Secondary Intention Research Articles

Secondary intent healing of Obstetric and Gynecologic surgical wounds complicated by abdominal wall abscess

Objective: Objective: To evaluate healing by secondary intention in obstetric and gynecological surgical wounds complicated by abdominal wall abscess. Methods: A prospective, descriptive, analytical, and observational study was conducted in 38 patients with abdominal wall abscess after cesarean section or gynecological surgery in whom healing by second intention of the wound was implemented. The data obtained were expressed as absolute values, in percentages and as mean + standard deviation. ANOVA was applied to analyze the factors that influenced wound closure time, considering a p-value < 0.05 as statistically significant. Results: Regarding the average general characteristics, age was 29.66 ± 10.65 years, weight 72.18 ± 14.21 kg, height 1.62 ± 0.05 meters, and body mass index 27.62 ± 4.58 Kg/m2. For risk factors, previous abdominal surgeries 44.74%, urinary tract infection 21.05%, vaginal discharge 28.95%, premature rupture of membranes 18.42%, hypertension 39.47%, diabetes 5.26%, obesity 31.58% and smoking 10.53%. The most frequent germ was Staphylococcus aureus (35.14%). A total of 52.63% required a change of antibiotic. Dressings were used in 55.26 %. It took an average of 31.30 ± 8.40 days to close the wound. Patients spent 12.61 ± 5.78 days in hospitalization. Conclusions: Good aesthetic and functional results were obtained; the use of dressings does not accelerate the wound healing time.

Posterior Positioning of Levator Veli Palatini with Intact Nasal Layer and Side-by-Side Bilateral Buccinator Flaps: Modified Approach for Palatal Lengthening.

To introduce a modified surgical method using bilateral buccinator flaps with posterior positioning of levator veli palatini muscles to treat velopharyngeal insufficiency. Cross-sectional clinical study. Non-syndromic patients with velopharyngeal insufficiency. We performed a modified surgical method using posterior positioning of levator veli palatini muscles and side-by-side bilateral buccinator flaps. Patients' characteristics, severity of hypernasality, palatal lengthening size, and operative complications were recorded and described. The severity of hypernasality was determined by a speech therapist before and after the operation. A total of 26 non-syndromic patients, with a median age of 8.5 years, were enrolled. All patients presented with severe hypernasality. Following the operation and during the follow-up period, 12 patients showed a complete resolution of hypernasality, while 9, 3, and 2 patients exhibited mild, moderate, and severe hypernasality, respectively. In addition, the mean palatal lengthening was measured to be 25.3 ± 3.5 mm. Overall, three patients experienced partial flap loss in one flap, which was successfully repaired with a secondary intention without the development of a fistula. In five cases, complete closure of the donor sites couldn't be achieved and thus were treated with secondary intention. Additionally, postoperative food restrictions were observed in seven cases but were resolved within one month. No other complications were noted in the remaining patients. This modified palatal lengthening technique results in a significant lengthening of the palate while maintaining favorable speech outcomes. Future randomized clinical trials are warranted to validate our findings.

P024 Dermatomyositis, a blurred clinical picture

Abstract Background/Aims We present a case of MDA5 dermatomyositis(DM) in a 25-year-old male, initially presenting with seronegative inflammatory polyarthritis affecting the hands. No classic features of DM were noted and CK was normal. Sulfasalazine was started and subsequently stopped after an ALT rise. Lung-function performed prior to planned methotrexate was abnormal. A CT neck, thorax and abdomen showed unusual pulmonary appearances with focal basal ground glass opacities with reverse halo, without widespread interstitial lung disease(ILD). A bronchoscopy excluded atypical infection. He then developed scaly lesions over the extensor PIPJs, periungual lesions, periorbital swelling and sicca symptoms. CK remained normal, extended myositis screening was negative. LDH and troponins were elevated. A skin biopsy of the hand rash was consistent with dermatomyositis. Methods Muscle pain persisted and an MRI proximal muscles showed muscle oedema and inflammation. A muscle biopsy was requested but not performed as he developed an olecranon bursa with staphylococcal aureus infection. The bursa broke down, required wash-outs, antibiotics and was left to heal by secondary intention. A repeat myositis screen was positive for MDA5 antibody. Immunosuppression was delayed because of concerns that prednisolone, Mycophenolate mofetil(MMF) or Rituximab would cause further wound breakdown and increased risk of infection. The patient was monitored with serial lung-function but didn’t develop ILD. Dermatology confirmed there was active dermatomyositis in the wound edges. The wound only finally healed with additional IVIG therapy. The patient is now established on Rituximab, having been unable to tolerate MMF. Results This case highlights that continued reassessment of the evolving clinical picture is vital to reach the correct diagnosis, and that one should not be reassured by a normal CK. Instead the ALT rise (along with mild elevations of LDH and troponin) was likely reflecting muscle inflammation, not liver inflammation secondary to Sulfasalazine. The repeatedly infected olecranon bursa and large open wound raised concerns about immunosuppressive agents. However, the lack of healing was due to active DM and escalation of treatment was required rather than treatment delay. IVIG was given with excellent and rapid effect. This is licensed for refractory skin involvement in DM, to be considered when infection concern is high. Conclusion The pulmonary involvement with reverse halo sign was felt by the MDT to be nonspecific initially, with a wide differential. In the clinical context, this was reflecting an atypical presentation of MDA5 positive ILD. This antibody can be associated with rapidly progressive ILD and death in approximately one third of cases. Had our patient shown evidence of significant pulmonary progression, high dose immunosuppression would have been commenced despite potential infection risk. Not all patients testing positive for MDA5 develop rapidly progressive ILD but clinical suspicion should be high with frequent serial monitoring of lung function and radiology. Disclosure L. Maltas: None. J. Vila: None. A. Ray: None.

Efficacy of modified vacuum-assisted dressing versus conventional betadine dressing in wound healing of open fractures

AimThis study aimed to compare the effectiveness of a customized vacuum-assisted dressing to traditional betadine dressings for wounds in open fractures. Materials and methodsIn this prospective comparative study, 30 patients from two groups—group A receiving V.A.C. while group B receiving traditional dressing—were given data from sixty participants with open fractures. Wound was evaluated on days 0, 3, 7, 11, and 15 of the study. ResultsIn group A, there was a statistically significant decrease in the mean dimension of the wound overall (15.66 mm vs. 7.4 mm in group B), and it took an average of 9.83 days for healthy granulation tissue to emerge. In contrast to the 21 patients who had split skin grafting, five patients needed a flap as a final closure surgery. In group B, it took an average of 17 days for healthy granulation tissue to emerge. The authors used split skin grafting to close the wounds in 18 patients, and the wound was allowed to heal by secondary intention in 8 patients, while the flap was used in 4 patients. ConclusionOn comparing the modified Vacuum-assisted dressing to the standard dressing, there was considerable wound contraction and accelerated healing. Therefore, the authors observed that vacuum-assisted dressing treatment is superior to traditional betadine dressing in open fractures.

Case report of surgical correction of acquired preputial stenosis in a calf

Diseases involving the reproductive tract of male ruminants, especially bulls, are a significant cause of economic and genetic loss to beef and dairy cattle industry worldwide. In calves, congenital hypospadia is the most commonly reported condition affecting genital organs. In the reviewed literature, there are no reports of surgical correction of acquired phimosis in calves. Therefore, the present paper aimed to report the surgical correction by circumcision of a traumatic-induced phimosis in a calf. A 6-months-old crossbred calf was submitted to surgical correction of acquired preputial stenosis by the Lazzeri circumcision approach. Surgery was uneventful and post-operatory complication was restricted to partial wound dehiscence, that did not compromise complete secondary intention healing. Long-term follow-up (30-months after surgery) was conducted by telephone call, revealing that the calf is now a bull with 3-years-old and still is the herd’s breeder. To the best of our knowledge, this is the first report of surgical correction by circumcision of a traumatic-induced phimosis in a calf using the Lazzeri technique. In this calf post-operatory complications were considered minor and long-term follow-up confirmed that the procedure was successful, and the animal obtained its reproductive capacity maintained.

Propeller Flap: A Feasible Flap for Distal Third of Leg Defects – Two Cases Done at the Plastic Surgery Unit of the Greater Accra Regional Hospital

Introduction: The traditional way of reconstructing soft tissue defects of the lower limb utilized muscle flaps as the ‘gold standard’ for Gustillo Anderson Grade III B fractures of the upper and middle thirds of the leg. Defects of the lower third of the leg are usually reconstructed with free flaps because of paucity and decreased reach of muscles. In resource constrained environments where free flaps are not routine with high failure rates, fasciocuataneous flaps are the only option left. We present our experience with the novel pedicled propeller perforator flaps for reconstruction of soft tissue defects in the lower limb. Case Presentation: Between June and October 2020, 2 consecutive patients - a 34-year-old male and a 51-year-old female, were referred for cover for their distal leg defects from the Orthopedics and trauma Unit. All patients were operated on under spinal anaesthesia. Perforators from posterior tibial and peroneal arteries respectively, were identified pre-operatively with hand-held doppler and the propeller-pattern skin paddle was designed around the perforator closest to defect. After elevation of flaps and skeletonization of perforators, they were then rotated (180 degrees) and inset into defects. Case 1 had whole flap (104 cm2) surviving with only minor marginal epidemiolysis at tip whilst the second flap (58.5cm2) had necrosis of only the business end of the flap but subsequently healed by secondary intention after serial dressings. Both had secondary defects proximally after the rotation, which were skin grafted with 100% take. Conclusion: Propeller flap in our experience, is a feasible versatile option for reconstruction of soft tissue defects in the distal third of the leg.

Prophylactic negative pressure wound therapy to improve wound healing rates following ileostomy closure: a randomized controlled trial.

Reversal of ileostomy is associated with morbidity including wound infection and prolonged wound healing. Negative pressure wound therapy (NPWT) has been shown to reduce time to wound healing by secondary intention. The aim of this study was to determine whether NPWT improved wound healing rates, compared with simple wound dressings, in patients undergoing reversal of ileostomy where the skin wound is closed with a purse-string suture. This was a dual-centre, open-label, randomized controlled trial with two parallel intervention arms. Patients undergoing elective loop ileostomy reversal were randomized 1:1 to receive NPWT or simple wound dressings. The primary endpoint of the study was assessment of complete wound healing at day 42 post reversal of ileostomy and the secondary endpoints were patient-reported wound cosmesis using a visual analogue scale and rates of surgical site infection (SSI). The study was conducted from June 2018 to December 2021. The trial was approved by the local ethics committee. We enrolled 40 patients, 20 in each arm. One patient in each arm was lost to follow up. Nine patients (9/19, 47.36%) in the simple dressing group had wound healing vs. 13 patients (13/19, 68.42%) in the NPWT group (P = 0.188). There was no significant difference in patient- reported wound cosmesis or SSI. There was no difference in wound healing rates when comparing NPWT to simple wound dressings at early and late time points post reversal of ileostomy, where the skin wound was closed with a purse-string suture.

The use of bone wax versus dermal regeneration matrix for the reconstruction of scalp defects.

Secondary intention healing is an alternative to consider in large tumors or tumors located in areas of limited skin mobility, such as the scalp. To promote epithelialization, we can use Dermal Regeneration Matrix (DRM) or bone wax. This study aimed to compare the efficacy of DRM and bone wax in secondary intention healing of cutaneous scalp tumors in elderly patients with comorbidities. The medical records of 18 patients with cutaneous scalp tumor healing by secondary intention from February 2022 to April 2023 were analyzed for demographic variables, tumor and surgical characteristics, time from withdrawal of material to complete epithelialization, and need for subsequent surgical intervention. Bone wax was used in 6 patients and DRM in 12. The mean patient age was 84.3 years, and the mean tumor size was 2.7 cm. There were no significant differences in demographics or postoperative complications between the groups. The median time to complete epithelization was 84.5 (60.2-108.7) days in the bone wax group and 105.0 (91.0-126.0) days in the DRM group, with no significant differences (P = 0.15). Bone wax is a simple and economical material that can be used for secondary intention healing of scalp tumors in elderly patients with high surgical risk.

Secondary Intention Healing for Fingertip Amputations in a Tropical Climate.

Background: Various studies have examined occlusive dressings in fingertip amputations and reported good outcomes. Occlusive dressing preserves appropriate pH, cell accumulation and moisture for healing, thereby limiting scar formation and deformity. To our knowledge, no study was performed in tropical Asia. This study aims to demonstrate the viability of healing fingertip amputations through secondary intention using an effective dressing technique, even in warm tropical climates. Methods: All patients who presented to our institution with fingertip amputations from 1 July 2020 to 31 July 2022 were analysed retrospectively. Seventeen patients (15 male, 2 female) of mean age 37.2 ± 9.4 years old with 18 injured digits were retrospectively analysed. Twelve (66.7%) were Allen Type III injuries, and one patient required distal phalangeal K-wire fixation. During the patient's final review, static 2-point discrimination, pulp sensation, fingertip contour and nail deformities alongside the last measured range of motion (ROM) of the injured finger was recorded. Treatment duration and days of leave taken were also summed and assessed. Results: Patients were dressed with semi-occlusive dressing for an average of 20.1 ± 6.83 days. The average total duration of dressing is 36.78 ± 18.88 days over an average of 7.18 ± 4.03 dressing visits. Mean duration of follow-up was 108 ± 63.46 days. Good outcome measures in sensation, pulp contour, nail deformity and ROM similar to existing literature were reported. Conclusions: Occlusive dressing remains a viable and feasible treatment option for fingertip amputation even in a tropical climate. While this simple treatment method may require more effort from patient, wound healing was attained after 36.8 ± 18.9 days of dressing. Level of Evidence: Level IV (Therapeutic).

Surgical Management of Idiopathic Scrotal Elephantiasis: A Rare Case Report

Abstract: Etiologically, massive scrotal lymphedema can be either congenital or acquired. Congenital is further divided into different types while the predominant variety in the acquired category includes infectious etiology. We present a case of a 35-year-old male presented with the complaint of scrotal swelling for 3 years. Blood tests for filarial, chlamydia, and tuberculosis were unremarkable. Excision of excessive scrotal skin was done and sent for biopsy. The wound was partially closed, and the remaining was left for healing by secondary intention. The biopsy report showed non-caseating granulomatous inflammation with no significant lymph node involvement.

Commentary on Surgical Excision With Healing by Secondary Intention: An Effective Treatment Option for Refractory Acne Keloidalis Nuchae.

Commentary on Surgical Excision With Healing by Secondary Intention: An Effective Treatment Option for Refractory Acne Keloidalis Nuchae.

The effects of a synthetic epidermis spray on secondary intention wound healing in adult horses.

To evaluate secondary intention wound healing in the horse's limbs when treated with the synthetic epidermis spray (Novacika®, Cohesive S.A.S, France) or with a standard bandaging technique. Six Standardbred mares were included in the study. Four 2.5 x 2.5 cm full-thickness skin wounds were created on each thoracic limb. Two wounds were located on the dorsoproximal aspect of the cannon bone and the other two at the dorsoproximal aspect of the fetlock. Six hours after creation, wounds were randomly treated with synthetic epidermis spray or standard bandaging. The wounds were assessed every 4 days by gross visual assessment and using a 3D imaging camera. Analysis was performed with a 3D imaging application. Out of 46 wounds, 22 showed exuberant granulation tissue and were part of the standard bandaging group. Whether the wounds were treated with synthetic epidermis spray or standard bandaging, the time for healing was the same. The synthetic epidermis spray studied in this model has allowed healing without the production of exuberant granulation tissue but did not reduce the median wound healing time compared to a standard bandaging technique. The synthetic epidermis spray is potentially an interesting alternative for the management of secondary intention wound healing of superficial and non-infected distal limb wounds in adult horses on economical and practical aspects. However, all statistical inference (p-values especially) must be interpreted with caution, given the size of the sample.

Esophageal perforation after anterior cervical spine surgery

ObjectiveTo report our updated experience in the management of esophageal perforation resulting from anterior cervical spine surgery, and to compare two wound management approaches. MethodsThis is a retrospective review of patients managed for esophageal perforations resulting from anterior cervical spine surgery (2007-2020). We examine outcomes based on 2 wound management approaches: closed (closed incision over a drain) versus open (left open to heal by secondary intention). We collected data on demographics, operative management, resolution (resumption of oral intake), time to resolution, number of procedures needed for resolution, microbiology, length of stay, and neck morbidity. ResultsA total of 13 patients were included (10 men). Median age was 52 years (range, 24-74 years). All patients underwent surgical drainage, repair, or attempted repair of perforation, hardware removal, and establishment of enteral access. Wounds were managed closed versus open (6 closed, 7 open). There were 2 early postoperative deaths due to acute respiratory distress syndrome and aspiration (open group), and 1 patient was lost to follow-up (closed group). Among the remaining 10 patients: resolution rate was 80% versus 100%, resolution in 30 days was 20% versus 100%, median number of procedures needed for resolution was 3 versus 1, and median hospital stay was 23 versus 14 days, for the closed and open groups, respectively. ConclusionsEsophageal perforation following anterior cervical spine surgery should be managed in a multidisciplinary fashion with surgical neck drainage, primary repair when feasible, hardware removal, and establishment of enteral access. We advocate open neck wound management to decrease the time-to-resolution, number of procedures, and length of stay.

Integrative management of high transsphincteric fistula-in-ano with a rectal opening: A case report

Abstract Transsphincteric fistula is a type of complex anal fistula, often considered a refractory surgical condition, which has the potential to produce complications, such as recurrent infections, abscess formation, and incontinence. A 48-year-old male farmer was diagnosed with a high transsphincteric fistula abscess with a secondary rectal opening based on clinical examination and magnetic resonance imaging findings. Under saddle block, incision and drainage of fistula abscess was performed, followed by threading of Apamarga Kshara Sutra (medicated seton) between the abscess cavity and the primary internal opening at 6 o’clock on the dentate line. Another internal opening was also identified in the lower rectum, left as it is. Panchavalkala Kwatha for sitz bath once a day, Varunadi Kwatha 20 mL twice a day orally, Kachanar Guggulu (500 mg) two tablets three times a day, and Apamarga Kshara Tail (AKT) dressing was prescribed for 124 days to facilitate optimal healing and management. Prophylactic as well as therapeutic antibiotics and analgesics were administered for 7 days. The fistula took 103 days for complete healing with a unit healing time of 0.251 day/cm3. Medicated seton on the dentate line facilitated drainage of the infected gland and healed the secondary rectal opening. Ischiorectal abscess cavity healed by secondary intention. This case report demonstrates that a high transsphincteric fistula-in-ano with a rectal opening can be successfully managed without fistulotomy to treat the secondary rectal opening. Chemical debridement of the infected anal gland was achieved by a medicated seton, and a new seton was replaced every 7 days until the cutting and healing of the fistula track. It also facilitated the drainage of the exudate. Wound management by AKT and adjuvant medicament supported faster recovery.

Managing Vascular Pedicle Exposure in Free Tissue Transfer Using a Reprocessed Micronized Dermal Substitute in Lower Extremity Reconstructions.

Lower extremity reconstruction is challenging because of its intricate anatomy and dynamic biomechanics. Although microsurgical free tissue transfer offers pivotal solutions to limited local tissue availability, vascular pedicle exposure after free tissue transfer is common. We evaluated a novel method of managing pedicle exposure after free tissue transfer using a reprocessed micronized dermal substitute. Ten patients who underwent lower-extremity reconstruction using free tissue transfer and micronized dermal substitute between January and December 2023 were retrospectively reviewed. When native tissue could not be closed over the pedicle, reprocessed micronized artificial dermal matrix (rmADM) was cut and stacked to protect and stabilize it. Epithelialization was achieved by secondary skin grafting or healing by secondary intention. Flap dimensions, recipient artery and vein, ADM size, time required for granulation tissue maturation and complete epithelialization, and flap outcomes were analyzed. The mean age was 55.80 ± 20.70 years, and six patients (60%) were diabetic. The mean rmADM coverage area was 8.70 ± 8.41 cm2, and the average time required for complete epithelialization was 50.89 ± 14.21 days. Except for one total necrosis due to bypass graft failure, nine limbs were successfully salvaged. Application of rmADM offers numerous advantages, including vascular collapse prevention, moisture maintenance, granulation tissue growth promotion, and pedicle stabilization.

Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures

ObjectivesUniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures.MethodsFrom our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System.ResultsOne hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%).ConclusionWe conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter ‘wound debridement’ to ‘appropriate wound care’ and to subcategorise ‘Simple’ into type A and B: healing via secondary intention and primary closure, respectively.

Hidradenitis Suppurativa in Association with Ulcerative Proctitis: Surgical Management in a Refractory Case to Topical and Systemic Treatment

Hidradenitis suppurativa (HS), a challenging dermatological condition, can be described as a chronic, painful, follicular, occlusive disease that is characterized by painful nodules, abscesses, and sinus tracts generally located in the intertriginous skin areas. This disorder places a considerable burden on affected individuals and often leads to significant impairment in quality of life for those grappling with its persistent and recurrent nature. We present the case of a 20-year-old male patient known to have ulcerative proctitis and diagnosed with hidradenitis suppurativa in 2020, for which he underwent various topical and systemic treatments, with periods of remission and recurrent flares without managing to obtain complete remission of HS. In our dermatology service, the patient underwent two surgical unroofing procedures combined with punch debridement, with the wounds being allowed to heal by secondary intention. This choice of treatment delivered great results with favorable outcomes, without recurrence of the lesions, proving to be an effective method for managing HS. By presenting this case, we underline the role of surgical procedures in managing HS, and our desire is to emphasize the importance of comprehensive understanding of this enigmatic and complex condition for more effective management strategies in patients with refractory disease.

ЭКСПЕРИМЕНТАЛЬНОЕ ОБОСНОВАНИЕ ПРИМЕНЕНИЯ БИОРЕЗОРБИРУЕМЫХ ПЕРСОНАЛИЗИРОВАННЫХ КОЛЛАГЕНОВЫХ МЕМБРАН ДЛЯ ЗАКРЫТИЯ ДЕФЕКТОВ СЛИЗИСТОЙ ОБОЛОЧКИ РТА

Subject. The subject of the study is the biomechanical properties of a personalized collagen membrane in the area of wound defects of the oral mucosa.
 Objectives. To increase the effectiveness of treatment of patients with extensive surgical wound defects of the oral mucosa by experimentally substantiating the use of developed collagen membranes from bovine Achilles tendon.
 Methodology. Based on the Central Vivarium of the First Moscow State Medical University named after I.M. Sechenov (Sechenov University) conducted an experimental study on laboratory animals (rabbits) (n = 12) to create a wound surface in the oral cavity (limited vestibuloplasty according to Clark on the upper jaw) and its closure with collagen membranes with an assessment of the course of the postoperative period and subsequent histological examination of biomaterials: 1st – using a personalized collagen membrane, 2nd – using a collagen membrane with lactoferrin, 3rd – using a Mucograft membrane, 4th group – control.
 Results. In the postoperative period, on the 3rd day, moderate swelling, and hyperemia in the area of vestibuloplasty were noted in the oral cavity of rabbits: the least pronounced swelling was in animals in the 2nd group of operations (1.5 ± 0.5 points) (p = 0.001), hyperemia – in the 3rd group (1.7 ± 0.4 points) (p = 0.001). On the 5th day in the oral cavity of experimental animals, hyperemia of the mucous membrane of the oral vestibule in the 2nd group was 0.8 ± 0.4 points (p = 0.001), and in the 3rd group – 1.8 ± 0.4 points (p = 0.001). According to the histological research method, a significant difference was noted in the quantity and quality of the formed soft tissues in the area of application of collagen matrices compared to healing by secondary intention (p < 0.05). The results of histological examination showed in group 2 epithelization with acanthosis and proliferation of the basal layer.
 Conclusion. The effectiveness of the developed collagen membranes from the Achilles tendon has been proven in eliminating extensive wound defects of the oral mucosa.

Improving Long-Term Projection in Nipple Reconstruction Using a New Human-Derived Acellular Dermal Matrix

Background: Loss of projection is a very common complaint after nipple reconstruction. In this paper, we present our experience with the use of a novel human cadaver-donor-derived acellular dermal matrix, named MODA (Matrice Omologa Dermica Acellulata) from the Regional Skin Bank to improve and stabilize nipple projection after oncoplastic breast surgery. Methods: We did a retrospective analysis of patients undergoing nipple reconstruction with local flap and MODA graft after breast reconstruction between February 2019 and May 2021. The analysis was done following the Declaration of Helsinki and was approved by the ethics committee; written consent was sought from all the participants. The main evaluation criterion was nipple projection measurement, performed immediately after surgery, 6 and 12 months postoperatively. The secondary endpoints were complications and patients’ satisfaction. Results: In this study, 50 patients underwent nipple reconstruction, with 57 reconstructed nipples. All cases except six followed delayed breast reconstruction. The patients were divided into 3 groups, according to the breast reconstructive technique. There were three cases of delayed wound healing and two cases of partial necrosis, but all of the cases healed by secondary intention. Five percent of the patients (3/57 reconstructions) presented more than 60% of nipple projection loss and required another procedure. The other reconstructed nipples maintained an average of over 60% projection after 12 months. Conclusion: The described technique presents a high success rate associated with low complications. Indeed, it provides the advantages of nipple reconstruction with ADM with low costs, appears safe after radiotherapy, and has similar results when used after different reconstructive techniques.

Continuous External Tissue Expansion for Closure of Forehead Flap Donor Site.

Continuous external tissue expansion has been shown to be effective in the management of craniofacial wounds resulting from tumor resection, trauma, and wound dehiscence. Forehead flap donor sites are typically managed with secondary intention healing. However, this can create esthetic problems in pigmented skin because of the tendency to form thick scars. Here, the authors describe the use of continuous external tissue expansion for the management of a paramedian forehead flap donor site. A Dermaclose device was used at the time of forehead flap elevation and removed at the pedicle division and inset. Sufficient skin expansion was achieved for primary closure. The final scar was esthetically pleasing. External tissue expansion is ideal for forehead flap donor sites as the second stage of the operation provides an opportunity for expander removal and wound closure.