nonhealed ulcers had an increased broadening of collagen fibers and rete ridges and reduced elastic fibers at the border of the ulcer. Significantly more obliterated vessels were in the upper dermis at the border of the nonhealed ulcers. Recurrent ulcers showed more signs of dermatoliposclerosis. Conclusion: In nonhealed and recurrent ulcers histomorphological aspects of dermatoliposclerosis are still detectable. Thus, a more extensive fibrosis seems to be associated with a poorer outcome. The hypothesis that possibly a more aggressive shave therapy can increase the healing rate should be verified in a prospective study.

Use of a collagen–elastin matrix for hard to treat soft tissue defects

As deep soft tissue defects with exposed bone, cartilage or tendons are not suitable for wound closure with skin mesh grafts, other techniques are needed. We report on six patients, one female and five males, aged between 32 and 89 years, and deep soft tissue defects with exposed tendons, cartilage or bone. The aetiology of these defects was vascular (n = 3), tumour surgery (2), and post-traumatic (1). Wounds were treated with a collagen-elastin matrix applied above the exposed structures. In five patients, the procedure was combined with mesh graft transplantation in the same setting. Follow-up varied between 12 and 40 weeks. Wound healing was uncomplicated in all transplanted patients until first dressing change after 7 days. All but one transplant showed a 100% take rate and the transplant was stable within 10-14 days. A complete wound closure was also achieved without transplantation, but this took 8 weeks. No adverse effects were noted. There was no skin contracture of the skin grafts. Collagen-elastin matrix with split-thickness skin grafts is a useful tool in deep soft tissue. The time to heal can be reduced.

Salmonella Arizonae– ein seltener Erreger einer Wundinfektion

SALMONELLA (S.) ARIZONAE is an emerging pathogen which has been described in the last years more frequently. It is a cause of enteritis, in rare cases this bacterium is responsible for extraintestinal infections, too. A 74 year old male patient suffered from a squamous cell carcinoma of the skin at the right lower leg. After excision and meshgraft transplantation for covering the defect a wound infection developed. Both STAPHYLOCOCCUS AUREUS and S. ARIZONAE could be detected. The patient was treated successfully by ciprofloxacin. A new meshgraft transplantation was performed, and wound healing was achieved without any further complications. The origin of the S. ARIZONAE strain could not be explained. However, this SALMONELLA subspecies occurs mainly in reptiles and amphibians. A transfer to pet holders and other contact persons is possible and is increasingly described.

Atypical fibroxanthoma: a series of 25 cases

Atypical fibroxanthoma is a rare mesenchymal tumour of skin that develops on skin of elderly patients. We analysed our patients with atypical fibroxanthoma over the last 8 years. We analysed the pathology files of our hospital for the period 2001-2009. In all cases, histology and immunohistology were performed. Data on co-morbidities, treatment and outcome were obtained. We identified 25 patients (except two female patients, the rest were men) aged 52-95 years (mean: 79.5 years; standard deviation +/- 9.06 years). All tumours were localized in the head and neck region, except a single tumour on the shoulder. Fourteen patients had a cancer history, six had actinic keratoses or Bowen's disease (n = 1). Five patients had cardiac surgery or pacemaker, one each had a renal transplant, systemic sarcoidosis or non-Hodgkin's lymphoma. Medical history was positive for radiotherapy or chemotherapy in four patients. Histology showed a spindle-shaped dermal and subcutaneous tumour growth intermingled with multinucleated giant cells. The phenotype of tumour cells was vimentin-positive, but S100- and keratin-negative. Some tumours showed a focal expression of CD68. Complete microhistographic controlled surgery ('Mohs like') was possible in all cases followed by mesh-graft transplantation in three patients. Eighteen patients showed a complete remission. Four patients had a relapse within 2 years of follow-up treated by surgery. One patient is still under radiotherapy. All patients with a safety margin of 2 cm had no recurrence or relapse during follow-up. Micrographic controlled surgery with wide 2 cm safety margins is the treatment of choice. A regular follow-up for the next 5 years is recommended.

The Nitric acid burn trauma of the skin

Nitric acid burn traumata often occur in the chemical industry. A few publications addressing this topic can be found in the medical database, and there are no reports about these traumata in children. A total of 24 patients, average 16.6 years of age, suffering from nitric acid traumata were treated. Wound with I degrees burns received open therapy with panthenol-containing creams. Wound of II degrees and higher were initially treated by irrigation with sterile isotonic saline solution and then by covering with silver-sulphadiazine dressing. Treatment was changed on the second day to fluid-absorbent foam bandages for superficial wounds (up to IIa degrees depth) and occlusive, antiseptic moist bandages in combination with enzymatic substances for IIb degrees -III degrees burns. After the delayed demarcation, necrectomy and mesh-graft transplantation were performed. All wounds healed adequately. Chemical burn traumata with nitric acid lead to specific yellow- to brown-stained wounds with slower accumulation of eschar and slower demarcation compared with thermal burns. Remaining wound eschar induced no systemic inflammation reaction. After demarcation, skin transplantation can be performed on the wounds, as is commonly done. The distinguishing feature of nitric-acid-induced chemical burns is the difficulty in differentiation and classification of burn depth. An immediate lavage should be followed by silver sulphadiazine treatment. Thereafter, fluid-absorbent foam bandages or occlusive, antiseptic moist bandages should be used according to the burn depth. Slow demarcation caused a delay in performing surgical treatments.

Vakuumtherapie bei tiefem Wundinfekt nach Achillessehnenrekonstruktion

Vacuum therapy is a valuable option for wound healing complications. After reconstruction of the ruptured achilles tendon, deep wound infections are difficult to handle due to impaired circulation of the bradytrophic tissue which leads to infection and a protracted healing process. Consecutive necrosis of the achilles tendon results in a poor clinical outcome. We could prove that vacuum therapy is the method of choice for wound healing complications in this delicate area. We treated 5 patients with deep wound infection and exposed achilles tendon after reconstruction. In all cases we achieved complete closure. The function of the achilles tendon was not impaired. Sonography confirmed the integrity of the tendon in all cases. Duration of therapy was 8.4 days for inpatient treatment and 64.4 days overall. 3 patients received a mesh-graft transplantation after wound ground preconditioning with vacuum therapy, all others achieved complete restoration with vacuum only. Vacuum therapy is a valuable option for the treatment of infected achilles tendon after surgical repair. After wound ground conditioning, it can protect mesh-graft transplants in this delicate area even in non-compliant patients.

Dystrophic Calcification in Chronic Leg Ulcers—A Clinicopathologic Study

Dystrophic calcification (DC) is a risk factor for conservative treatment failure in chronic leg ulcers of various pathologies. We performed a retrospective noncontrolled trial of 212 patients with 362 chronic leg ulcers who underwent ulcer shave excision with subsequent skin grafting. The ulcers existed for at least 3 months, and no healing was achieved with good ulcer care. Tissue was subjected to histopathology (hematoxylin-eosin and van Kossa stains). DC was evident in 39 patients (18%). Metaplastic subcutaneous bone formation was observed in 15 patients (7%). Clinical symptoms associated with DC were resistance to good ulcer care, pain, and ineffective effects of compression therapy (in venous ulcers). Ulcers were treated with deep dermatome shaving of the ulcer bed and surgical removal of DC. In the same setting, defects were closed using mesh graft transplantation. The procedure achieved a complete take rate in 80% and a significant decrease of pain in 95% of cases. When comparing the take rates in patients with and without DC, DC had a negative effect on outcome (take rate: 91% without DC vs 80% with DC, p<.05). DC is resistant to conservative treatment. The first-line treatment is deep ulcer dermatome shaving and complete removal of calcifications whenever possible.

Multiple giant scalp metastases of a follicular thyroid carcinoma

BackgroundThe occurrence of skin metastases are rare events in the course of a follicular thyroid carcinoma (FTC) and usually indicate advanced tumor stages. The scalp is the most affected area of these metastases.Case presentationWe present a case of a 76 year old Woman with multiple giant scalp metastases of a follicular carcinoma. These metastases had been resected and wounds had been closed with mesh graft. The 14-months follow up is presented.ConclusionWe demonstrate another case with multicentric form. Because of its location and size a primary wound closure was not possible. A healing could be reached using vacuum therapy and mesh graft transplantation.

Painful ANA-Positive Scleroderma-Like Disease With Acral Ulcerations: A Case of Chronic Gangrenous Ergotism

Chronic ergotism is a rare cause of limb ischemia. In this case report, the authors present a 62-year-old woman with history of long-term use of ergotamine alkaloids for the treatment of menstrual pain, who developed a severe painful disease initially misdiagnosed as systemic sclerosis (scleroderma) for 3 decades. She presented with a combination of acral gangrene, foot ulcer, renal obstruction, mild pulmonary fibrosis, and reduced esophageal motility. Right-sided renal obstruction was evident. The condition was extremely painful and had led to muscular contractions and immobility, drug abuse, and anemia. After establishing the diagnosis of chronic gangrenous ergotism, changing drug therapy, mobilization, and treatment of chronic wounds, she showed a remarkable recovery. Eventually the foot ulcer was closed successfully using a mesh graft transplantation, and the patient was able to walk alone. Chronic ergotism is rare but has to be taken into account when presented with painful chronic digital and foot ulcers.

3-Dimensionale Verlaufsdokumentation von Wundheilung

The objective evaluation of the course of wound-healing represents a substantial parameter for the quality assurance of a modern wound management in chronic wounds. Established procedures exclusively based on a two-dimensional measurement of the wound surface with planimetry or digital photo documentation in combination with a metric statement of size. Thus so far an objective method is missing for the evaluation of the volumes of chronic wounds. By the linkage of digital photography, optical grid by means of digital scanner and an image processing software in co-operation with the company RSI we were able to do an accurate 3-dimensional documentation of chronic wounds (DigiSkin). The generated scatter-plots allow a visual, computer-assisted 3-dimensional measurement and documentation of chronic wounds. In comparison with available systems it is now possible for the first time to objectify the volume changes of a chronic wound. On the basis of a case report of a female patient with an venous leg ulcer, which has been treated with a vacuum closure therapy before and after performing a mesh-graft transplantation, we would like to describe the advantages and the resulting scientific use of this new, objective wound documentation system in the clinical employment.

Die V.A.C.®-Therapie als Behandlungsoption von Wundheilungsstörungen nach Achillessehnenrekonstruktion

The postoperative course after Achilles tendon reconstruction is associated with a high incidence rate of infections and wound healing complications, which can lead to protracted healing process and, hence, limit the clinical outcome. PATIENT-METHODS: A 66-year-old male was referred to our clinic with an Achilles tendon rupture. MRI confirmed the diagnosis, an augmented tenoplasty was performed for tendon reconstruction. 11 weeks after surgery the patient presented himself again with an open wound and local infection signs. The surgical treatment included debridement and jet lavage. The V.A.C.-device with the white polyvinyl sponge at an initial pressure of 200 mm Hg was used. A pathogen organism could not be identified. For infection eradication a broad spectrum systemic antibiosis (cefuroxime and gentamicin) was applied. On 3., 6. and 14. day the dressings were changed and the wound was revised under progredient closure. At beginning formation of granulation tissue the pressure was reduced to 150-100 mm Hg. At decreasing blood inflammation parameters and amelioration of the local wound condition the patient could check out after 3 weeks hospitalization. After further successful ambulant management by means of the V.A.C.-therapy a meshgraft transplantation was performed (enlargement factor 1.5; layer thickness 0.3 mm). The V.A.C.-device was applied again at a pressure of 150 mm Hg with a single dressing change after 5 days. At a follow-up of 31 months no further complications occurred. The V.A.C.-therapy seems to be a valuable tool in the treatment of wounds with a critical local vascularity. After successful wound preconditioning the healing process of skin grafts transplants can be also optimised by means of the V.A.C.-device.

Letters to the Editors

Dear Editors In the recent issue of the International Wound Journal Enoch et al. provided an excellent overview on calcification of tissue with particular emphasis on dystrophic calcification and of ossification in leg ulcers (1). Dystrophic calcification was defined as calcification due to local tissue injury and/or a persisting local abnormality such as a wound. Three case reports and a review on literature were given. One of the author's conclusions was that surgical removal of calcium deposits is of limited value. Our experience at the Department of Dermatology, Hospital Dresden-Friedrichstadt is somewhat different. Our department is one of the units that work together in the Vascular Centre together with the Department of Vascular Surgery and the Department of Angiology of the Internal Medicine Branch. We perform about 200 leg ulcer surgeries per year, mostly with subsequent skin grafting. In about 50% of the longstanding venous and mixed arterio-venous leg ulcers we found different degrees of dystrophic calcification from mild symptoms mostly evident in histopathology to the extensive formation of scar bones. In our department the procedure of choice is the removal of dystrophic calcification during the ulcer shaving procedure. We prefer the deep shaving in general anaesthesia mostly with a single shot intravenous antibiosis in the operation theatre. Calcification may involve all tissue layers from subcutaneous dermal to subcutaneous fat tissue and even the muscle fascia. In stage IV of the venous compression syndrome according to Hach (2), fascia involvement is common. In such cases, the deposits have to be removed with forceps and a curved scissor. Shaving alone is not sufficient under these circumstances. After careful treatment of bleeding the defect is usually closed by mesh graft transplantation. In our hands the procedure leads to complete ulcer healing in more than 80% of cases and to a significant relief from pain. This is in accordance with some other authors 3-5). Recurrence can be seen if there is another or an additional cause different from the chronic wound alone, e.g. renal disease. Ulcer surgery has to be completed by phlebosurgery to ensure good long-term results. This is done by an interdisciplinary approach.

Neurovaskuläre Lappenplastiken zum Verschluss problematischer Weichteildefekte am Unterschenkel

Soft tissue covering on the lower leg is a difficult challenge. A plastic surgical method for covering of these soft tissue defects is presented. From May 1997 until May 2003 36 patients were treated using neurovascular flaps. Above the sural or the saphenous nerve an adipo-facial flap is dissected, rotated into the defect and fixed without tension. Wound closure of the donor-site defect is done primarily or by mesh-graft. In 35 cases the flap healed without functional impairment. Primary healing was achieved in 30 patients. In 5 cases partial loss of the skin island was registered, whereby subcutaneous tissue remained vital. Revision by mesh-graft transplantation led to successful healing in these patients. In only one patient necrosis of the flap was seen. Neurovascular flaps usually result in reliable and complete healing of soft tissue defects of the lower extremity.

Vacuum-sealed mesh graft transplantation in chronic cutaneous ulcers of the lower leg.

The covering of defects caused by chronic ulcers on limbs affected by peripheral arterial disease or chronic venous insufficiency is often difficult due to extensive secretion and edema, while chronic bacterial contamination of the wound bed further compromises the conditions for successful healing. Vacuum-sealed dressing (VSD) offers the option of a closed dressing system for moist wound care that assures firm contact with the wound surface and protection against contamination with nosocomial microbes and decontamination of existing bacteria by means of constant drainage of secretion independent of gravity. VSD is particularly useful in difficult wounds featuring extensive secretion and unfavorable localization and offers many advantages over conventional dressing techniques in terms of improved healing of skin transplants. A total of 35 patients with chronic leg ulcers were treated with vacuum-sealed mesh graft transplantation. Complete healing of the mesh graft transplant was observed in 20 patients (57%). Twelve patients (34%) experienced partial healing (75-90%) of the transplant, while three patients exhibited less than 75% healing of the graft and therefore required a second mesh graft transplantation. VSD is a simple, quick and inexpensive technique that promotes excellent healing of skin transplants. It is particularly useful in difficult wounds with extensive secretion and/or contamination or infection.

Chronische Ulcera crurum mit Fasziensklerose - Erfolgreiche Behandlung durch krurale Fasziektomie -

Wir berichten über zwei Patienten mit Ulcera crurum, die seit 4 beziehungsweise mehr als 50 Jahren kontinuierlich bestanden und bei denen kernspintomographisch jeweils eine ausgeprägte Fasziensklerose gesichert wurde. Nach vorausgegangenen wiederholten konservativen und operativen frustranen Therapieversuchen wurde bei beiden Patienten eine Dermatolipofasziektomie vorgenommen und der Gewebedefekt am Unterschenkel anschließend mittels Mesh-graft-Transplantat gedeckt. Dies führte innerhalb von 6 Wochen in beiden Fällen zur anhaltenden Abheilung der Ulzera. Die Kasuistiken verdeutlichen, dass sich eine wirkungsvolle chirurgische Therapie chronischer und therapierefraktärer Ulcera crurum bei chronisch-venöser Insuffizienz mit begleitender Sklerose der Fascia cruris nicht nur auf die Sanierung der insuffizienten Venen beschränken darf, sondern die krurale Fasziektomie inklusive Entfernung der Dermatoliposklerose als wesentliches Moment der Beseitigung eines lokalen, hämodynamisch adversen Kompressionssyndroms letztlich unverzichtbar ist.

Therapy possibilities for locoregional recurrences in breast cancer

In 10–30 % of cases, locoregional recurrence is accompanied by distant metastasis; a further 25 % develop distant metastasis within the year after diagnosis of recurrence. In treatment of recurrent tumor in the thoracic wall, axillary or supraclavicular disease surgery plays a major role. Since – another long-lasting courses occur even in the metastatic situation, recurrence is not an infrequent event, and therapy then needs a multidisciplinary approach. Surgical techniques such as local, myocutaneous or omental flaps and mesh graft transplantation are used to cover large defects after tumor resection. Additional and innovative modalities are combined in the management of this complex problem: locoregional or systemic chemotherapy, topical application of chemotherapy, certain radiation regimens and in otherwise resistant tumors the experimental use of photodynamic laser therapy (PDT). The most important goal hereby is to restore or at least maintain organ function and quality of life.