Meshed Split-thickness Skin Graft Research Articles

A comparative analysis of advanced techniques for skin reconstruction with autologous keratinocyte culture in severely burned children: own experience.

IntroductionThe local treatment in burns larger than 50% of total body surface area is still the great challenge for surgeons.AimThis paper presents a review of different solutions for deep burn wound healing in children and the early outcomes of treatment with combined autologous cell culture technique.Material and methodsFor this study, 20 children aged between 4 and 12 years with 55–65% of TBSA III grade burn injury were analyzed. A skin sample, 1 cm × 1 cm in size, for keratinocyte cultivation, was taken on the day of the burn. After necrotic tissue excision, the covering of the burned area with an isolated meshed skin graft was carried out between day 4 and 7. After 7 days of keratinocyte cultivation, the mentioned areas were covered with cells from the culture. We divided the burned regions, according to the way of wound closure, into 3 groups each consisting of 15 treated regions of the body. We used meshed split thickness skin grafts (SSG group), cultured autologous keratinocytes (CAC group), and both techniques applied in one stage (SSG + CAC group).ResultsIn the SSG group, the mean time for complete closure of wounds was 12.7 days. Wounds treated with CAC only needed a non-significantly longer time to heal – 14.2 days (p = 0.056) when compared to SSG. The shortest time to heal was observed in the group treated with SSG + CAC – 8.5 days, and it was significantly shorter when compared to the SSG and CAC groups (p < 0.001).ConclusionsThis study suggests that cultured keratinocytes obtained after short-time multiplication, combined with meshed autologous split thickness skin grafts, constitute the optimal wound closure in burned children.

Technical Note on Vacuum Assisted Closure-Basket Fixation of Scrotal Skin Grafts

With great interest, we have read the publication Vacuum Assisted Closure (VAC)-Basket for Easy Fixation of Scrotal Skin Grafts by Huettinger et al. [1]. The authors describe their experience with a self-constructed vacuum-assisted closure basket for fixation of split-thickness skin grafts in the urogenital area for defect coverage after Fournier's gangrene. We would to congratulate the authors for their superior result in the case reported. At our institution, we have long-standing experience in the treatment of defects of the noted area after both traumatic and infectious tissue loss, as we serve as a tertiary referral center providing care for the whole of Western Austria and Northern Italy. In our experience, we feel that following Gillies' principle of reconstructing with like [2] in selected minor scrotal defects such as the one depicted by Huettinger et al. [1], a bilateral thigh lift with permanent fixation sutures to the pubic branches can yield excellent functional and aesthetic results [3]. In case of more extensive defects involving both scrotal and perineal skin loss, we favor split thickness skin grafts for defect coverage. As noted by Huettinger et al. [1], graft fixation remains a challenge. We have developed a VAC fixation technique, the so-called sandwich technique [4], that we have used successfully for many years now. We feel that it is well worth sharing with the reader, given its ease of application and superior outcome. We would to present an illustrative case: A 47-year-old male was referred to our institution after debridement in the scrotal and perineal area for treatment of Fournie's gangrene in another hospital (Fig. 1). Defect coverage was carried out using bilateral gracilis muscle flaps rotated by 180 degrees around their proximal pedicles. Immediate coverage of the muscle flaps was performed by split-thickness skin grafts (Fig. 2), which were fixed immediately by the aforementioned sandwich technique (Figs. 3, ​,4).4). The final outcome 3 months postoperatively is shown in Fig. 5. Fig. 1 The patient presented with scrotal and perineal tissue loss after debridement of dead tissue following Fournier's gangrene. Fig. 2 Defect coverage was carried out using bilateral gracilis muscle flaps rotated by 180 degrees around their proximal pedicles. Coverage of the muscle flaps was performed by meshed split-thickness skin grafts. Fig. 3 Split-thickness skin grafts were fixed immediately by the sandwich technique. Fig. 4 Appearance of the urogenital region after application of the vacuum-assisted wound dressing. Fig. 5 Final appearance of the urogenital region after 3 months. We agree with Huettinger et al. [1] that VAC fixation in the perineal area provides all-important factors for excellent graft take. With our alternative fixation method, the risk of shearing and tearing forces on the grafts leading to graft loss may be minimized. Our clinical results support this finding.

A Modified Free Muscle Transfer Technique to Effectively Treat Chronic and Persistent Calcaneal Osteomyelitis

Successful management of chronic calcaneal osteomyelitis presents a major challenge for the plastic and reconstructive surgeon, especially in cases involving soft-tissue defects. This article describes a modified free muscle transfer technique to effectively eradicate chronic and persistent calcaneal osteomyelitis. Between February 2009 and September 2009, 3 male patients with persistent calcaneal osteomyelitis were treated in our clinic. All 3 had purulent drainage for a minimum of 6 months and a maximum of 23 years. Multiple surgical debridements and vacuum-assisted closure had been used in the past, but the infection remained. We used a therapeutic protocol of repeated and radical surgical debridement with removal of nearly all cancellous bone and preservation of the cortical shell of the calcaneus. After the final debridement, the bone cavity was plugged by a free gracilis muscle flap from the contralateral side. A meshed split thickness skin graft was applied. Culture-specific antibiotics were administered for 2 weeks. All flaps healed uneventfully except for a minor hematoma that was treated conservatively. All 3 patients were able to return to ambulatory status with regular foot apparel. At last follow-up evaluation, they had no clinical, laboratory, or radiologic signs of osteomyelitis. This modified free muscle transfer technique seems to be successful in managing chronic and persistent calcaneal osteomyelitis. Infected and healthy cancellous bone of the calcaneus is removed to eradicate all possible foci that maintain inflammation. The resulting bony defect after the aggressive surgical debridement is sufficiently filled with a well-vascularized muscle that ensures a good wound healing. We consider this method to be a promising treatment option, which needs to be supported by further cases.

Quality evaluation of meshed split-thickness skin grafts stored at 4 °C in isotonic solutions and nutrient media by cell cultures

ObjectiveExcess split-skin autografts harvested and meshed during burn surgery are often stored at 4°C temporarily for later use. The quality of the stored skin is critical to clinical outcome and needs to be assured. MethodsMeshed split-thickness skin graft (mSSG) stored in saline, Hartmann's solution and two cell culture media, Dulbecco's Modified Eagle Medium (DMEM) and DMEM/Ham F12 (DMEM/F12, 3:1 mixture) were analyzed by trypan blue staining, cell culture and microbiological testing through a 28-day time course for cell viability and microbial contamination. ResultsmSSG samples in all groups showed a progressive decrease of cell viability and colony forming efficiency through the time course of storage at 4°C. Cell culture media were better than saline and Hartmann's solution in maintaining the viability and growth capability of skin cells. The viability observed by trypan blue staining did not truly reflect the cell growth capacity after storage. mSSG in saline and Hartman's solution retained minimal keratinocyte growth potency after 7 days. mSSG in cell culture media had significant loss of keratinocyte colony growth potency after 7 days and minimal keratinocyte growth after 14 days. Dermal fibroblasts of all groups were less tolerant than keratinocytes to the storage. Microbial contaminations were common in mSSG harvested from burn surgery. ConclusionsCulture media instead of saline or Hartman's solution should be used for temporary storage of mSSG at 4°C. The stored mSSS should be used within seven days to have sufficient viable number and cell growth efficiency. After then, the efficacy of stored mSSG as a source of living cells for wound closure could be full of uncertainty due to significant decrease of keratinocyte colony forming efficiency. Precaution should be taken during skin harvest and storage to minimize the risk of sample contamination. Inclusion of antimicrobial agents in storage solution and microbiological testing are advisable to ensure the quality and clinical outcome.

Exploration of Nonsurgical Scar Modification Options

The purpose of this study was to determine, in principle, whether microdermabrasion can alter waffle-pattern (meshed split-thickness skin graft) burn scars after scar maturation. Matured waffle-pattern mesh-graft scars were treated with multiple microdermabrasion sessions over the course of a year (maximum 20). Before and after treatment, the treated scars and the control scar on the same patient were assessed with subjective and objective scar assessment tools (scar scales, cutometer [elasticity], laser Doppler flowmeter [vascularity], Semmes-Weinstein filaments [sensation], and high-resolution ultrasound [thickness]). The treatment resulted in continuous improvement of some physiologic skin functions like perfusion response (feedback), thickness, and elasticity when compared with nontreated scar, although no statistical significance was reached. Both Vancouver scar scale and patient assessment scales showed significant improvement. The study showed that even mature waffle pattern scars can be modified by minimally invasive interventions. Larger study groups and more economic treatment modalities need to be studied in the future.

Comparison of healing parameters of full thickness wounds transplanted with micrografts, spit thickness skin grafts or cultured keratinocytes

INTRODUCTION: Transplantation of split-thickness skin grafts, culturedautologouskeratinocytesandskinmicrograftsresultinhealing of full-thickness wounds. This study compares these methods in a porcine wound model, investigating the utility of micrograft transplantation in skin restoration. METHODS: Full-thickness wounds were created on Yorkshire pigs and assigned to one of the following treatment groups: meshed splitthickness skin graft (STSG), cultured autologous keratinocytes (CK), skin micrografts (MG), wet environment (W) and dry environment (D). Dry wounds were covered with gauze and the other groups were enclosed in a polyurethane chamber containing 2 mL of saline. Samples were taken 6, 12 and 18 days post wounding. Macroscopic wound healing was quantified using the Vancouver Scar Scale (VSS). Wound healing parameters such as contraction, reepithelialization, epidermal characteristics and scar formation was determined by quantitative morphometric or morphologic analysis. RESULTS: Grafted wounds had a lower VSS score compared to non-grafted wounds (STSG:4, CK:6, MG:3, W:8.5, D:10, unwounded skin:0). Wounds grafted with STSG and MG showed significantly reduced contraction compared to non-grafted wounds (STSG:25%, CK:35%, MG:28%, W:43%, D:44%). All grafted wounds showed increased epidermal healing compared to nongrafted wounds. Furthermore, transplantation with STSG or MG led to less scar tissue formation compared to the non-grafted wounds andnosignificantimpactonscarformationwasobservedaftertransplantation of CK.

Use of a Retrograde Pedicled Double-Barreled Osteocutaneous Fibula Flap for Reconstruction of Distal Tibia and Soft-Tissue Defects

Sir: After trauma or oncologic surgery, distal lower extremity reconstruction is often challenging. Although microsurgery allows composite transfer of bone, muscle, and skin, free tissue transfer to the lower extremity is marred by high failure rates.1 Traditionally, free osteocutaneous fibula flaps have been the workhorse flaps for reconstructing dual bone and soft-tissue defects.2,3 In 1986, Chen et al. described a pedicled, osteocutaneous fibula flap for distal femur reconstruction.4 Later, Minami et al. described the retrograde fibula flap based on communicating branches between the peroneal and posterior tibial vessels for reconstruction of distal tibia defects.5 To our knowledge, no retrograde, pedicled fibula flap has been harvested with an overlying soft-tissue component supplied by underlying peroneal septocutaneous perforators. Such a skin paddle allows reconstruction of accompanying soft-tissue defects and serves as a marker for total flap viability. Furthermore, cutaneous harvest has not been reported in a retrograde, pedicled fibula flap in which the fibula is osteotomized. A patient suffered an open tibia-fibula fracture complicated by osteomyelitis and nonunion. After débridement, she had a 7-cm distal tibia and soft-tissue defect (Fig. 1). We used a retrograde, pedicled, osteocutaneous fibula flap for reconstruction.Fig. 1.: (Above, left) A 7-cm distal tibia defect (filled with antibiotic bone spacer) had loss of overlying soft tissue following surgical débridement. Intraoperative marking of the tunnel site for skin paddle was marked with a checkerboard pattern. (Above, left) A retrograde osteocutaneous fibula flap was mobilized on the distal pedicle after ligation of the peroneal vessels at their takeoff. (Below, left) After contouring osteotomy, a double-barreled vascularized fibula and a single strut of nonvascularized fibula were cerclage-wired together to fill the distal tibial defect. (Below, right) After final inset, the skin paddle appeared viable.Intraoperatively, the fibula was traced from the lateral condyle of the knee to the lateral malleolus. The area between the defect and harvest sites (checkerboard pattern) marks where the flap would be tunneled. We used Doppler ultrasonography to identify peroneal perforators and accordingly designed a 12 × 6-cm skin paddle. Using both anterior and posterior approaches, the osteocutaneous fibula flap was harvested in situ in the standard fashion.3 Next, we dissected cephalad to the tibial-peroneal trunk, ligating the peroneal vessels at their takeoff. This converted the in situ flap into a retrograde flap mobilized on its distal pedicle (Fig. 1). The recipient site was prepared by elevating fasciocutaneous edges and the previously marked tunnel. A reconstruction plate was presecured in the anteromedial tibia (spanning the defect) with five proximal and four distal screws, and then removed. The fibula was osteotomized into thirds: the distal segment was used as the main bony bridge and was telescoped into the proximal and distal ends of the tibia, the middle third was buttressed alongside this segment, and the proximal portion was osteotomized off at the original fibula fracture site and used as a nonvascularized bone graft. This left a vascularized double-barreled fibula and a nonvascularized third strut acting as a fibula graft. These three struts were cerclage-wired together using 16-gauge wires and the reconstruction plate was resecured (Fig. 1). A drain was placed in the recipient bed. The proximal donor site was closed primarily and a meshed split-thickness skin graft was used distally. The skin paddle was inset in layers (Fig. 1). A posterior resting splint was fashioned to maintain the ankle at 90 degrees. At 12-month follow-up, the patient could bear weight, had radiographic evidence of good bony union, and had an acceptable final soft-tissue contour (Fig. 2). The retrograde, pedicled fibula osteocutaneous flap advances previously described variations of the fibula free flap to safely provide autogenous reconstruction of distal tibia and soft-tissue defects.Fig. 2.: (Left) Lateral radiograph shows the reconstructed tibia at 20-month follow-up. (Right) At 12-month follow-up, the patient was able to bear weight and had stable soft-tissue coverage and acceptable final contour.DISCLOSURE The authors have no financial interests in or commercial associations with any product or technique advocated in this article. Raj M. Vyas, M.D. Division of Plastic Surgery John E. Ready, M.D. Department of Orthopedic Surgery Lifei Guo, M.D., Ph.D. Division of Plastic Surgery Brigham and Women's Hospital Harvard Medical School Boston, Mass.

Potential of Fibroblast Cell Therapy for Recessive Dystrophic Epidermolysis Bullosa

Recessive dystrophic epidermolysis bullosa (RDEB) is a severe inherited skin-blistering disorder caused by mutations in the COL7A1 gene that lead to reduced type-VII collagen and defective anchoring fibrils at the dermal-epidermal junction (DEJ). Presently there are no effective treatments for this disorder. Recent mouse studies have shown that intradermal injections of normal human fibroblasts can generate new human type-VII collagen and anchoring fibrils at the DEJ. To assess potential clinical benefits in humans, we gave single intradermal injections of allogeneic fibroblasts to five subjects with RDEB. We noted increased type-VII collagen at the DEJ at 2 weeks and at 3 months following injection and increased anchoring fibrils, although none of these had normal morphology. No adverse effects, clinical or immunopathologic, were noted. We believe the major effect of allogeneic fibroblasts is to increase the recipients' own COL7A1 mRNA levels with greater deposition of mutant type-VII collagen at the DEJ and formation of additional rudimentary anchoring fibrils. Nevertheless, this mutant protein may be partially functional and capable of increasing adhesion at the DEJ. This is the first study demonstrating that intradermal injections of allogeneic fibroblasts have therapeutic potential in human subjects with RDEB.

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

Effect of artificial dermal substitute, cultured keratinocytes and split thickness skin graft on wound contraction

In this study, the effect of different wound treatments on contraction was evaluated in an established porcine model. In two separately conducted experiments full thickness wounds treated with artificial dermal substitute, split thickness skin graft (STSG), meshed STSG applied in combination with cultured keratinocytes or meshed STSG alone were compared with untreated wounds. The surface area of all wounds was quantified at regular time intervals. After 20 days wounds from some groups were subjected to histological analysis to establish the degree of epithelialization. Wounds treated with STSG contracted more than with artificial dermal substitute until day 21. From day 21 to day 35 wounds treated with STSG showed the least contraction. Wounds sprayed with cultured keratinocytes demonstrated a slower rate of contraction than those with meshed STSG alone after 20 days. The untreated control wounds showed a greater rate of contraction and had almost closed by day 20. This study demonstrates that there is a significant difference in contraction between wounds treated with artificial dermal substitute and control wounds and between wounds treated with STSG with cultured keratinocytes and meshed STSG alone. STSG with cultured keratinocytes, unmeshed STSG, and artificial dermal substitute all reduced wound contraction significantly.

Incidence and Management of Abdominal Wall Defects after Intestinal and Multivisceral Transplantation

Successful primary closure of the abdominal wall following visceral organ transplantation is not always feasible. Primary closure under tension can lead to fascial ischemia or necrosis, with subsequent dehiscence. Thus, alternate techniques to achieve abdominal wall closure are an important technical aspect in intestinal transplantation. The authors review their experience managing abdominal wall defects following intestinal or multivisceral transplantation. A retrospective review of the transplant database revealed 28 intestinal transplants in 24 patients from program inception in 1991 to January of 2002. The management of six intestinal transplant recipients with giant posttransplant abdominal wall defects is reviewed, and a novel technique is described for initially managing defects with prosthetic grafts that were serially reduced in size until a clean granulating bed was established, at which time they underwent permanent coverage using a meshed split-thickness skin graft. Of the 28 transplants, primary fascial closure was possible in only 14. In the other 14 patients, the fascia could not be closed primarily at the time of transplantation. The donor weight-to-recipient weight ratio was significantly greater in patients with abdominal wall closure problems (0.64 versus 1.09; p < 0.005). The incidence of retransplantation was also higher in those with abdominal closure problems compared with those whose fascia could be closed primarily (five of 14 versus one of 14). The six patients managed with skin graft closure did not have any wound complications after grafting. Abdominal wall defect after intestinal and multivisceral transplantation is a common problem without an ideal solution. Use of a skin graft on granulating abdominal viscera frozen with adhesions is a simple and reasonable solution to a complex problem.

Visceral coverage with absorbable mesh followed by split-thickness skin graft in the treatment of ruptured giant omphalocele

We report a case of ruptured giant omphalocele in whom herniated organs were successfully covered by an absorbable mesh and a subsequent skin graft. A 2,200 g male baby was born at 35 weeks of gestation. An abdominal wall abnormality was detected by prenatal ultrasound at 21 weeks of gestation. At birth, the entire liver, stomach, and small and large bowel had herniated from the defect of the abdominal wall. The thorax and abdomen were highly underdeveloped, and attempts to reduce the organs into the abdomen were unsuccessful due to the extremely small abdominal cavity and associated pulmonary hypoplasia. To protect the herniated organs and prevent abdominal infections, the organs were covered by a polyglycan mesh and subsequently a meshed split-thickness skin graft. Ten weeks later, it was confirmed that the organs were completely covered by epithelialized tissue. However, the patient suffered from frequent respiratory infections and finally died of respiratory insufficiency. Based on the experience of the patient, we conclude that coverage of the herniated organs with an absorbable mesh and a skin graft is a recommendable treatment in ruptured giant omphalocele.

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

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

MESHED UNEXPANDED SPLIT-THICKNESS SKIN GRAFTING FOR RECONSTRUCTION OF PENILE SKIN LOSS

Sheets of unmeshed, split-thickness skin grafts (STSGs) have been advocated in potent men with penile skin deficiency. Since the survival of sheet grafts is rarely 100% and the appearance of unexpanded 1:1 mesh grafts is quite good, we used this technique. We report our experience with meshed, unexpanded STSGs for all penile resurfacing regardless of erectile function. Nine consecutive patients with penile skin loss were prospectively treated between March 2001 and January 2003 with meshed STSGs to the penis. The underlying condition was Fournier's gangrene in 4 cases, chronic lymphedema in 2, skin deficiency from prior surgeries in 2 and Crohn's disease in 1. Graft thickness was 0.012 or 0.016 inches and meshing was performed in a 1:1 ratio. Meshed slits were oriented transversely without expansion and the graft juncture was located on the ventral surface in zigzag fashion. Graft take, appearance, and sexual and voiding function were assessed postoperatively. All 9 patients had 100% graft take. At a mean followup of 6 months a satisfactory cosmetic outcome was documented photographically in all except 1 case involving chronic penile manipulation. Erectile function and ejaculation were preserved in potent patients. Unexpanded meshed STSGs of penile skin loss yielded satisfactory functional and cosmetic outcomes.

Securing meshed split-thickness skin grafts with 2-octylcyanoacrylate

Meshed split-thickness skin grafts (STSGs) secured with 2-octylcyanoacrylate (2-OCA) were compared with meshed STSGs secured by suture and bolster (S&B). The 2 techniques were compared for graft survival, foreign-body giant cell response, inflammatory response, appearance, texture, and application time. Sixteen 2.5 × 2.5 cm meshed STSGs were harvested from the dorsa of 2 pigs for a total of 32 grafts. On each pig 8 grafts were sprayed with 2-OCA, and the other 8 were secured with S&B. Evaluations were performed on postoperative days 14, 24, 48, and 56. Biopsy specimens were obtained on postoperative days 14 and 56. There were no significant differences in percent survival, foreign-body giant cell response, inflammatory response, and appearance between control and study grafts. The average time to apply the 2-OCA onto a graft was 3 seconds, compared with 8 minutes for S&B application. 2-OCA provides a quick and reliable means of securing meshed STSGs and would be especially useful in areas where it is difficult to use S&B, such as total maxillectomy defects. (Otolaryngol Head Neck Surg 1999;121:562-6.)

The use of composite acellular allodermis-ultrathin autograft on joint area in major burn patients--one year follow-up.

Scar contracture is a major long-term sequelae of meshed split-thickness skin grafts in the case of full-thickness burn injuries, and especially in joint areas. Severe contracture around joints may lead to loss of mobility. The thickness of the dermis in the autograft plays a major role in the functional and cosmetic outcomes of the third degree burn. How to replace lost dermis is a major problem in skin restoration following severe burns. The human allograft skin (AlloDerm) is an acellular dermal matrix with normal collagen bundling organization and intact basement membrane complex. We present 12 cases of clinical application of a composite grafting technique in which the allogeneic skin (AlloDerm) provided source of dermis, and an ultrathin autograft (0.004-0.006 inch in thickness) provided epidermis. In these patients, The composite grafts were applied to full-thickness burn wounds over various articular skin surfaces. The average skin graft take rate was 91.5%. These ultrathin autografts allow the donor sites to heal faster. The mean time of donor site reepithelization was 6 days. All patients had a nearly normal range of joint motion (average 95% of normal) after one year's follow up. Wound assessment over time has shown supple skin that has been resistant to trauma and infection. The cosmetic results were judged to be fair to good by surgeons and patients after one year's follow up.

Temporary closure of full-thickness abdominal-wall defects with mesh grafts.

A simple technique is presented here for temporarily covering massive, full-thickness, abdominal-wall defects, when they cannot be closed directly. The exposed viscera can be covered with a meshed split-thickness skin graft to close the wound and seal off the abdominal cavity from the outside. Once the patient's general condition improves, the epidermal layer of the mesh graft should be removed by dermabrasion to minimize the risk of epidermal cysts, and the defect should be closed either by primary closure or by a local or free flap, depending on the defect size.

Role of melanoma growth stimulatory activity (MGSA/gro) on keratinocyte function in wound healing.

Melanoma growth stimulatory activity/gro alpha (MGSA), a member of the alpha-chemokine family, is produced by a variety of dermal and epidermal cells and can act in a paracrine and autocrine fashion. However, little is known about the importance of MGSA in wound healing. In this study, we quantified the levels of MGSA protein in burn blister and donor site wound fluids. We studied the effects of MGSA on proliferation and migration of primary human keratinocytes and modulation of their integrin expression. Blister fluids contained 0.79 ng/ml (range 0.018 to 4.86 ng/ml) MGSA. Substantial increasing amounts of MGSA were found in donor site fluids from day 1 through day 5 with mean levels ranging from 1.77 to 103 ng/ml at postoperative day 5, which correlated with increasing amounts of tumor necrosis factor alpha (r = 0.86), a known stimulus for MGSA production. In vitro proliferation experiments revealed a maximum stimulation (2.6-fold) with 10 ng/ ml MGSA for 7 days over unstimulated keratinocyte controls; the ED50 was 0.2 ng/ml. DNA content analysis revealed an increase in S phase with 10 ng/ml MGSA stimulation. In cultured keratinocytes, MGSA enhanced the mean fluorescence intensity for alpha 6, while no significant change was seen for beta 1, alpha 2 and alpha 5. We also studied the effect of topically applied MGSA (50 ng/cm2) on the healing of meshed split-thickness human skin grafts on athymic mice. In these wounds, MGSA stimulated the rate of epithelialization (P < 0.05) at day 7, and an increased proportion of mitotic keratinocytes was observed. Wound contraction was significantly (P < 0.05) reduced on days 7 and 14 in the MGSA-treated group. These results suggest that MGSA participates in wound healing by stimulating keratinocyte proliferation.

Treatment of vaginal agenesis with modified Abb�-Mclndoe technique

In a patient with vaginal agenesis reconstruction of the neovagina is very important both functionally and psychologically. The absent vagina can be constructed either by surgery or by an intermittent pressure technique defined by Frank. In this paper simple modification is presented which has good anatomical and functional results. For a young woman without a vagina the ideal operation should create a vagina in one stage and at the same time produce a cosmetically attractive scar. This goal can be achieved by the Abbe-McIndoe technique. A modification using a meshed split thickness skin graft for lining the neovagina is presented. Between 1985–1991 in our clinic, 46 patients were treated. A follow-up study has been performed and biopsies were taken from this neovagina; these showed normal vaginal mucosa.

Split-thickness skin grafting of leg ulcers. The University of Miami Department of Dermatology's experience (1990-1993).

Skin grafting for large and recalcitrant lower extremity ulcers is a commonly used therapy. However, the success rate for grafts performed by dermatologists is largely unknown. To analyze our experience with meshed split-thickness skin grafts for leg ulcers. We retrospectively analyzed all hospitalized dermatology patients who underwent meshed split-thickness skin grafting for lower extremity ulceration due to a variety of causes performed by the Department of Dermatology at the University of Miami over a 3-year period (1990-1993). Twenty-nine patients with 36 ulcers were grafted. Greater than 90% of ulcers had initial graft take. At long-term follow-up, 52% of ulcers were healed, 26% were partially healed, and 22% recurred. We conclude that meshed split-thickness skin grafting is a safe and effective therapy for recalcitrant lower extremity ulcers.