Required Skin Grafting Research Articles

Complications in skin grafts when continuing antithrombotic therapy prior to cutaneous surgery requiring skin grafting: an observational study

Use of anticoagulants is common and practice regarding continuation or discontinuation of the medication peri-operatively for cutaneous surgery lacks evidence-based consensus. Therefore, we aimed to do a prospective observational study with patients who were referred to cutaneous surgery and needed full thickness or split skin grafting and using antitrombotic or non-antitrombotic therapies. Data on patients characteristics, diagnosis, location of surgery and surgery performed, antithrombotic medication and complications in skin grafts were collected. Skin grafts were traced on a transparent film and areas of unhealed skin graft were marked. All patients were routinely followed-up on days 5–7 postoperative. Chi-square test, Fisher’s exact test or Mann-Whitney U-test were used to compare patients taking antitrombotic medication with patients receiving no antitrombotic therapy. In addition, associations were calculated for treatment with the different antithrombotic therapies. No severe bleeding requiring blood transfusion or re-operation was observed in this study. The results showed no statistically significant difference between patients who continued treatment with antithrombotic therapy compared with patients having no antithrombotic treatment regarding sub graft hematomas or graft take. Continuing antithrombotic monotheraphy with acetylsalicylic, clopidogrel, warfarin or fish oil in relations to cutaneous surgery do not seem to increase risk of haematoma or graft lost.

Keystone Flap as a Reconstructive Option for selected areas; A Prospective Study

ObjectiveA very few flaps would be described as versatile as the Keystone Flap. There is an increasing demand for coverage of defects in lower limb due to traumatic defects as well as other parts of the body. Keystone flap is one of its kind, which is simple and easy to perform. It is a safe option for conditions where microsurgery may not be a viable option. The relative simplicity of this flap makes it a to go option at many places. MethodsA prospective study was developed from October 2017 to December 2019 at SMS Hospital, Jaipur. We assessed the size of the flap, operation time, average hospital stay and the complications. Perforators over the leg were Doppler marked preoperatively over which the flap was raised. Results50 patients were taken into the study. 30 key stone flaps were done to cover lower limb defects, 10 flaps were done for upper limb defects and the remaining 10 were for trunk defects. The average intraoperative time from skin incision to final suture was 50 min (range 20–90 min). The largest defect covered by keystone flap in our series measured 50 × 20 cm and the smallest defect covered was 8 × 4 cm. The average hospital stay was 3 days. We observed partial flap necrosis in 2 cases which required skin grafting. 3 other cases had wound infection leading to wound dehiscence, which required secondary suturing. The overall success rate was 95%. ConclusionThe Keystone flap being a versatile flap with its qualities of replacing “like with like”, easy to perform, use of local tissue, good vascularity and a low complication rate makes it an excellent flap for a variety of defects. The KeyStone flap allows reconstruction in a single stage and is a relatively easy and fast technique for the beginner as well as the experienced surgeon. We believe it should be incorporated more into a surgeons practice.

Submental and Anterior Neck Originated Full-Thickness Skin Grafts for Periocular Procedures.

The submental and neck regions share cutaneous features with the face and are suitable donor sites for facial full-thickness skin grafts (FTSGs). Age-related laxity and skin redundancy in the cervicomental region may be an additional motivator to use its skin. We aim to describe, raise awareness, and remind surgeons of the utilization of submental and anterior neck as sources of FTSG for the periocular region, particularly when traditional donor sites are unavailable. Retrospective case series of 5 patients who underwent periocular FTSG from anterior neck and submental regions between January 2017 and January 2019. All patients had contraindications to the usually preferred graft donor sites. Main outcome measures were surgical functional results and cosmesis. Five patients (all female) received FTSGs using anterior neck and submental regions as donor sites. Two patients required skin grafts due to eyelid retraction and anterior lamella shortening; one due to previous multiple basal cell carcinoma excisions with FTSG reconstructions and the other due to chronic Bell's palsy. Three patients required skin grafts for Hughes flap reconstruction after excision of lower eyelid basal cell carcinoma. In all patients, conventional skin donor sites were unavailable or unsuitable due to previous skin grafting, actinic changes, postauricular situated hearing aids or patient's preference. All patients achieved good cosmesis and functional results. None of the patients experienced donor site morbidities. Submental and anterior neck regions are useful FTSG donor sites for periocular procedures, particularly in elderly female patients with submental fullness and neck skin redundancy.

Versatility of Pedicled Perforator-Based V-Y Advancement Flaps for Reconstruction of the Upper Limb: A Case Series and Review of the Literature.

The aim of any reconstruction is to provide a robust and cosmetically pleasing result that does not significantly alter function. We describe our experience of using the V-Y principle in advancement flaps designed around a distinct perforator to reconstruct soft tissue defects of the upper limb. The shortcomings of fasciocutaneous and fascial flaps requiring skin grafting can be eliminated. This was a 10-year retrospective review of patients who had V-Y flaps based on a distinct perforator for defects of the shoulder, axilla, arm, elbow, forearm, wrist, and hand. Defects of the digits and thumb were excluded. There were 59 flaps in 52 patients with an average age of 44 years (18-72 years). Skin malignancy was the most common primary etiology. The average defect size was 35 cm (9-80 cm). There were no total flap failures; however, there were 4 partial losses, which healed by secondary intention. Seven flaps had to be explored for the hematoma evacuation. The use of V-Y flaps based on distinct perforators in the upper limb retains limb aesthetics, allows early mobility and is a safe and reliable technique.

Diyabetik Ayakta Anatomik Değişiklikler

Objective: Diabetic patients are 15 times more likely to develop gangrene, requiring amputation. Most of the non-traumatic limb amputations are due to complications of diabetes. The aim of this study was to analyse the various anatomical changes occurring in patients with diabetic foot ulcers.Materials and Methods: A prospective study was carried out in 70 patients presenting to the Diabetic Clinic at a tertiary care hospi-tal in Delhi, India under the Professor and Head of Department Surgery BHDC India, regarding the site, size, nature of foot le-sion, etiology of foot lesions and culture and sensitivity patterns of the wound swabs.Results: Most common lesions were noticed to have skin and nail changes (47 patients,67.1%) in the form of corns, callosities, dry skin, fissures, hypertrophied and brittle nails.20 patients (28.5%) presented with ulcers and 3 patients (4.2%) had gangrene. 56 patients (80%) were managed by multiple wound debridements and serial dressings.11 patients (15.7%) required skin grafting for wound healing.3 patients (4.2%) required some form of amputa-tion.Conclusion: It was found that with strict diabetic control, daily dressings, surgical intervention in the form of adequate, aggressive and timely debridement and culture specific antibiotics, the diabetic foot wounds healed well. Amputation at appropriate levels should be performed as life-saving measures in severe infections to pre-vent septicaemia and lifesaving takes precedence over limb / toe saving.

76 The Effect of Splinting of Metacarpophalangeal Joints After Skin Grafting: A Review of the ACT Database

Abstract Introduction Hands are the most common area of the body to sustain a burn injury. Maintaining motion and function throughout the healing process of a burn injury is one of the most important goals of the rehabilitation process. After a deep burn to the dorsal aspect of the hand requiring skin grafting, the adjacent metacarpophalangeal (MCP) joints are at risk for developing a burn scar contracture (BSC), limiting the joints’ ability to fully flex towards a fist position. Post-operative positioning protocols state that patient’s hand should be temporarily immobilized for graft protection. A resting hand splint is used to maintain the wrist in approximately 20–30 degrees of extension, MCP joints at approximately 50–70 degrees of flexion and the interphalangeal joints in full extension. The purpose of this study was to assess the benefit of splinting as a treatment intervention to prevent MCP joint extension contractures following dorsal hand skin grafting. Methods This was a retrospective review of prospectively collected observational data from the “Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Time Related to Patient Outcomes” (ACT) study. Patients were included with grafted dorsal hand burns occurring within 1 of the 4 established cutaneous functional units (CFU) along the dorsal aspect of the second through fifth metacarpals. Since most subjects had more than one dorsal hand CFU involved, the number of CFUs were analyzed as opposed to the number of subjects. Isolated MCP joint flexion measurements were utilized to determine incidence of contracture. Included causes of contracture were scar tissue or other soft tissue limitations. Data were then analyzed by two groups: contracted and non-contracted. Results A total of 221 dorsal hand CFUs were included in this study; 119 contracted and 102 non-contracted. There was no statistical significant difference between the average splint wear time between the 2 groups. The average percent of affected CFUs grafted within the contracted group was 92.4% compared to 76.8% in the non-contracted group. In burns to the dorsal hand with less than 99% of the CFU grafted, splinting was effective in preventing 60% of MCP joint extension contractures. When greater than 99% of affected CFU was grafted, splinting was effective in prevention only 36% of contractures. Conclusions Splinting can be an effective intervention option in preventing MCP extension contractures when less than 75% of the affected CFU has been grafted; however, its effectiveness decreases as the percentage of CFU involvement increases to greater than or equal to 99%. Applicability of Research to Practice Determine most effective post-operative rehabilitations plan following dorsal hand skin grafts.

95 Early Clinical Experience with an Autologous Homologous Skin Construct to Treat Deep Partial-thickness and Full-thickness Burns

Abstract Introduction Split-thickness skin grafting (STSG) is the standard of care for treating deep burns. They often contract, have limited cosmesis, lack dermal appendages, and result in painful, conspicuous donor sites. An Autologous Homologous Skin Construct (AHSC) has been shown to result in full-thickness skin formation.1,2 This study examined the safety profile, graft take, and quality of healing of a pilot group of AHSC-treated burn wounds. Methods Following IRB approval and informed consent, patients with deep-partial/full-thickness burns requiring grafting underwent side-by-side treatment with AHSC and STSG. A 2cm2 full-thickness harvest was processed into AHSC at an FDA-registered facility, returned within 48 hours, and applied to a 4cm2 area alongside a STSG. AHSC donor site was closed primarily. Wounds were evaluated for healing with digital photography and investigator assessments for 90 days. All adverse events (AEs) were recorded. Results Eight patients with 12% TBSA [range 2–40%] burn wounds were treated; 5 Caucasian and 3 African American with an average BMI of 26.8. Injury was due to predominantly flame burn, with additional injury from grease, scald, contact, friction, and flash. Mean time between injury and AHSC treatment was 11 days [range 5–35 days]. All patients had graft take and complete epithelialization by the end of the study. Patients required one application of AHSC and no other additional surgical procedures at the application sites. The most common AEs for STSG-treated wounds included hypertrophic scarring, pruritus, and insomnia. One non-infected AHSC harvest site experienced a mechanical dehiscence. There were no other AEs related to AHSC treatment. Conclusions No related adverse events at the treatment sites were noted in this study. However, the size of the treatment area limited the ability to comment on the presence of complex dermal elements including hair follicles. Additional investigation with application to larger areas is warranted to evaluate the utility of AHSC for the treatment of acute burn wounds. Applicability of Research to Practice Novel therapy may provide an alternative treatment for burns requiring skin grafting however larger studies are needed.

734 A Comparison of Burn Depth Assessment Between Clinical Diagnosis and Laser Doppler Imaging

Abstract Introduction Accurate burn assessment is crucial to prescribing appropriate treatment and is dependent upon the experience of the provider and the timing of diagnosis relative to the burn injury evaluation. Differentiating between a deep partial thickness and full thickness burn may not be easily discernible. To augment the clinical diagnosis of burn depth, a laser doppler image measures the microvascular blood flow of injured tissue to predict burn wound healing. The aim of this study is to evaluate the clinical assessment of burn wounds by experienced burn providers compared to the laser doppler image assessment in predicting which burn wounds should heal spontaneously in 3 weeks. Methods A retrospective chart review from 2012–2016, included 54 subjects. The clinical assessment included a description of burn variables relevant to the determination of spontaneous burn wound healing (burn depth, total body surface area, mechanism of injury, anatomical location, clinical burn depth diagnosis, and laser doppler image). A chi-square analysis compared the clinical diagnosis and the laser doppler assessment of burn wound depth, as well as the correlation between clinical diagnosis versus laser doppler image in predicting spontaneous burn wound healing. Results Comparing partial thickness burn injuries, there were 38 clinically diagnosed partial thickness injuries (by experienced burn providers) and 38 partial thickness burn injures diagnosed via LDI. Deep partial thickness burn injuries were diagnosed clinically in 9 subjects, compared to 10 via LDI. Full thickness burn injuries were diagnosed clinically in 7 subjects and 6 via LDI. A chi-square test was performed to examine the relationship between clinical diagnosis of burn depth and laser doppler image. The relation between these variables was significant,X2= 26.884, p< .000. Comparing clinically diagnosed burn depth to LDI, each approach (clinical or LDI) diagnosed 42 subjects with partial thickness or deep partial thickness burn injuries and all healed spontaneously. Two of the clinically diagnosed full thickness burn injuries required skin grafting. Six patients were lost to follow-up (X2= 17.745, p < .001). Conclusions This study confirms there is no difference between an experienced burn provider’s clinical diagnosis of burn wound depth and prognosis for spontaneous healing compared to a laser doppler image prognosis of burn wound healing. Applicability of Research to Practice In an era of advanced technologies, expert clinical bedside assessment is the standard of care.

Closed Incisional Negative Pressure Wound Therapy at Flap Suture Line: An Innovative Approach for Improving Outcomes in Suboptimal WoundConditions.

Background Persistent dead space following flap cover is a frequently encountered challenge following the reconstruction of complex wounds. It may lead to a hematoma, seroma, wound infection, and wound dehiscence. Wound dehiscence could be a devastating complication. Closed incisional negative pressure wound therapy (ciNPWT) over the surgical incisions was found to reduce surgical site infection (SSI) and wound dehiscence. We applied this principle at the closed flap suture line and through this article, we share the indications, technique, and outcomes. Methods A retrospective analysis (January 2018–June 2019), in which selected high-risk patients who underwent ciNPWT at the flap suture following complex reconstruction (pedicled or free flap) were included in the study. The indications include deep incisional/organ SSI after debridement and flap coverage, persistent dead space following flap coverage, chronic osteomyelitis. Patients were analyzed in the follow-up period in terms of complications, wound healing. Results Nine patients underwent ciNPWT over the flap suture line. The mean age was 32.2 years (range: 10–48 years). The mean duration of the NPWT application was 7.3 days (range: 3–21 days). Three of the nine patients had flap-related minor complications. One patient had marginal flap necrosis and required skin grafting, one patient had minor wound dehiscence (1 cm) which required secondary skin suturing and one patient had chronic discharging sinus related to osteomyelitis of ischium, which subsequently healed with antibiotics and local wound care. None of the patients had NPWT-related complications. Conclusion Closed incisional NPWT decreases the untoward effects of dead space following the reconstruction of complex wounds. The incidence of SSI and wound gaping can be reduced.

Finger pulp reconstruction with thenar flap: Aesthetic and functional outcome

PurposeFingertip injuries are common in industrial production activities as well as in domestic work. Loss of pulp hampers daily life activities. Functional and aesthetic aspects are important in fingertip reconstruction. The bone is usually exposed along with soft tissue loss. Therefore to reconstruct the pulp flap with adequate bulk is required. MethodsWe reported a case series of 12 patients with the injury over the volar aspect of distal phalanx of the index or middle finger. In all cases, laterally based thenar flap was chosen. The flap donor site was closed primarily in most of cases, while 4 patients required skin graft. The flap was detached between 2–3 weeks. Functional assessment was done using static and dynamic 2-point discrimination and range of motion at each joint. The aesthetic outcome was assessed through questionnaire. The results were analyzed using the unpaired t-test (SPSS version 21). ResultsPartial necrosis occurred in 2 cases while rest of flaps survived successfully. Static 2-point discrimination ranged from 6–10 mm, mean 8.6 mm; and dynamic 2-point discrimination ranged from 8–10 mm, mean 8.9 mm. The mean satisfaction score was (4.0 ± 0.55). ConclusionThenar flap is a good choice for reconstruction of the finger pulp as it provides the bulk with good functional and aesthetic outcome.

Oncological Benefit of Melanoma Scar Excision with Surgical Safety Margins

Background: Melanomas represent about 1% of all skin cancer with an increasing incidence despite prevention campaigns. In Switzerland, one person out of fifty will develop this disease. After diagnosis by the general practitioner or dermatologist, the patient is referred to a specialized centre. According to T stage, the first step is scar excision and sentinel lymph node (SLN) biopsy. Surgical margins depend on the Breslow index (depth in millimetre of the tumour) and may be up to 2 cm. According to localization, it can be a mutilating procedure requiring skin grafts or flaps. The aim of the present study was to assess the efficiency of the scar excision with surgical margins and identify risks factors/correlation in patients presenting residual disease after first excision

The risk of early complications in patients with hand infections

Background: The aim of this study was to identify the risk factors associated with the development of early complications in patients with hand infections. A secondary objective was to describe the bacteriology and resistance profile in our study population. Methods: This retrospective observational descriptive study was performed at a regional referral centre in South Africa. All primary hand infection cases treated over a period of one year were reviewed. Children under 18 years, cases with incomplete primary outcome data and post-operative infections were excluded. Clinical and demographic data was extracted from clinical records. Amputation, re-debridement and tissue loss requiring skin grafting were regarded as early complications. Bacteriological analysis comprised identification of causative organisms as well as evaluation of their resistance profiles. Risk factors that were found to be significant for development of early complications were entered into a multivariate regression analysis. Results: After inclusion and exclusion criteria were applied, 78 patients were deemed eligible for inclusion to the study. The patientassociated risk factors that were found to be associated with the development of early complications after univariate analysis were increasing age and poorly controlled diabetes mellitus. Human bites and polymicrobial infections were the only aetiological factors that were identified to be significant on a univariate level. Initial presentation to a private sector general practitioner (GP) was the only management factor to reach significance on univariate analysis. Human immunodeficiency virus (HIV) infection, CD4 count, viral load and duration of ARV treatment were not found to be significantly associated with the development of early infections. On multivariate logistic regression analysis, poorly controlled diabetes mellitus, human bites and first presentation to a private GP were the only risk factors that remained significant for the development of early complications. The culture yield was 68%. Staphylococcus aureus (S. aureus) was the most frequently isolated organism (37%), followed by polymicrobial infections (10%). S. aureus encountered in our study population remained mostly sensitive to cloxacillin; however, high levels of resistance (50%) to ampicillin were observed. Klebsiella sp. and Acinetobacter sp. were the most frequently observed Gram-negative organisms. Conclusion: After multivariate regression analysis, hand infections in poorly controlled diabetic patients, infections occurring after human bites as well as those affected by polymicrobial infections were identified as independent risk factors for development of early complications in patients with hand infections. HIV infection was not found to be a significant risk factor. Our bacteriological profile is in keeping with trends demonstrated in the literature where S. aureus infections seem to be declining in frequency while polymicrobial infections seem to be encountered more frequently. Level of evidence: Level 4

A review of the reconstructive methods in the management of axillary hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic debilitating inflammatory disease of the apocrine gland-bearing body areas, characterized by painful recurrent abscess, sinus tract formation, and scarring. The treatment for HS consists of medical and surgical treatments in a multidisciplinary approach. Wide excision and reconstruction over the axillary hidradenitis suppurativa can be challenging due to possible morbidities; for example, scarring can lead to contracture over the axilla. In this report, we present 10 patients who underwent wide excision and reconstruction for the axilla hidradenitis suppurativa in our center from the year 2007 until the year 2017 with a mean follow-up of 3.17 years. All relevant operative information and data were collected from past medical records. Seventeen sites of affected axilla were reconstructed post-wide excision using various methods; from primary closure (n = 5), split thickness skin grafting (n = 5), and local fasciocutaneous flap (n = 2) to pedicle partial latissimus dorsi myocutaneous flap (n = 5). Primary closure is only achievable in smaller axillary defects with mean size of 65.2 cm2. Larger defects with averages 2 to 3 times the size are not amenable for primary closure and require skin grafting or flap coverage. Complications include wound dehiscence (n = 1), poor graft take (n = 3), and marginal flap edge necrosis (n = 1). Local fasciocutaneous flap is versatile and easily designed with the shortest mean operative time of 95 min. Hospital stay is shorter for primary closure and local fasciocutaneous flap with an average of 6 days for each as compared to using skin grafting (20 days) and pedicle partial latissimus dorsi myocutaneous flap (9 days). Only one recurrence (5.8%) was noted in a patient with primary closure post excision. All patients are satisfied with the surgical outcome and have no restriction of movement over their shoulders. Esthetically, reconstruction using primary closure and flap coverage methods is superior to skin grafting. Axillary HS requires complete excision to prevent future recurrence. Reconstructive method with soft tissue coverage presented a better outcome compared to split thickness skin grafting in terms of surgical time, recovery rate, morbidity, as well as functional and esthetic outcomes. Level of evidence: Level IV, therapeutic study.

\u201cStreets of Fire\u201d revisited: contact burns

BackgroundPavement-street contact burns are rare. This study compared recent contact burns to those published in “Pavement temperature and burns: Streets of Fire” in 1995. The hypothesis was that there were a significantly increased number of pavement-street burns, as a result of increased ambient temperatures, and that motor vehicle crash (MVC) contact burns were less severe than pavements-street burns.MethodsThis was a retrospective burn center registry study of naturally heated surface contact burns during May to September from 2016 to 2018. Statistical analyses were performed with one-way analysis of variance (ANOVA) and Maximum Likelihood chi-squared for age, percent of total burn surface area (% TBSA), treatment, hospitalization, comorbidities, hospital charges, mortality, ambient, and surface temperatures (pavement, asphalt, rocks).ResultsIn the 1995 study, median ambient temperatures were 106 (range 100–113) °F compared to the 108 (range 86–119) °F highest noon temperature in the current study. No ambient temperature differences were recorded on days with pavement burn admissions compared to days without these admissions. There were 225 pavement, 27 MVC, 15 road rash, and 103 other contact burns. The major injuries in the pavement group were due to being “down” (unknown reason), falls, and barefoot. Compared to the others, the pavement group was older, 56+ years, p < 0.001, and had smaller burns but similar length of stay. Fifty percent of the 225 pavement group patients with full-thickness burns required skin grafts. There were 13 (6%) fatalities in the pavement group vs 1 (4%) in the MVC group, p = 0.01. Fatalities were secondary to sepsis, shock, cardiac, respiratory, or kidney complications. Compared to survivors, the non-survivors had a significantly higher % TBSA (10% vs 4%), p = 0.01, and lower Glasgow Coma Scores (10 vs 15), p = 0.002.ConclusionThere was a median 2 °F increase in ambient temperature since 1995. The increase in pavement burn admissions was multi-factorial: higher temperatures, population, and the number of older patients, with increased metropolis expansion, outreach, and urban heat indices. Pavement group was similar to the MVC group except for significantly older age and increased mortality. Morbidity associated with age contributed to increased mortality.

Dermo traction as a solution to major skin defects: a prospective study in a tertiary care hospital of South Odisha

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Soft tissue loss with exposure of underlying tissue is a challenge to all Orthopedics surgeons. The present prospective study described dermo-traction technique using infant feeding tube or prolene suture as an alternative method for the wound closure.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective study described 30 cases where dermo-traction technique was used for the closure of the wound using infant feeding tube or prolene suture. Study was conducted in Orthopaedics Department of MKCG Medical College, Berhampur from June 2016 to May 2018. Patients requiring skin grafting for their major soft tissue defects or in whom skin grafting or fasciocutaneous flap could not be done were included in study.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Out of 30 patients,&lt;strong&gt; &lt;/strong&gt;2 were lost to follow-up. Average age of study participants was 39.1 years. Male constituted 67.8%. 78.5% of patients had wound in leg, 14.3% in thigh region, rest had on ankle. 82.1% had an open fracture wound, 10.7% had post-operative wound dehiscence and 7.1% soft tissue injury. Average wound healing time was 15.3days with average 5 tightening session of suture. Wounds healed eventually in 26 patients and 2 patients had an infection. Among 26 patients 9 patients had delayed primary and 17 had secondary closure of wound.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; It can be concluded that gradual closure of the wounds with soft tissue defects can be achieved by applying dermo-traction technique using prolene suture or infant feeding tube with average 15 days of time. So dermo-traction using infant feeding tube or prolene suture is a simple, inexpensive, effective and technically sound alternate solution for closure of wound.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

An Epidemiological Analysis of Pediatric Dog Bite Injuries Over a Decade

BackgroundAn estimated 800,000 dog bites require medical attention every year. The purpose of this study is to review the characteristics of dog bite injuries in children and examine temporal trends. MethodsThe Kids’ Inpatient Database was used to identify pediatric patients with dog bite injuries over a 10-y period. Demographic data, primary payer, injury characteristics, length of hospitalization, and treatments were recorded. Statistical analysis was performed in SAS 9.3 (SAS Institute Inc, Cary, NC). ResultsA total of 6308 patients were identified. Average age at time of injury was 6.4 ± 4.3 y. Children under age 5 y were the most affected subgroup (39.3% in 2000 versus 44.7% in 2009, P < 0.001). Most bites were to the head/neck and significantly increased from 53.9% in 2000 to 60.1% in 2009. Cellulitis complicated many injuries (33.7% in 2000 versus 44.8% in 2009, P < 0.001). Overall, 50% of patients underwent a procedure; 31% had an invasive surgical procedure; and 5.1% of patients required skin grafts or flaps. ConclusionsDog bites are a common cause of pediatric injuries and are a significant burden on families and the health care system. Evaluating the characteristics of these injuries can guide educational efforts.

A novel method of Mohs defect closure using posterior deltoid skin

Patients who undergo Mohs surgery may be left with sizeable defects and require skin grafts. Repair may prove especially challenging when the surgeon is faced with a large defect in a patient who is elderly with fragile, atrophic skin. Traditional donor sites for harvesting grafts can be difficult for patients to care for, heal slowly, and result in poor cosmesis.

Acute tissue expansion by pretaping to achieve elliptical excision and closure for skin tumours and soft tissue tumours

An elliptical excision of skin for treating a tumour is technically simple. Our objective was to recruit lateral laxity by stretching the skin prior to surgical excision of a tumour. A retrospective cohort of 20 consecutive patients who were treated with pretaping over a period of 7 years is presented. The surgeon used pretaping in patients with skin and soft tissue tumours where the pinch test for the planned ellipse failed to simulate easy closure. Data collated and analysed included patient demographic profile, tumour profile, parameters associated with pretaping and clinical outcome. A descriptive account demonstrating the technique is provided. The average age in the cohort was 44 years. The sample represents 24 sets of pretaping applications prior to 24 excisions. Twenty-three (96%) of these were performed on limbs. The 24 lesions treated were made up of five melanomas, 16 non-melanoma cutaneous neoplasms and three soft tissue sarcomas. The total time period of each set of applications per lesion varied from 15 min to 26 days. The mean width of the ellipse removed was 27 mm for cutaneous neoplasms (n = 21) and 84 mm for soft tissue sarcomas (n = 3). The pretaping allowed for simple direct wound closure with healing in all cases. Pretaping applied for as little as 30 min to several days prior to surgery can, within limits, expand skin tissue to achieve simple skin closure following elliptical excision of skin and soft tissue tumours in patients that would otherwise require skin grafting or skin flaps. Level of Evidence: IV Type of Study: Therapeutic

Pre-Radiotherapy and Its Use in Large Keloid Treatment

Keloids are serious scars that often extend beyond the borders of the original wound. They are difficult to cure because of their high recurrence rate, particularly in large keloids that require skin grafts. Keloid mass resection and post-operative radiotherapy is an effective method in keloid treatment. But skin graft in large keloid may impose many obstacles in post-operative radiotherapy. We use pre-radiotherapy to solve this problem. Eighty-six patients with chest wall keloids were treated from April 2005 to December 2015. The patients were treated with the pre-cut and pre-radiotherapy method. As for keloid pre-cut surgery, an incision was made down to the subcutaneous layer around the edge of the keloid. The wound was then closed after coagulation. 900cGy radiotherapy was applied on the following day. Then, the keloid was removed, and the wound was closed with a skin graft. Another 900cGy radiotherapy was applied when the graft was found to have survived. The patients received follow-up examinations at 6 and 24 months post-surgery. The scar at the operation site and aesthetic satisfaction were recorded and analyzed. Keloid recurred in eleven patients in 6 to24 months follow-up time. The overall recurrence rate was 12.79%. Six of them were cured by the second time keloid scar resection and radiotherapy. Hypertrophic scar was observed in two patients. The scar resumed after 8 to 13 months garment pressure treatment. Four patients complained of local pruritus. Their symptoms disappeared gradually. The other patients achieved satisfactory results with no recurrence. The pre-radiotherapy with keloid edge pre-cut may be a promising treatment option for patients with large keloids that require skin graft operations.

Transcatheter arterial chemoembolization improves the resectability of malignant breast phyllodes tumor with angiosarcoma component: a case report

BackgroundA giant phyllodes tumor of the breast is a rare fibroepithelial lesion, and its treatment is controversial. Many case reports have reported performing skin graft reconstruction after tumor excision. Chest wall resection may be required if the tumor has invaded the chest muscle layer. We speculated that transcatheter arterial chemoembolization (TACE) can improve the resectability of malignant phyllodes tumor of the breast without requiring skin grafting. The English literature contains only one case report similar to our experience.Case presentationWe report a rare case of a 51-year-old woman who had a giant malignant phyllodes tumor with heterologous sarcomatous differentiation in her right breast. The tumor was 19.43 × 12.98 × 21.47 cm. Whole-body computed tomography (CT) and bone scan did not reveal distant metastasis. Chest magnetic resonance imaging showed chest wall tumor invasion. Considering that skin defects after mastectomy can be extensive, we administered four courses of chemoembolization in the 5 weeks before surgery (30 mg of epirubicin and embozene microspheres [400, 500, and 700 μm]/week). Each process was well tolerated, with no serious complications. Only fever and local pain at the tumor site were noted, and these symptoms resolved with time. The follow-up CT scan showed a 45% reduction in tumor volume. Therefore, simple mastectomy was performed without skin grafting reconstruction. Wound healing was satisfactory, and the patient was discharged 1 week after surgery. Pathological and immunohistochemistry (IHC) findings showed a malignant phyllodes tumor with an angiosarcoma component. Because of tumor invasion of the chest wall, we recommended the patient receive radiotherapy, but she refused. Two months after surgery, recurrence of the malignant phyllodes tumor with right axillary lymph node involvement and lung metastasis was confirmed.ConclusionInitial surgical resection of giant phyllodes tumors is often challenging. For initial presentation with unresectable giant phyllodes tumor, we recommend to perform TACE prior to surgery. In our patient, preoperative TACE was effective and safe. If the tumor has invaded the chest wall, early radiotherapy after surgery may be recommended for preventing recurrence.