Paraffin Gauze Research Articles

The NHS and the financial storm: practical solutions with Jelonet dressing

Sir, Jelonet is a sterile tulle gras paraffin gauze dressing widely known for its properties of low adherence, allowance for exudate passage and suitability for combination with use of other topical agents. These features have allowed its global use for burns, scalds, donor and recipient skin graft sites, skin loss wounds and leg ulcers [1]. In our daily practice, we have developed uses for the Jelonet enveloping paper. A major use of this is as a template for planning full-thickness skin grafts. The paper is placed over the host site with low adherence, and the impression from the wound gives an exact outline of the graft needed from the donor site. The properties of low adherence extend its use as a foundation to place a harvested split-thickness skin graft for fenestration. This is often done on the theatre trolley or on the surface of a kidney dish. This could result in the potential for shearing of the epidermal or dermal layers of the graft. Some of the paraffin that is impregnated into the Jelonet remains as a residue on the enveloping paper. This can be used on the donor site for split-thickness skin grafts as an alternative to other agents such as Vaseline [2]. This residue can also lubricate multifilament suture materials to encourage smooth and atraumatic passage through the tissues. Surgical procedures at anatomical sites where hair is present can be challenging, for example, during pinnaplasty or scalp surgery. Hair can often obstruct the operating field, making preparation, draping and the procedure itself difficult. The paraffin residue on Jelonet's enveloping paper can be very helpful in sticking back hair and thus reducing this unnecessary complication [3]. Financial restraints have never been more prevalent than today. Whereas, in the past, they may not have had such an impact on the choice and use of dressings in theatre, today this is not the case [4]. By employing the techniques described above, the uses of the Jelonet dressing can be more far reaching and reduce the need for additional materials in the operating room. We look forward to and hope this article will stimulate other departments to find innovative methods to improve cost efficiency and also reduce waste.

Pressure at the Bowel Surface during Topical Negative Pressure Therapy of the Open Abdomen: An Experimental Study in a Porcine Model

Topical negative pressure (TNP) therapy is increasingly used in open abdomen management. It is not known to what extent this pressure propagates through the dressing to the bowel surface, potentially increasing the risk of bowel fistula formation. The present study in a porcine model was designed to evaluate pressure propagation. A commercially available TNP therapy system (ABThera/VAC) was applied in six pigs after laparotomy. Pressure sensors were placed in predetermined positions in the dressing and in the abdominal cavity and the pressure was registered at TNP settings of -50, -75, -100, -125, and -150 mmHg. Next, after infusing 200 ml of saline into the abdomen through a catheter, the amount of fluid drained through the system during 10 min of TNP therapy was registered. Finally, pressure was measured above and below eight layers of paraffin gauzes during TNP therapy. Observed pressure within the outer two foams and the foam of the visceral protective layer correlated with preset TNP. The median pressure at the bowel surface was between -2 and -10 mmHg, regardless of preset TNP. Median fluid drainage was 95% of the infused fluid at -75 mmHg and 124% at -150 mmHg. Paraffin gauzes had a limited isolating effect, reducing the pressure by 13% in median. Negative pressure reaching the bowel surface during TNP therapy with the ABThera system is limited for all TNP levels. Reduced therapy pressure does not lead to reduced pressure at the bowel surface. The system drains the abdominal cavity completely of fluid. Paraffin gauzes are of limited value as a means of pressure isolation.

Partial nail avulsion: habit or evidence based?

Onychocryptosis is a relatively common condition that can cause significant pain and discomfort. Partial nail avulsion (PNA) with phenolisation is a straightforward procedure performed by podiatrists on a daily basis. The procedure has shown a high rate of efficacy and low recurrence rate, and can be performed on high risk patients with close post-operative monitoring and those with concomitant infection. PNA with phenolisation of the nail matrix is a non-invasive procedure that does not require the use of an operating theatre and can be carried out in the podiatrist’s rooms. Pre-operative measures do need to be taken, a local sterile field should be set up and the toe and forefoot should be scrubbed. Once the procedure has been completed healing can be expected in 4-8 weeks. The PNA procedure has been taught to undergraduate podiatrists since the late 1970’s and has developed many small variations in how the procedure is carried out. Variations vary from pre-operative management (type of antisepsis used), phenolisation time (reported to be between 1 to 5 minutes), type of post phenol irrigation (saline, isopropyl alcohol or no irrigation) and post-operative dressing regimen. These variations however are usually operator dependant and based on personal experience. Post-operative management of PNA wounds have attracted a lot of interest, with the use of different dressings (provodone-iodine impregnated gauze and paraffin gauze) and topical medicaments (manuka honey, intrasite gel) aimed at increasing the healing rate and reducing the rate of infection, but quantitative analysis of the colonisation of the wound bed shows a bacterial count of zero after the use of phenol. The case of the phenolised wound is an interesting one, an acute wound that heals by secondary intention and freely discharges for 2-4 weeks postoperatively. After the application phenol and the destruction of all microbiological matter the post-operative focus should be in nurturing the recolonisation of the nail bed. Wounds that have a high as well as a low bacterial count have been shown to have an effect healing rates, but no studies have investigated the microbiological behaviour of a phenolised PNA wound.

An Inexpensive and Easy Technique for Placing and Fixing Dorsal Grafts in Rhinoplasty

Sir: Cartilage grafting has been a common surgical practice in aesthetic and functional rhinoplasty since 1980.1 This technique is performed to augment the nasal dorsum, to support the lateral nasal wall, and to manage nasal valve collapse. In fixing the cartilage graft, the surgeon has to cope with the poor accessibility of the tunnel, which precludes the use of standard sutures in a situation where the graft must be placed accurately and firmly. Percutaneous sutures are widely used in anchoring cartilage grafts because they have been demonstrated to close dead space and thus prevent fluid accumulation or hematoma. Graft migration is avoided because of the anchoring of skin and soft tissues to the grafted nasal scaffold.2 Classically, a suture with a straight needle is used. Stephenson and Brotherston suggest using a straight-sucker tube,3 whereas other authors use straight and curved needles.4 We describe here an easy and accurate technique for proper placement of grafts in rhinoplasties by open and closed approaches, both for minimal nasal dorsum correction and for total nasal reconstruction. A polyglactin braided suture (3-0 or 4-0) and two spinal needles are required. Alternatively, two 23-gauge needles could be used. The free tip of the thread is first introduced into the spinal needle using the needle hub as a funnel (Fig. 1). The spinal needle is then crushed with a needle holder to block the thread inside. The needle hub is then removed by detaching it from the needle and sliding it along the thread. At this point, the graft is threaded onto the suture, with two passages, and the needle of the thread is cut. Then, this tip of the thread is introduced into the other spinal needle, from which the hub was previously removed, and the needle is crushed as for the case of the preceding one.Fig. 1.: (Above) The thread is introduced into the needle. In this case, the needle hub was previously removed. Alternatively, the needle hub can be used as a funnel in the first passage. (Below) The needle is then crushed with a needle holder.The two spinal needles are introduced into the nasal fossa and guided to the point where the anchoring stitch is required, using a retractor to better expose the area (Fig. 2). The spinal needles pass from inside to outside, leading the thread and thus fixing the graft. The two needles are cut from the thread and the two tips are tied externally, leaving the suture loose to let the skin expand in the event tissue edema occurs. Properly adapted paraffin gauze is placed under the suture knot to prevent skin damage. The suture is left in place for 6 to 7 days.Fig. 2.: (Above) An Aufricht is used to facilitate the needle placement. (Below) The two needles and the graft threaded onto the suture are introduced.The procedure is very simple and highly accurate, and requires no expensive tools. Moreover, the surgeon can use his or her hands to direct the needle and choose with absolute precision the point at which to fix the graft. By comparison, other techniques2,4 require more passages of the needle through the skin, which increase the risk of damage to soft tissues because they are less precise and increase the time required for surgery. We have used this method with success widely over the years, achieving good results in graft fixation, even in complete nasal reconstructions with large cartilage grafts. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received. Luciano Ariel Lanfranchi, M.D. Riccardo Gazzola, M.D. Unit of Plastic and Reconstructive Surgery IRCCS San Raffaele Hospital, and IRCCS Istituto Ortopedico Galeazzi Alessandro Addis, D.V.M. Centro di Ricerche e Applicazioni Biotecnologiche in Chirurgia Cardiovascolare “Piera Santambrogio” Istituto Sperimentale Italiano “Lazzaro Spallanzani” Valeria Puggioni, M.D. Matteo Marino, M.D. Franz Wilhelm Baruffaldi Preis, M.D. Unit of Plastic and Reconstructive Surgery IRCCS San Raffaele Hospital, and IRCCS Istituto Ortopedico Galeazzi Milan, Italy

Negative-pressure wound therapy following cardiac surgery: bleeding complications and 30-day mortality in 176 patients with deep sternal wound infection

Negative-pressure wound therapy (NPWT) has been used for the treatment of deep sternal wound infection (DSWI) with promising results. However, questions have been raised regarding the potential risk of right ventricle (RV) rupture during treatment. In the present study, we evaluate our clinical experience of NPWT focusing on RV rupture and major bleeding complications and its potentially negative impact on 30-day mortality during an 11-year period. Serious bleeding complications during NPWT were reviewed for 176 patients treated for DSWI between January 1999 and April 2010. The 30-day mortality following DSWI was 1.1% (2/176). Four patients (2.3%) suffered bleeding from the RV rupture during NPWT of the sternal wound (two spontaneous and two debridement related). Furthermore, two patients had debridement-related bleedings from the venous bypass grafts during wound dressing change. The very low 30-day mortality (1.1%) following DSWI supports the use of NPWT. Overall, even if major bleeding complications may occur, the risk of RV rupture seems to be outweighed by the benefit of superior infection control. However, surgical experience is recommended when debriding sternal wounds and we recommend the use of a wound dressing, such as paraffin gauze, in order to protect the RV from direct contact with the polyurethane foam.

Major complications during negative pressure wound therapy in poststernotomy mediastinitis after cardiac surgery

Negative pressure wound therapy is the first-line treatment modality for poststernotomy mediastinitis in many heart centers. The aim of this study was to analyze major complications and possible preventive methods during negative pressure wound therapy in patients with deep sternal wound infections. We retrospectively analyzed 69 consecutive patients treated with negative pressure wound therapy for poststernotomy mediastinitis between June 2006 and September 2009. Five (7.2%) patients sustained major complications during negative pressure wound therapy. Bleeding from coronary artery venous bypass grafts was observed in 4 patients and fulminant bleeding from an infected homograft of the ascending aorta was observed in 1 patient during routine dressing changes of the negative pressure wound therapy system. Bleeding is the major complication during negative pressure wound therapy for poststernotomy mediastinitis. Covering the heart with several layers of paraffin gauze is a necessary protective maneuver but cannot completely prevent major complications during negative pressure wound therapy. All operative procedures, including dressing changes, should be performed in the operating room under optimal hygienic and monitoring conditions to increase the salvage rate and to guarantee optimal surgical and anesthesiologic conditions in case of negative pressure wound therapy-related complications.

A tie‐over dressing for graft application in distal penectomy and glans resurfacing: the TODGA technique

• To describe a novel method of split-skin graft (SSG) fixation for neo-glans formation after distal penectomy for penile cancer and glans resurfacing for carcinoma in situ or lichen sclerosus (LS); the TODGA technique. • Rather than 'quilting' the graft onto the neo-glans, which requires up to 5 days bed rest, the tie-over method fixes the graft adequately enough to allow immediate patient mobilization. • In all, 41 consecutive operations, with a follow-up of ≥ 12 months, were performed on 40 patients (mean age 62 years, range 32-83) from December 2000 to October 2008, where a SSG was applied to the raw glans or penile stump. • The protocol varied for the first 12 operations on 11 patients. The tie-over dressing was left in place for 6 (one patient) or 7 days (11) and various materials were used; paraffin gauze (one), expanded foam (five) and proflavine-soaked gauze (six). The first two patients had their dressing removed under general anaesthetic but all subsequent patients had their dressing removed on the ward. • The subsequent 29 operations used the same protocol where a proflavine-soaked gauze dressing was left undisturbed for 10 days. • In the original 11 patients, two required re-grafting. After this initial development period, we amended the technique to use stronger sutures and left the dressing undisturbed for 10 days. • In addition, we standardized the use of proflavin-soaked gauze, as we found it easy to apply and remove. Since we adopted this protocol, we have performed 29 operations over a 3-year period. • The cosmetic results were excellent with only one patient requiring re-grafting. The mean and median postoperative length of stay was 2 days. • One patient with a urethral squamous cell carcinoma associated with urethral and glans LS required a urethral dilatation to allow a check cystoscopy, and a further asymptomatic patient had a meatal dilatation in the clinic but meatal stenosis was otherwise not seen, with no patients requiring regular meatal dilatation. • The TODGA technique of SSG application and fixation allows immediate mobilization and reduces hospital stay whilst providing excellent cosmetic results with a high percentage of graft uptake.

Silver sulfadiazine for the treatment of partial-thickness burns and venous stasis ulcers

For decades silver-containing antibiotics such as silver sulfadiazine (SSD) have been applied as standard topical therapy for patients with partial-thickness burns and venous stasis ulcers. This evidence-based review intends to answer the following research question: in ambulatory patients with partial-thickness burns or stasis dermatitis ulcers, does the use of topical SSD compared with nonantibiotic dressings improve mortality, wound healing, re-epithelialization, or infection rates? MEDLINE, EMBASE, Cochrane Library, and other databases were searched. We considered trials that enrolled patients of any age with partial-thickness burns or venous stasis ulcers and randomized them to either topical SSD or placebo, saline-soaked gauze, paraffin gauze, sterile dry dressing, or nonantibiotic moist dressing. Outcomes included mortality, wound healing, speed of re-epithelialization, and infection rates. For burns, our search revealed 400 potential articles. No human studies met the inclusion criteria. Only 7 animal studies (1 mouse, 4 rat, and 2 pig) were relevant to the proposed question. These animal studies provided conflicting results. Whereas some support the use of SSD for treatment of partial-thickness burns, others question its effectiveness. For stasis dermatitis ulcer, the search identified 50 articles for review, of which 20 abstracts were reviewed, and one article met the inclusion criteria. This study did not show any significant improvement in the rate of complete healing in SSD group compared with placebo either at 4 weeks (relative risk 6.2, 95% confidence interval 0.8-48) or at 1 year (relative risk 5.2, 95% confidence interval 0.6-41.6) of follow-up. There is insufficient evidence to either support or refute the routine use of SSD for ambulatory patients with either partial-thickness burns or stasis dermatitis ulcers to decrease mortality, prevent infection, or augment wound healing in human beings.

Prevention of Wound Infection after Release of Apert Acrosyndactyly

Sir: A succession of Apert syndrome patients with infection and graft loss after acrosyndactyly correction with the trilobed flap technique and at our medical center prompted a modification of the conventional surgical prophylactic protocol used by the senior author (J.H.C.). Conventionally, patients undergoing syndactyly release would receive one intravenous dose of antibiotics (amoxicillin/clavulanate) at induction with, apart from a sterile nonadherent paraffin gauze dressing (Unitulle; Roussel B.V., Hoevelaken, The Netherlands), no added measures for the graft recipient site. The modified or extended protocol involved 7 days of oral antibiotics (amoxicillin/clavulanate) in additional to the conventional single intravenous antibiotic dose given at induction and treatment of the graft recipient sites with Unitulle dressings impregnated with an antibiotic 0.2% nitrofurazone solution (Furacine; Norgine, Heverlee, Belgium). A preliminary retrospective study was performed to study the effectiveness of the new protocol compared with the conventional protocol for reducing the postoperative infection and revision rate, to evaluate whether an objective justification exists for empirically prescribing the prolonged use of antibiotics. The group of procedures (27 webs in nine patients with Apert syndrome) performed by the senior author between January of 2004 and December of 2005 could be divided into two cohorts (Table 1): (1) 15 web corrections in nine patients under the conventional antibiotic prophylaxis, and (2) 12 webs in six patients under extended prophylaxis. It should be noted that all patients represented in the second cohort were also represented in the first. All cases were corrected with the dorsal trilobed flap technique, and all had secondary defects that required coverage with full-thickness skin grafts taken from the groin.Table 1: Demographics of Patients with Apert Syndrome Operated on for Primary Syndactyly of the HandAlthough we found a lower incidence of postoperative infections and reoperations in the extended compared with the conventional group (25 percent versus 46 percent and 8 percent versus 13 percent, respectively), the difference was not statistically significant (p = 0.35 and p = 0.69, respectively). Similar techniques for syndactyly release and web reconstruction using local transposition flaps and full-thickness skin grafts in patients with Apert syndrome have been reported in the literature, with infection rates ranging between 6 and 8 percent and revision rates ranging between 13 and 18 percent.1–3 Skin grafts are associated with poor surgical outcome,4 but their use is often unavoidable in complex abnormalities, such as those presented here. Different techniques, such as tissue expansion, defatting, and novel commissural flap designs, that omit the use of large skin grafts, may reduce the need for reoperation. These techniques, however, have not yet been widely accepted, and their place in the treatment algorithms remains to be determined. We acknowledge that this study has major limitations, including those inherent in the retrospective design, and the preliminary data do not provide enough evidence to recommend a prolonged course of antibiotics. Also, although meticulous surgical technique, adequate postoperative dressings, and splinting are crucial for a successful outcome, we do feel that the described prophylactic protocol could be a useful adjuvant in complex cases such as those presented here. We therefore suggest a prospective, randomized trial with a larger cohort of patients be performed to validate our findings. Michael Ananta, M.D. University College London Institute of Orthopaedics and Musculoskeletal Sciences Stanmore, Middlesex, United Kingdom J. Henk Coert, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Erasmus Medical Center Rotterdam, The Netherlands

A retrospective analysis of ambulatory burn patients: focus on wound dressings and healing times

In this study, we retrospectively analysed healing times of ambulatory burn patients after silver-based dressings were introduced in late December 2005, and compared the results with those obtained before. Data were collected in November-December 2005 and in January-February 2006. We excluded from the study: (i) admitted patients; (ii) patients with mixed superficial partial thickness and deep partial thickness burns; (iii) patients with full-thickness burns; and (iv) operated patients that came for follow-up. We recorded the age, sex, cause (flame vs scald), burn depth, dressings used and healing times. We selected 347 patients corresponding to 455 burned areas (64.4% superficial and 35.6% deep; 47.7% treated in 2005 and 52.3% in 2006). During the years 2005 and 2006, there was an increase in the use of silver-based dressings (2005, 9.7%; 2006, 38.7%; chi-squared test, P < 0.001) and a decrease in the use of paraffin gauzes (2005, 66.4%; 2006, 40.3%; chi-squared test, P < 0.001). The healing time of overall burns and of superficial burns showed no significant differences between 2005 and 2006. However, in deep partial thickness burns, a significant reduction was present (2006, 19; 2005, 29 days; Student's t-test, P < 0.01). Among all dressings, paraffin gauzes had the shortest healing times in superficial burns (5 days); with silver-based dressings in deep burns, the healing times were nanocrystalline silver (16 days) and silver carboxymethylcellulose (21 days). Results of our retrospective study would suggest that paraffin gauzes are a valuable option in superficial burns, while silver-based dressings are preferable in deep burns.

Preventing heart injury during negative pressure wound therapy in cardiac surgery: Assessment using real-time magnetic resonance imaging

Heart rupture is a devastating complication to negative pressure wound therapy in cardiac surgery. Also, reduced cardiac output during negative pressure wound therapy has been reported. The present study aimed to examine the effects of negative pressure wound therapy on the position of the heart in relation to the thoracic wall using magnetic resonance imaging in a porcine sternotomy wound model. Six pigs had median sternotomy followed by negative pressure wound therapy at -75, -125, and -175 mm Hg. Real-time magnetic resonance imaging movies (10 images/s) were acquired in a midventricular transverse plane or a midsagittal plane during the application of negative pressure wound therapy. Similar finding were observed at all different negative pressures studied. Negative pressure wound therapy caused the heart to be displaced toward the thoracic wall, and in some cases, the right ventricular free wall bulged into the space between the sternal edges, and the sharp edges of the sternum jutted into and deformed the anterior surface of the right ventricular free wall. These events were not affected by the interposition of 4 layers of paraffin gauze dressing but were hindered by the placement of a rigid barrier between the anterior portion of the heart and the inside of the thoracic wall. The results show altered position of the heart in relation to the sternum during negative pressure wound therapy. This may explain 2 potentially hazardous events associated with negative pressure wound therapy, namely, risk for heart rupture and reduced cardiac output. Inserting a rigid barrier over the heart may be a protective measure that is clinically practicable.

A randomised controlled trial of amniotic membrane in the treatment of a standardised burn injury in the merino lamb

Burn injury is associated with disabling scar formation which impacts on many aspects of the patient's life. Previously we have shown that the fetus heals a deep dermal burn in a scarless fashion. Amniotic membrane (AM) is the outermost fetal tisue and has beeen used as a dressing in thermal injuries, though there is little data to support this use. To assess the efficacy of AM in scar minimisation after deep dermal burn wound, we conducted a randomised controlled study in the 1-month lamb. Lambs were delivered by caesarian section and the amniotic membranes stored after which lambs were returned to their mothers post-operatively. At 1 month, a standardised deep dermal burn was created under general anaesthesia on both flanks of the lamb. One flank was covered with unmatched AM, the other with paraffin gauze. Animals were sequentially euthanased from Day 3–60 after injury and tissue analysed for histopathology and immunohistochemically for α-smooth muscle actin (αSMA) content. AM resulted in reduced scar tissue as assessed histopathologically and reduced αSMA content. This study provides the first laboratory evidence that AM may reduce scar formation after burn injury.

Comparison of the Ionic Silver-Containing Hydrofiber* and Paraffin Gauze Dressing on Split-Thickness Skin Graft Donor Sites

The split-thickness skin graft (STSG) donor site dressing has been an inconclusive topic. Each of the Hydrofiber (Aquacel, ConvaTec A Bristol-Myers Squibb Company, Deeside, UK) and silver dressings have applied in many types of wound care with favorable outcomes. Our study compared the ionic silver-containing Hydrofiber dressing and paraffin gauze dressing. The subjects were randomized into group A: ionic silver-containing Hydrofiber and group B: paraffin gauze. From February 2006 to 2007, 20 donor sites were recorded. The mean donor site surface area was 145.5 cm2 (group A) and 135.8 cm2 (group B). The completed re-epithelization day was 7.90 and 11.20 days, respectively (P = 0.031). The average pain score at rest were 0.74 and 0.80, respectively (P = 0.894). The average pain score on dressing removal were 3.12 and 4.70, respectively (P = 0.027). There was no infection or seroma in both groups. In conclusion, ionic silver-containing Hydrofiber dressing can reduce STSG donor site pain and promote re-epithelization compared to paraffin gauze dressing.

Monitoring the microcirculation to evaluate dressing performance in patients with venous leg ulcers

To compare the effect on the microcirculation in venous leg ulcers (VLUs) of two treatment regimens that promote a moist wound environment versus paraffin gauze. The hypothesis is that moist wound dressings are more likely to stimulate the microcirculation and therefore angiogenesis. Patients with non-healing VLUs were randomised to receive either a foam dressing (Suprasorb P), a collagen dressing (Suprasorb C) plus the foam dressing, or paraffin gauze (control). All patients wore short-stretch high compression bandages. Parameters used to measure the effects of the treatments on the microcirculation were: TcPO2 measurements, video laser Doppler measurements and the number of capillaries in the wound bed. The progression towards healing was measured by the reduction in ulcer area and formation of granulation tissue. The treatment period was four weeks. Significant increases in TcPO2 values were reported between baseline and week 4 for patients receiving the foam dressing only or the collagen plus foam dressing combination (p<0.008 versus p<0.003 respectively). There was also a significant increase in the number of capillaries for the collagen plus foam treatment only (p<0.002). This pilot study suggests that a moist wound environment stimulates perfusion of blood and oxygen to the wound tissue, thereby promoting angiogenesis. The collagen and foam dressing combination demonstrated superior results to the control and the foam dressing only. Monitoring the microcirculation may help to assess the effect of dressings on VLU healing, although more research is needed. This pilot study was supported by a limited grant from Lohmann & Rauscher GmbH, Germany.

Management of split skin graft donor sites – results of a national survey

The authors wished to obtain a 'snapshot' of the range of practice in the management of split skin graft donor sites in the British Isles. Questionnaires were sent to all British consultants and locum consultant plastic surgeons on 1 July 2006. Of the 357 questionnaires, 279 were returned (a response rate of 78%). Alginates were the most popular dressings, especially in adult donor sites--first choice for 167 respondents (60%). Adhesive fabrics were less popular--first choice for small adult donor areas for 46 respondents (16%). Plastic film dressings and Biobrane were even less popular--being the first choice for small and large donor areas, respectively, in children (for approximately 5% of respondents). Ten percent of respondents said they avoid paraffin gauze and another 10% avoid plastic film dressings in all cases. Five percent avoid hydrocolloid and another 5% avoid adhesive fabric in all cases. On the basis of these results, we feel that any future study of donor-site dressings should incorporate the most commonly used dressing (alginate) as a control.

Conservative surgical debridement as a burn treatment: Supporting evidence from a porcine burn model

In thermal deep-dermal burns, surgical debridement is normally used in conjunction with skin grafting or skin substitutes and debridement alone as a burn treatment is not usually practiced. The current study addresses whether or not debridement alone would enhance burn wound healing on small deep-dermal-partial thickness burns. This was a prospective and blinded experimental trial using a porcine deep-dermal-partial thickness burn model. Four burns, approximately 50 cm(2) in size, were created on each of eight pigs. Two burns from each pig were immediately surgically debrided and the other two were not debrided as the internal control. Hydrate gel together with paraffin gauze were used to cover the burns for four pigs and silver dressings for the other four. Clinical assessment of wound healing was conducted over a 6-week period. Skin samples were collected at the end of the experiment and histopathological evaluation was performed. The results show thinner scar formation and lower scar height in the debrided compared with nondebrided wounds in the hydrate gel/paraffin gauze groups. There were no statistically significant differences in wound healing assessment between the debrided and nondebrided wounds dressed with silver dressings. This study provides supporting evidence that immediate debridement with an appropriate dressing and without skin grafting may promote wound healing, suggesting its potential benefit for clinical patients.

Split-skin graft in the management of diabetic foot ulcers

To compare the effects of split-thickness skin grafts versus a conservative wound dressing on the healing times of diabetic foot ulcers and the length of hospital stay. In this prospective case-controlled study, 50 patients consented to skin grafting (graft group) and 50 preferred to be managed by conservative dressings (control group). Wound management in both groups was standardised with regard to the dressing materials (which comprised a multilayer dressing including paraffin gauze and diluted povidone-iodine soaked gauze), wound care and surgeon involvement. Graft take, ulcer recurrence rate and donor-site morbidity were assessed. Healing times and the length of hospital stay were compared between the two groups. A 100% skin graft take was recorded in 84% of the patients on the fifth postoperative day and in 62% on weeks 3 and 8. All patients in the graft group healed completely, but 8% had an ulcer recurrence and 4% a superficial infection within the following year. The mean healing time and mean length of hospital stay were significantly less in the graft group compared with the control group (p<0.001), reflecting results of similar studies. Split-skin grafting is an effective method of managing diabetic foot ulcers as, compared with the conservative dressings used in this study, it reduced healing times and the length of hospital stay, while donor-site morbidity was minimal.

A Versatile Technique for Repositioning of the Umbilicus in Abdominoplasty

Sir: Umbilical repositioning is a main step during abdominoplasty. The surgeon aims for minimal visible scars and a natural-looking result.1 Several techniques have been described, but none of them completely satisfy the aesthetic targets in all patients. Evidence of scar or retraction with umbilical stenosis may occur.2 The use of Y or double-Y cutaneous incisions has improved aesthetic results.3,4 We introduce a versatile technique for umbilicoplasty: an elliptical vertical incision of the umbilical skin and a double-opposing Y incision on the abdominal flap, to create a stable, natural-looking umbilicus. A prospective, open-label study was performed. Forty patients underwent abdominoplasty using the present technique for umbilicus repositioning. Patient age ranged between 24 and 63 years (36 women and four men). Body mass index ranged from 26 to 47 kg/m2 (mean, 33 kg/m2). Patient satisfaction and postoperative results were evaluated over a 12-month follow-up period. A modified 5-ml syringe was used to assess the depth and volume of the umbilical stalk. Variations in depth between 1 and 12 months were statistically compared using the Wilcoxon test. The umbilical skin is sharply incised vertically. The umbilical pedicle blood supply is preserved. The umbilical dermis is attached to the abdominal rectus fascia in four cardinal points with polyglecaprone 25 4–0 suture. In patients with a thin habitus, it is important to plicate the periumbilical fascia sufficiently to create an inverted umbilicus. The elliptical umbilical island is tightened against the tensed abdominal fascia without distortion. The site of umbilicus repositioning is determined by its projection on the abdominal flap. A small, double-opposing Y cutaneous incision is made in this point. The vertical size must be approximately the same as that of the original umbilicus. The angle and size of the four lateral incisions can be modified according to the width we want to obtain. Defatting is performed through the double-opposing Y incision. The umbilical skin is sutured to the surrounding abdominal skin with 4–0 nylon sutures. Four of these sutures are left longer and tied over a paraffin gauze patch to ensure deep umbilicus positioning. In all patients, an umbilicus with adequate depression was created. In one case, de-epithelization of the umbilical skin occurred and healed spontaneously in 2 weeks. After 12 months, no significant changes in shape, dimension, and appearance were observed. All patients were pleased with the final result. No cicatricial umbilical stenosis occurred, and no statistical significance was found comparing mean depth variations between 1 and 12 months (10.67 ± 1.34 ml and 10.4 ± 1.19, respectively; p = 0.0543). This technique gives a natural depth appearance, ensures optimal position, pulls scars deeply, avoids visible scarring, and allows achievement of different shapes according to the patient’s habitus (Figs. 1 and 2). Any umbilical size, in either obese or thin patients, can be created with this method. The double-opposing Y incision reinforces the vertical shape, creates natural umbilical dimpling, and prevents stenosis with stable results. This technique is easy to learn and simple to perform, effectively hides scars, and gives a youthful appearance to the umbilicus.Fig. 1.: Preoperative view of the umbilicus.Fig. 2.: Twelve-month postoperative view.Marco Mazzocchi, M.D., Ph.D. Luca A. Dessy, M.D. Andrea Figus, M.D. Department of Plastic Surgery University “La Sapienza” Rome, Italy DISCLOSURE The authors did not receive any financial support for this study, nor were they in any way commercially involved with any company.

Inverted Nipple: Use of an Effective and Personalized Splint after Surgical Correction with Pitanguyʼs Technique to Avoid Relapse of the Inversion in 28 Cases

Sir: The inverted nipple is a common deformity characterized by the relative shortness of the lactiferous ducts, which tether the nipple and prevent it from projecting.1 This condition is combined with resistant collagen fibers and insufficient bulkiness of connective tissue beneath the nipple. It has been recognized since 1849, when Sir Ashley Cooper first made note of it.2 This deformity can be either congenital or acquired. It has been widely described and graded, and it is possible to correct it using a broad variety of surgical techniques in relation to the severity of the inversion presented by the nipple.3,4 Relapse of the inversion is very common and is the most noticeable consequence of correction, when the lactiferous ducts are not exactly divided. For this reason, it is fundamental to stress the importance of follow-up as well as that of the surgical maneuvers chosen to achieve and maintain a lasting result. We used Pitanguy's technique,5 which involves the actual release of the fibrous tissue between the ducts with a direct approach made through a trans–nipple-areola incision, to correct 28 grade II inverted nipples, following the classification proposed by Han and Hong (the nipple can be pulled out, but it cannot maintain the projection and tends to return to its original position). The ducts were dissected free from the surrounding fibrous muscular tissue and released. The tissues were then approximated and sutured using a 3.0 Vicryl suture, the deep layers first, to provide more bulk to the nipple-areola complex. Surgery was performed with the patient under local anesthesia. To prevent relapse of the inversion, we combined this technique with the use of a splint, designed by us and made of Thermoplast, which must be round, without a triangular piece, to allow the edges to overlap (Fig. 1). We formed the device by taking a mold of the nipple after surgical correction. A paraffin gauze pad was interposed to prevent pressure sores from developing on the areola. Using a 16-gauge needle, we made two holes in the device and maintained nipple eversion by suturing the nipple to the splint with a transfixed 4.0 Ethilon suture.Fig. 1.: The round Thermoplast splint after removal of a triangular piece so that the edges could overlap. A 16-gauge needle is used to create two holes in the splint, and the splint is placed on the nipple-areola complex.At first patients had to keep the splint in place for 3 weeks. We then removed the stitch, but patients had to keep the splint in place for an additional 4 weeks, to protect the surgical site beneath the brassiere and to make patients feel safe. After removal of the splint, we found no evidence of nipple necrosis or any kind of skin distress. At the 3-, 6-, and 12-month follow-ups, we found no evidence of relapse. We finally obtained complete symmetry of the nipple-areola complex with no noticeable scars. The splint is very easy and cheap to construct, and it guarantees effective prevention of nipple re-eversion at long-term follow-up (Fig. 2).Fig. 2.: Preoperative and postoperative views of grade II inverted nipple.Caviggioli Fabio, M.D. Ventura Domenico, M.D. Andretto Amodeo Chiara, M.D. Klinger Francesco, M.D. Istituto di Chirurgia Plastica Universita’ degli Studi di Milano Istituto Clinico Humanitas Rozzano, Mi, Italy

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