Required Skin Grafting Research Articles

Prospective Evaluation of a Negative Pressure Dressing System in the Management of the Fibula Free Flap Donor Site

The fibula free flap donor site has been associated with short-term donor site morbidity, most commonly delayed healing. To evaluate the effectiveness of a negative pressure dressing (NPD) system in the management of fibula free flap donor sites that required skin graft closure. Cohort study comparing a prospective cohort whose donor sites were managed with the NPD system from June 2009 through March 2012 with a retrospective cohort whose donor sites were managed with a conventional pressure (bolster) dressing (CPD) from August 2006 through May 2009. Tertiary regional head and neck reconstructive and maxillofacial surgery unit. All patients who had a composite fibula free flap for maxillofacial reconstructive surgery and required donor site closure with split-thickness skin grafts from August 2006 through March 2012. Negative pressure dressing used to manage the skin-grafted fibula donor site. Primary: time until complete healing of the fibula donor site. Secondary: skin graft take rate, infection rate, returns to operating theater for donor site problems, delayed hospital discharge due to donor site problems, and community intervention required for donor site dressing. All healing outcome measures were similar for the 21 patients in the NPD group and the 19 patients in the CPD group, with no statistically significant difference. Two patients in the CPD group required surgical debridement of the fibula donor site, compared with none in the NPD group (P = .22). The NPD group had a higher skin graft take success rate (15 [71%] vs 11 [58%]; P = .51) and required less nursing intervention for donor site dressings (8 [38%] vs 9 [47%]; P = .75) but had a higher wound infection rate (6 [29%] vs 2 [11%]; P = .24). Our findings would, at best, suggest that NPD may decrease the rate of return to the operating theater for donor site problems. The fibula donor site healing remains problematic, and our results suggest that routine use of the NPD system in the management of the fibula free flap donor site is not justified from a health economic perspective.

Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap

IntroductionVulvar reconstruction using the “lotus petal” fascio-cutaneous flap offers a relatively novel means to restore symmetry and functionality after extirpative gynecologic or oncologic procedures. We sought to assess the success rates and morbidity in a large series of consecutively treated patients. MethodsWe performed a retrospective review of 59 consecutive cases of lotus petal flaps performed at a single institution to more accurately assess success and complication rates. ResultsWe identified 80 flaps performed among the 59 patients between September 1, 2008 and March 30, 2013. The median (range) age was 59years (24–89) and the median (range) BMI was 27kg/m2 (19–34). The indications for vulvar/perineal excision were as follows: 39 (66.1%) vulvar carcinoma or melanoma, 12 (20.3%) vulvar dysplasia, 5 (8.5%) colorectal disease and 3 (5.1%) cases of hidradenitis suppurativa. The mean defect area, determined by post-fixation pathology specimen was 29cm2. Medical or surgical complications occurred in 36% of patients of which superficial wound separation was the most common (15%). There were no cases of complete flap loss, but partial loss occurred in 7 (8.8%) cases. 3 (5.1%) patients required re-operation prior to discharge with one case requiring skin grafting. Delayed surgical revision was required in 4 patients for partial flap loss (2) or stricture/stenosis (2). ConclusionThe lotus petal flap is safe for use in gynecologic reconstruction, with acceptable short- and long-term complication rates. Previous reports of smaller series likely underestimate the risk of complications through case selection.

Fireworks injuries in children: A prospective study during the festival of lights

We studied the epidemiology of paediatric firework-related injury in the urban population of Delhi during the festival of lights (Diwali). In this prospective observational study, data were collected on the day of Diwali for two consecutive years, 2010 and 2011. All children with firework injuries coming to the emergency room were included in the study. Data were recorded in a predesigned proforma. Of the 65 cases, 75% were males and 25% were females; most children were more than 10 years of age and majority (90%) of them were unsupervised. Half (49%) of the cases were due to misuse of the fireworks or erratic behaviour, among which the most common observed mode was igniting cracker while holding it (18 cases; 24% of total injuries), which led to injuries to the hand and palm. Device failure was the next common cause for firework injuries, including unexpected blast of the crackers and string bomb as the most common. Overall, the most commonly injured body sites were hands (62%), face (32%) and eyes (10%). Crackers and string bomb mainly caused injuries to hands; fountains and gunpowder caused injuries to the face. Sixty (94%) children were managed conservatively and 5 (6%) required skin grafting and tendon repair. We recommend parental supervision especially for males, wearing non-synthetic and non-flowing clothes, promoting branded crackers and educational campaigns in schools to curtail the rising trend in firework-related injuries in the paediatric population.

Epidermal growth factor regulates NIKS keratinocyte proliferation through Notch signaling

BackgroundCutaneous wound healing is a significant health issue in the US, often requiring skin grafts. StrataGraft (Stratatech Corporation, Madison, WI), a second-generation living human skin substitute created from NIKS human keratinocyte progenitors, was recently found to be a promising skin graft in phase I/II safety and efficacy clinical trial. NIKS proliferation is optimal in the presence of epidermal growth factor (EGF). Our preliminary data suggested that Notch signaling also plays a role in NIKS keratinocyte proliferation. Therefore, we hypothesized that EGF might stimulate NIKS proliferation by regulating Notch1 signaling. MethodNotch1 messenger RNA (mRNA) levels from NIKS cells in monolayer culture were assessed by real-time polymerase chain reaction and Notch1 protein levels were detected by Western blot. To determine the role of EGF on Notch1 regulation, cells were incubated in basal media and then treated with EGF (10 ng/mL). A 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was performed to test NIKS cell proliferation. Cells were grown in basal media supplemented with EGF for 72 h in the presence or absence of N-[N-(3,5-Difluorophenacetyl)-L-alanyl]-S-phenylglycine t-butyl ester (DAPT) (0–30 μM), an inhibitor of Notch1 signaling. ResultsNotch1 mRNA levels were cell confluence-dependent, being more abundant in a subconfluent cell monolayer. We detected a 2-fold decrease in Notch1 mRNA expression and a reduction in active Notch1 protein level in response to EGF. EGF treatment stimulated NIKS cellular proliferation. However, co-treatment with DAPT inhibited NIKS proliferation to basal levels. Blocking Notch1 activation by DAPT alone inhibited NIKS cellular proliferation (P < 0.01%). ConclusionOur results suggest that Notch1 is an essential downstream mediator of NIKS cellular proliferation via the EGF signaling pathway.

O-020 Head and Neck Endovascular Repair of Vascular Malformations

ObjectiveTo determine the efficacy of ethanol embolotherapy of extracranial head and neck vascular malformations of all types, particularly after failure of other endovascular and surgical treatments.MethodsOne hundred and sixty-six patients...

Not so fast to skin graft

Damage-control laparotomy (DCL) has revolutionized the surgery of injury. However, this has led to the dilemma of the nonclosable abdomen. Subsequently, there exists a subgroup of patients who after resuscitation and diuresis, remain nonclosable. Before the adoption of our open abdomen protocol (OAP) and use of transabdominal wall traction (TAWT), these patients required skin grafting and a planned ventral hernia. We hypothesize that our OAP and TAWT device, which use full abdominal wall thickness sutures to dynamically distribute midline traction, achieve an improved method of fascial reapproximation. From 2008 to 2011, all DCL and decompressive laparotomy patients in our urban trauma center were managed by our OAP. Thirty two were noncloseable "domain loss abdomens" after achieving physiologic steady state and near dry weight. All patients received the TAWT device when near dry weight was achieved. Wound size, days to closure, days to TAWT, and TAWT to closure were tracked. During this 36-month period, OAP/TAWT was applied to 32 patients. All patients demonstrated domain loss precluding fascial closure. Average wound size was 18.5-cm width by 30.5-cm length. Mean time DCL surgery to TAWT was 9.5 days. At time of placement, TAWT decreased initial wound width by an average of 9.8 cm (51.4%). Patients returned to the operating room for tightening/washout an average of 2.2 times (excluding TAWT insertion and final closure operations). Mean time TAWT to closure was 8.7 days. Mean time from admission surgery to primary closure was 18.2 days. All patients achieved primary fascial closure using this method without components separation or biologic bridge operations. OAP/TAWT has revolutionized the way we manage "domain loss" open abdomen patients and has virtually eliminated the acceptance of planned ventral hernia. TAWT consistently recaptures lost domain, preserves the leading fascial edge, and eliminates the need for biologic bridges, components separation, or skin grafting. Therapeutic study, level III.

Epidemiology and treatment of paediatric burns in a large children’s hospital in Morocco: Analysis of 394 cases

Abstract Introduction Injury from burns represents 2% of emergency admissions in university hospitals in Morocco. Burn injuries can lead to substantial morbidity in the paediatric population including an impact on later life. Methods A retrospective study of 394 paediatric burn patients was performed. Subjects were identified by review of the emergency centre logs and data were extracted from patient records. Data included demographic information, mechanism of burn, treatment prior to arrival at the hospital, hospital management and follow up condition. Results The majority (65.7%, n =259) of patients were between 1 and 4years old with an average age of 4.26years and male predominance (male:female=2:1). Scalding was the main mechanism of injury (83.5%, N =329). The trunk and upper limbs were the most commonly affected areas of the body (59% and 50%, respectively) with the face affected in 9.6% of cases. The total body surface area burned ranged from 1% to 10% in 86% of patients. Seventy-five patients (19%) required hospitalisation, 57 patients (14%) required skin grafting and 27 (6.9%) had major sequelae. Discussion This large case series highlights the current epidemiology, management and outcome of paediatric burn victims in Morocco. Current burn management in low resources settings can be challenging and several additional measures should be taken to reduce morbidity among paediatric burn victims.

Skin Contracture Following Upper Eyelid Orbiculectomy: Is Primary Skin Excision Advisable?

Aim: To report the incidence and consequences of skin contracture following upper eyelid orbiculectomy.Methods: A retrospective case note review identified 8 consecutive patients undergoing skin sparing upper eyelid limited orbiculectomy for essential blepharospasm associated with apraxia of eyelid opening. Clinical data collected from this review included age, gender, type of surgery performed, surgical complications, the need for additional surgeries, botulinum toxin treatment after surgery, dry eyes and blepharospasm functional disability assessment score. Pre and post operative photographs (at 1 year follow up) were used to assess the change in upper eyelid skin.Results: The mean preoperative functional disability score was 72 ± 18 and improved to 25 ± 18 postoperatively at last follow-up. One patient needed botulinum toxin injections postoperatively. Intraoperative complications included bleeding in one case and haematoma in another case. Although we did not excise excess skin in any of our cases, we noted a reduction in upper eyelid skin excess in all cases, postoperatively. Restrictive lagophthalmos was noted in 3 cases (who had orbiculectomy alone) which required skin grafting and/or levator recession.Conclusion: Upper eyelid limited orbiculectomy with meticulous attention to pre-tarsal and pre-septal orbicularis only is effective in improving apraxia of eyelid opening and blepharospasm. Although we did not excise excess skin in any of our cases, we noted skin contracture postoperatively in three cases severe enough to require skin grafting or scar release. In our experience, skin contracture and orbital septal scarring appears to be relatively common following upper eyelid orbiculectomy, particularly if pre-tarsal and septal orbicularis is meticulously excised. In such a scenario we suggest avoiding concurrent excision of any dermatochalasis.

Pediatric Sink-Bathing

Our burn center previously reported a significant incidence of scald burns from tap water among patients treated at the center. However, mechanism of these scalds was not investigated in detail. A recent series of pediatric patients who sustained scalds while bathing in the sink was noted. To evaluate the extent of these injuries and create an effective prevention program for this population, a retrospective study of bathing-related sink burns among pediatric patients was performed. Patients between the ages of 0 and 5.0 years who sustained scald burns while being bathed in the sink were included in this study. Sex, race, age, burn size, length of stay, and surgical procedures were reviewed. During the study period of January 2003 through August 2008, 56 patients who were scalded in the sink were admitted, accounting for 54% of all bathing-related scalds. Among these, 56% were boys and 45% were Hispanic. Mean age was 0.8 ± 0.1 years. Burn size and hospital length of stay averaged 5 ± 0.7% and 11 ± 1 days, respectively. Of this group, 10.7% required skin grafting. The overwhelming majority (94% of patients) were discharged home. The remaining patients were discharged to inpatient rehabilitation, foster care, and others. Pediatric scald burns sustained while bathing in a sink continue to be prevalent at our burn center. Because of limited space and the child's proximity to faucet handles and water flow, sinks are an unsafe location to bathe a child. While such practice may be necessary for some families, comprehensive burn prevention education must address this hazard.

Combined Use Of Ultrasound Guided Infraclavicular Block And Lateral Femoral Cutaneous Nerve Block In Upper Extremity Reconstruction Requiring Large Skin Graft: Case Report

Combined nerve blocks of the upper extremity and lower limb in same operation rarely performed due to the risk of systemic toxicity of local anesthetics. Therefore, general anesthesia is generally preferred in this operations. However, use of ultrasound allows reliable deposition of the anesthetic around the nerves, potentially lowering the local anesthetic requirement. In this case report, we present a 44-year-old, ASA physical status I, male patient who was operated for upper extremity reconstruction requiring skin graft from anterolateral thigh region under ultrasound-guided infraclavicular brachial plexus block and lateral femoral cutaneous nerve block. The block was successful and no block-related complications were noted. We think that combining an ultrasound guided infraclavicular brachial plexus block and a lateral femoral cutaneous nerve block is a clinically useful and safe technique and an alternative anesthetic method for procedures requiring skin grafts for the upper extremity.

Combined Arterial Reconstruction and Free Tissue Transfer for Patients with Critical Limb Ischemia

The purpose of treatment for critical limb ischemia (CLI) is to prevent major amputation. The purpose of this study was to evaluate our experience of treating CLI with free tissue transfer (FTT) and revascularization. From January 2010 to December 2012, seven lower extremities in seven patients were treated with revascularization and free tissue transfer for CLI with tissue loss. All seven patients had tissue loss with a Rutherford category 6 status. Six patients underwent bypass surgery, and one patient underwent percutaneous transluminal angioplasty for revascularization. All patients also underwent free tissue transfer using the latissimus dorsi muscle simultaneously and separately in two and five patients, respectively. Five of the seven patients exhibited flap patency and survival. One patient obtained flap survival and limb salvage, although the flap graft was occluded after the patient achieved limb salvage. One patient developed partial flap necrosis requiring skin grafting and acquired limb salvage. The flap survival rate was 85%, and the limb salvage rate was 100%. FTT with arterial reconstruction for CLI achieves successful wound healing and limb salvage. Both bypass surgery and endovascular treatment are useful for maintaining the vascular supply.

Statewide Ban on Recreational Fires Resulted in a Significant Decrease in Campfire-Related Summer Burn Center Admissions

Every summer, there is an increase in the number of burn injuries caused by accidents around campfires. Because of the prevalence of drought, high winds, and uncontrolled wild fires, a statewide ban on recreational fires was instituted in New Mexico from June to July 2011. We hypothesized that this legislation would have a significant impact on burn admissions caused by campfire-related injuries. A retrospective review of summer admissions to a state burn center was conducted to assess the effect of this ban on recreational fire injuries, and these data were compared with that of the previous summer when no ban was in effect. All burn admissions to a state burn center were reviewed from Memorial Day to Labor Day in 2010 and 2011. Data collected included cause, % TBSA, age, days of hospitalization, intensive care unit days, and total surface area grafted. Nonparametric statistical analysis was performed with Fisher exact test for dichotomous data and Mann-Whitney test for continuous data with significance at P < .05. There were 164 burn center admissions between Memorial Day and Labor Day in 2010 (n = 82) and 2011 (n = 82). Compared with all summer burn center admissions, patients injured by campfires were younger (18 vs 37 years; P = .002) with smaller total surface area burns (3.2 vs 6.2%; P = .41) and had shorter lengths of stay (10-11 vs 6-7 days; P = .62). There was more than a 3-fold decrease in burn admissions due to recreational fires during the study period (n = 14 [17%] in 2010 and 4 [5%] in 2011; P = .02). This resulted in a decrease in the number of patient-days from 91 in 2010 to 25 in 2011. Half of the camp fire admissions required skin grafts to definitively close the wounds (6/14 in 2010 and 2/4 in 2011). Recreational fire bans targeted at controlling wildfires during conditions favoring rapid spread were associated with a 3- to 4-fold decrease in campfire-related burn admissions. Compared with a summer when no fire ban was in effect, the number of patient-days decreased from 91 to 25.

Functional and Cosmetic Outcome of Full- Versus Split-Thickness Skin Grafts in Pediatric Palmar Surface Burns

Palmar hand burns continue to be a common injury in the pediatric population, with long-term implications for function, hand rehabilitation, and psychosocial well-being in a growing child. Debate over the choice of full-thickness skin grafts (FTSG) and split skin grafts (SSG) for optimal subsequent functional and cosmetic outcomes continues. This study prospectively evaluated children who required skin grafting of palmar burns at our institution between January 2008 and December 2009. A clinical assessment of the grafted area and donor site using the Vancouver Scar Scale, together with assessment of sensation, hair growth, and the development of contracture was performed by an independent clinician. Thirty-four (16%) of 214 palm burns that presented to our institution during this period required grafting, of which 26 (77%) agreed to participate in this study. At a mean 13.5 months postsurgery, pliability was significantly enhanced in FTSG compared with SSG (P < .001). Although not statistically significant, vascularity and height of SSGs were preferred. There was no difference in sensation between the two types of graft or donor site outcomes, although hair growth was significantly (P = .002) more prominent in FTSG. There were an equal number of contractures in the two groups, with grafts of either type that extended from the palm onto the volar aspect of digits more commonly affected. These data suggest an improved outcome in children with deep palm burns after FTSG, although with the exception of scar pliability these differences were small.

Dorsal foot resurfacing using free anterolateral thigh (ALT) flap in children

Very limited literature described the use of the free anterolateral thigh (ALT) among other flaps for pediatric lower limb reconstruction. The aim of this study is to present our experience using the free ALT flap for reconstruction of soft tissue defects over the dorsum of the foot and ankle in children. The study included 42 children aged 2.5-13 years with a mean of 6.18 years. Three children had crush injuries while the rest were victims of run over car accidents. All of the flaps were vascularized by at least two perforators; 88.23% were musculocutaneous and 11.77 were septocutaneous perforators. All flaps were raised in a subfascial plane. Initial thinning was performed in five flaps and 35% required subsequent debulking. Mean Flap surface area was 117.11 cm(2). The recipient arteries were the anterior tibial artery in 38 cases and posterior tibial artery in four cases. Venous anastomosis was performed to one vena commitant and in nine cases the long saphenous vein was additionally used. Mean ischemia time of the flap was 2 hours while total operative time averaged 6.3 hours. About 41% of donor sites were closed primarily while 59% required skin grafting. Primary flap survival rate was 92.8% (39/42 cases). Three flaps showed venous congestion. After venous reanastomosis, two flaps showed partial loss and one flap was lost completely. Post-operative hospital stay averaged 7.5 days. The free ALT flap could be as safe, reliable, and aesthetically appealing option for foot/ankle resurfacing in children after traumatic soft tissue loss.

Closure of Scalp and Forehead Defects Using External Tissue Expander

To describe the novel use of an external tissue expander in the reconstruction of scalp and forehead defects. A prospective review was performed on 7 patients who underwent extirpation of head and neck malignant neoplasms resulting in scalp and forehead defects. Reconstruction was performed using an external tissue expander device. Patient clinical factors, defect size, and photographs were collected. Seven patients had large scalp and forehead defects ranging in greatest dimension from 5.0 ×4.0 to 8.0 ×7.0 cm. The external tissue expander was in place for 6 to 14 days, reducing the defect sizes by 50% to 99%. At the time of device removal, primary closure was achieved in 5 patients. One patient required bilateral advancement rotation flaps, and 1 patient healed by second intention. One patient with a history of scalp irradiation and diabetes had partial skin loss after device removal and required reconstruction with a latissimus dorsi myocutaneous free flap. There were no other postoperative complications, wound breakdown, or device failures. External tissue expansion is a safe and effective technique for closing large scalp and forehead defects that would otherwise require skin grafting or free flap reconstruction.

Resolvin D2 prevents secondary thrombosis and necrosis in a mouse burn wound model

Deep partial thickness burns are subject to delayed necrosis of initially viable tissues surrounding the primary zone of thermally induced coagulation, which results in an expansion of the burn wound, both in area and depth, within 48 hours postburn. Neutrophil sequestration and activation leading to microvascular damage is thought to mediate this secondary tissue damage. Resolvins, a class of endogenous mediators derived from omega-3 polyunsaturated fatty acids, have been shown to regulate the resolution of inflammation. We hypothesized that exogenous resolvins could mitigate the deleterious impact of the inflammatory response in burn wounds. Using two different mouse burn injury models involving significant partial thickness injuries, we found that a systemically administered single dose of resolvin D2 (RvD2) as low as 25 pg/g bw given within an interval of up to 4 hours postburn effectively prevented thrombosis of the deep dermal vascular network and subsequent dermal necrosis. By preserving the microvascular network, RvD2 enhanced neutrophil access to the dermis, but prevented neutrophil-mediated damage through other anti-inflammatory actions, including inhibition of tumor necrosis factor-α, interleukin-1β, and neutrophil platelet-endothelial cell adhesion molecule-1. In a clinical context, RvD2 may be therapeutically useful by reducing the need for surgical debridement and the area requiring skin grafting.

Infraareolar pectoralis major myocutaneous island flap as treatment of first choice for deep sternal wound infection

Deep sternal wound infection (DSWI) is a grave complication of median sternotomy, associated with high morbidity, mortality and escalating treatment costs. There is general consensus that optimal treatment comprises radical debridement followed by coverage with a vascularised flap. However, there is ongoing debate regarding the ideal operative procedure. We present our experience with the infraareolar pectoralis major island myocutaneous flap (PEC-MI flap) as treatment of first choice in DSWI. Following a retrospective chart review, data pertaining to patient demographics, type of cardiac surgery performed, prevalence of known DSWI risk factors, identified pathogens, duration of surgery, flap-related complications, duration of hospital stay and antibiotic therapy, as well as mortality were noted. Additionally, we describe the operative technique and review the relevant literature. Twenty-five patients underwent coverage with the PEC-MI flap in our department. The average age was 69.2 years. Nineteen patients underwent coronary artery bypass surgery, 10 valve replacement, two aortic replacement surgery and one pericardiectomy. In six cases, no internal mammary artery was used in cardiac surgery, in 11 cases one and in seven cases both internal mammary arteries were used. The average duration of surgery was 154.2min and the average hospital stay was 28.4 days. Complications which required revision surgery were haematoma in three cases, one wound dehiscence and one recurrent infection. Two cases required coverage with an additional regional flap. The PEC-MI flap has been used as flap of first choice in our clinic for treatment of DSWI. It is sufficient to raise the flap unilaterally, and it does not require skin grafting. The combination of immunocompetent bulky muscle tissue used to obliterate the sternal cavity and the large skin paddle enabling a low-tension skin closure allows reliable and efficient treatment of this severe complication.

Changes in the plasma cytokine and growth factor profile are associated with impaired healing in pediatric patients treated with INTEGRA® for reconstructive procedures

BackgroundLarge full thickness skin defects caused by trauma or surgery require skin grafting, often in conjunction with dermal scaffolds such as INTEGRA®. Due to the size and severity of these procedures, complications such as infection may occur. This can lead to poor healing outcomes. ObjectiveTo identify early biomarkers of complications during INTEGRA® healing. MethodsLevels of EGF, TGF-β1, FGF-2, VEGF, IFN-α, GM-CSF, IL-4 and IL-8 were measured pre-surgery and at days 1, 7 and 25 post-surgery in peripheral blood of 15 pediatric patients treated with INTEGRA® for reconstructive procedures. The levels of these molecules were analysed with respect to the occurrence of complications. ResultsComplications (local infection) occurred in a group of 4 patients. This resulted in a reduced INTEGRA® take rate comparing to the group without complications (71.5±5.4% vs. 98.1±0.7%). In cases with complications there were significantly higher plasma concentrations of IL-4 and FGF-2 on day 7 (p=0.037 and p=0.008 respectively). Other markers were not significantly different between groups or at very low level at all time-points. WCC and CRP remained within normal ranges at all time-points. ConclusionsThis data suggests that elevated levels of IL-4 and FGF-2 at early time-points after surgery may predict the development of complications in patients with INTEGRA®. This may enable early interventions to prevent complications in procedures involving the use of INTEGRA®.

A kick in the shins: The financial impact of uncontrolled warfarin use in pre-tibial haematomas

Warfarin is increasingly prescribed in the elderly population for a number of medical conditions. Pre-tibial haematomas are a common cause of morbidity in this group. The aim of the study was to identify the proficiency of INR monitoring at a primary care level in correlation with their recommended INR range and to study the treatment outcome in this group.A retrospective single-centre study of patients diagnosed with pre-tibial haematomas was conducted over a two-year period. Length of hospital stay, time delay until operative intervention, blood transfusion and warfarin reversal requirements, social care input and cost to the NHS were considered.A total of 62 patients were admitted with pre-tibial haematomas of which 20 were on Warfarin. Females were predominantly more affected (5.6:1). The mechanism of injury was as a result of minor trauma. The mean INR level was 3.8 with a standard deviation of 3.1. Mean length of hospital stay was 11 days with a standard deviation of 13.6. Nine patients required skin grafting. Average cost for the acute episode was £3500 per patient.INR levels were significantly outwith the target range causing substantial patient morbidity and imposing a significant financial burden on the NHS. Tighter regulation at a primary care level should help reduce this risk.

Management of Massive Mastectomy Skin Flap Necrosis Following Autologous Breast Reconstruction

The optimal management of severe mastectomy skin flap necrosis continues to remain a challenge. Following autologous reconstruction, small or minor areas of ischemia/tissue necrosis can result in multiple office visits, increased expenses due to dressing supplies and nursing care, and revisional operations. The purpose of this study is to describe outcomes of a common management strategy for surgeons when confronted with a patient with extensive mastectomy skin flap necrosis. Between 1997 and 2010, autologous breast reconstructions were performed in 805 women and 1076 breasts. Of these, 12 patients (15 breasts) were identified who met the criteria for massive skin flap loss (>30%). Patient photographs and wound measurements were used to estimate areas of necrosis. All patients were managed initially with local wound care followed by delayed scar excision. Wound closure was ultimately achieved in all patients. Of the patients, 40% were active smokers in the perioperative period. The average patient age was 49.6 (range, 28-59) years with a body mass index of 30.9. The average mastectomy weight was 959.5 g (range, 223-1520). In-office soft-tissue debridement and local wound care was performed until wound closure was complete, which took place at a mean of 120 days (range, 30-300) after initial surgery. The average patient had a mean of 10 office visits before scar revision. There was an average of 1.7 types of dressing changes needed before wound closure. Topical wound therapy included moisturizing gels, wet-to-dry dressing, and antibiotic ointment. Oral antibiotic therapy was used in 60% of patients. Late scar revision was performed in 87% of the patients at an average of 8.9 months (range, 1-14) after initial surgery. After the initial flap surgery, no patient required skin grafting or hospitalization. Early conservative management followed by late scar revision produced excellent results in patients with massive mastectomy skin flap loss. The outcomes described may help clinicians and patients in the decision-making process when confronted with this difficult problem.