Secondary Skin Grafting Research Articles

Early results of an orthoplastic multidisciplinary approach to diabetic foot ulcer soft tissue reconstruction.

Diabetic foot ulcer (DFU) is a common complication in patients with diabetes. With current treatment, only two-thirds of patients heal, with a median duration of 3-6 months. Hard-to-heal DFUs are a major source of morbidity and mortality. Improving wound healing via soft tissue reconstruction may be the key to improving clinical outcomes. Thus, the Diabetic Limb Salvage (DLS) service in Sengkang General Hospital, Singapore, was established to provide patients with a streamlined, one-stop, comprehensive service dedicated to DFU soft tissue reconstruction. The reconstruction was carried out using secondary closure, skin grafting, local flaps or free flaps, depending on the severity of the wound and patient suitability. This study aims to audit the early outcomes of the DLS service. Patients with DFUs treated by the DLS service were compared with patients with DFUs treated prior to the launch of the DLS service (control). Outcomes including major and minor amputation rates, wound healing rate, mortality and DFU recurrence rates were analysed statistically. A total of 103 patients took part in the study (50 in the DLS service cohort and 50 in the control cohort). There was no significant difference in demographics, comorbidities and wound profiles between the two cohorts. All (100%) patients in the DLS service cohort received soft tissue reconstruction versus only 13% in the control group. The DLS service cohort had a significantly higher healing rate (96% versus 68%, respectively), shorter healing duration (77±30 days versus 111±43 days, respectively), reduced major amputation rate (0% versus 9%, respectively), and reduced recurrence rate (6% versus 25%, respectively) compared with the control cohort within the one-year follow-up. The findings of this study showed that an orthoplastic multidisciplinary approach focused on DFU soft tissue reconstruction improved wound healing rates, shortened healing duration and, as a result, lowered amputation rates and reduced recurrence.

Dermal Substitute Integra for the Treatment of Mammalian Bite Injuries of Nose: a New Reconstructive Ladder.

Bite injuries affecting the nose are uncommon occurrences characterized by their intricate nature and potential for severe complications. These injuries, inflicted by animals such as dogs and cats, and occasionally by humans, often result in traumatic nasal defects, with the lower third of the nose being the most affected area. Current reconstructive options for nasal defects include full-thickness skin grafts, local or regional flaps, and composite grafts. The traditional reconstructive ladder serves as a valuable guide for surgeons, outlining a continuum of treatment options from simpler to more complex interventions. Advancements in reconstructive technologies, such as the introduction of dermal substitutes, have reshaped the decision-making process, ushering in a new era of facial reconstruction. In this context, dermal substitutes have emerged as promising adjuncts in nasal reconstruction, drawing from their success in burn surgery. Notably, the bilayered dermal substitute Integra has demonstrated efficacy in promoting wound healing and facilitating tissue regeneration. By harnessing the regenerative potential of Integra, plastic surgeons can address specific nasal defects arising from bite injuries with greater precision and improved outcomes. This study aims to present a case series of patients with bite injuries to the nose, showcasing the successful application of Integra dermal substitute in conjunction with secondary full-thickness skin grafting. Through a retrospective analysis of patient demographics, injury characteristics, surgical interventions, and postoperative outcomes, we seek to underscore the utility of this combined approach in achieving optimal functional and aesthetic results. We aim to contribute to the evolving paradigm of nasal reconstruction.

Clinical application of iliac myocutaneous flap pedicled with deep circumflex iliac artery in repair of complex defect of lower limb with cavity

To explore the effectiveness of iliac myocutaneous flap pedicled with deep circumflex iliac artery (DCIA) on the repair of lower limb composite defect wounds with cavity. A retrospective analysis of 7 patients with lower limb composite defect wounds treated between March 2017 and September 2020 was conducted, including 4 males and 3 females, aged 24-58 years, with a median age of 37 years. The causes of injury were machine twisting injury in 2 cases, fall from height injury in 2 cases, and traffic accident injury in 3 cases. According to Gustilo-Anderson classification, there were 1 case of type Ⅲa, 4 cases of type Ⅲb, and 2 cases of type Ⅲc (combined with anterior tibial artery rupture); according to AO/Orthopaedic Trauma Association (AO/OTA) classification, there were 2 cases of type 42-C3, 2 cases of type 43-A2, and 3 cases of type 43-B1. The time from injury to admission ranged from 2 to 10 hours, with an average of 6 hours. Tibial bone defect and surrounding soft tissue defect with deep cavity were left after primary emergency debridement. In the second stage, according to the characteristics of the wound, the three-dimensional repair of the composite defect was designed with DCIA embedded iliac myocutaneous flap. The size of the iliac flap was 2.0 cm×2.0 cm×2.0 cm to 7.0 cm×3.0 cm×2.5 cm, and the size of the flap was 12.0 cm×8.0 cm to 21.0 cm×13.0 cm. The internal oblique muscle flap was harvested in size of 3.0 cm×2.0 cm×2.0 cm to 5.5 cm×4.0 cm×4.0 cm. The donor site was primarily closed. All the flaps survived after operation, except for 1 case of partial necrosis of the flap edge, which healed after secondary skin grafting, and the donor and recipient wounds healed by first intention. All patients were followed up 16-24 months, with an average of 18 months. The broken end of the bone defect healed well, and the healing time was 8-10 months, with an average of 7.3 months. At last follow-up, the shape of the flap was satisfactory, the texture was soft, and there was no abnormal hair growth, pigmentation, and so on. Only linear scar was left in the donor site, and no complication such as abdominal hernia occurred. According to Paley fracture healing scoring system, bone healing was rated as excellent in 5 cases and good in 2 cases. The limb function was satisfactory, and full weight bearing was achieved at 12-16 months after operation. According to the lower extremity functional scale (LEFS), 6 cases were excellent and 1 case was good. The iliac myocutaneous flap pedicled with DCIA is flexible in design and highly free in tissue composition, which can repair the composite defect wound of lower limbs with deep cavity in a three-dimensional way, and repair the limb shape and reconstruct weight-bearing function to the greatest extent.

DS06 A multicentre qualitative study of patient perceptions and experiences with secondary intention wound healing and skin grafting

DS06 A multicentre qualitative study of patient perceptions and experiences with secondary intention wound healing and skin grafting

A comparative prospective study between the outcomes of one-stage Pelnac reconstruction and full thickness skin graft on donor site healing in the radial forearm and fibula flaps

ObjectivesDermal substitutes are classically used in a 2-stage procedure followed by skin graft for wound healing. This study aims to evaluate the possibility to use an alternative technique for radial forearm and fibula donor sites coverage using one-stage Pelnac reconstruction. Materials and methods21 patients who underwent radial forearm and fibula flaps harvest for reconstruction of head and neck defects after oncological surgery were enroled in the study. 13 patients were treated by one-stage Pelnac reconstruction of the donor site defect, 8 patients underwent full thickness skin graft. The Vancouver Scar Scale was used to evaluate the scar quality. ResultsMost patients treated with one-stage Pelnac reconstruction showed good healing of the flap donor site, with minor complications, scar quality comparable to other treatment options and unimpaired function of the implicated limb. One patient had wound dehiscence at the radial forearm site, which was treated with secondary full thickness skin graft. In the group treated with FTSG we had three patients that developed complications, such as dehiscence of the graft and seroma. Overall, we reported comparable satisfaction with donor sites both for aesthetic and functional outcomes, in both groups of patients. ConclusionThe use of Pelnac without a following skin graft provides a viable method for the reconstruction of radial forearm and fibula flaps donor site. A longer postoperative care is needed, but the long-term aesthetic and functional results are satisfactory in comparison with full thickness skin graft.

An evaluation of ChatGPT compared with dermatological surgeons' choices of reconstruction for surgical defects after Mohs surgery.

ChatGPT is an open-access chatbot developed using artificial intelligence (AI) that generates human-like responses. To evaluate the ChatGPT-4's concordance with three dermatological surgeons on reconstructions for dermatological surgical defects. The cases of 70 patients with nonmelanoma skin cancer treated with surgery were obtained from clinical records for analysis. A list of 30 reconstruction options was designed by the main authors that included primary closure, secondary skin closure, skin flaps and skin grafts. Three dermatological surgeons who were blinded to the real reconstruction, along with ChatGPT-4, were asked to select two reconstruction options from the list. Seventy responses were analysed using Cohen's kappa, looking for concordance between each dermatologist and ChatGPT. The level of agreement among dermatological surgeons was higher compared with that between dermatological surgeons and ChatGPT, highlighting differences in decision making. In the selection of the best reconstruction technique, the results indicated a fair level of agreement among the dermatologists, ranging between κ 0.268 and 0.331. However, the concordance between ChatGPT-4 and the dermatologists was slight, with κ values ranging from 0.107 to 0.121. In the analysis of the second-choice options, the dermatologists showed only slight agreement. In contrast, the level of concordance between ChatGPT-4 and the dermatologists was below chance. As anticipated, this study reveals variability in medical decisions between dermatological surgeons and ChatGPT. Although these tools offer exciting possibilities for the future, it is vital to acknowledge the risk of inadvertently relying on noncertified AI for medical advice.

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.

Salvage of Extensive Skin Graft Necrosis After Auricle Reconstruction by Using Modified Nagata Method.

Extensive skin graft necrosis after auricle reconstruction surgery is a thorny problem for plastic surgeons. Four unilateral microtia patients were enrolled for extensive skin graft necrosis after ear elevation surgery. Early debridement and daily dressing changes were important for preoperative preparation. Surgical treatments involved local flaps and secondary split-thickness skin graft. After 3 to 12 months of follow-up, clear surface structures and obvious auricular sulcus were shown in all 4 patients. No cartilage exposure, skin necrosis, healing impairment, or other complications were found. We attribute the cause of extensive skin graft necrosis to subcutaneous hematoma. Local skin flaps and split-thickness skin grafting can be effective treatments for such situations. The use of temporoparietal fascial flap is unnecessary when poor graft survival is caused by subcutaneous hematoma.

The sucker-like end-to-side arterial anastomosis for free flap in extremities reconstruction: a retrospective study of 78 cases

BackgroundThe application of end-to-side (ETS) anastomosis for flap transfer poses challenges, particularly in cases of significant size discrepancy between the donor and flap arteries. Herein, a novel ETS anastomosis technique, termed “sucker-like ETS anastomosis”, is developed to mitigate and rectify such vessel discrepancies. This study aims to evaluate the efficacy of this technique in tissue defect reconstruction through free flap transfer.MethodsBetween September 2018 and March 2023, the medical records and follow-up data of 78 patients who underwent free flap transfer using sucker-like ETS anastomosis for significant artery size discrepancies were collected and retrospectively analyzed.ResultsAmong the 78 cases that received free flap transfer, the range of artery size discrepancy (flap artery vs donor artery) was 1:1.6–1:4 (mean: 1:2.5). Following anastomosis with the sucker-like ETS technique, 75 cases achieved flap survival without requiring additional surgical intervention, yielding a one-stage success rate of 96.2%. Three cases experienced post-operative venous crises, with two cases surviving after vein exploration and one case undergoing flap necrosis, necessitating a secondary skin graft. Seven cases faced delayed wound healing but eventually achieved complete healing following dressing changes. No arterial crisis was observed during hospitalization. With an average follow-up of 13 months, the surviving flaps exhibited excellent vitality without flap necrosis or pigment deposition. Overall, the application of sucker-like ETS arterial anastomosis for flap transfer resulted in a high overall surgical success rate of 98.7% (77/78).ConclusionThe application of sucker-like ETS anastomosis for free flap transfer is highly effective, particularly in cases with significant size discrepancy between the recipient and donor arteries.

Hyalomatrix coverage in scalp wounds with exposed cranium and dura

The armamentarium of options available for soft tissue reconstruction of the scalp spans the reconstructive ladder. The purpose of this paper is to describe a case series of patients with exposed cranium and dura who were successfully reconstructed using esterified hyalomatrix (eHAM, Hyalomatrix, Medline Industries Inc., US). After obtaining Institutional Review Board approval, a retrospective review of the senior author's (ALF) patient database was completed. Patients who underwent scalp reconstruction using eHAM were identified. Each patient's chart was reviewed and data collected on demographics, days to skin graft, duration of follow-up, pathology, comorbidities and complications. This case series consisted of five patients aged ≥18 years, with scalp wounds exposing dura or cranium, who were treated with eHAM as a bridge to definitive coverage with a skin graft. Each wound successfully granulated the exposed critical structure with the use of the eHAM. The mean time to skin graft coverage was 41 days, with a range of 13-79 days. Of the series of five patients, four had a follow-up of ≥12 weeks. The mean defect size was 90.2cm2. Complex scalp reconstruction can be accomplished using healing by secondary intention, skin grafts, local flaps, tissue expansion and free tissue transfer. As shown in this case series, another option available in select patients is using a dermal substitute such as eHAM. This is one treatment option available to reconstructive surgeons in multiple specialties.

Reconstruction of Small-Sized Complex Defect on the Foot Dorsum Without Microsurgery: Intrinsic Adipofascial Flap.

Dorsal foot defects are difficult to cover and often require major flap surgery by microsurgeons, even for defects of limited sizes. Intrinsic adipofascial flaps for small-sized complex defects are simple and do not require microsurgery; thus, a flap specialist is unnecessary. This study aimed to assess our institutional experience with this technique and define its role in dorsal foot reconstruction. Nine patients aged 48 to 86 years with soft tissue defects of the dorsal foot were treated with the intrinsic adipofascial flap by rotating the adjacent adipofascial tissues from May 2019 and January 2021 in our institution. Demographic, clinical, and followup data were evaluated. Primary outcomes include flap viability, flap bulkiness, ability to wear shoes, and donor site morbidity. The mean followup period was 24.5 months (range, 10-30 months) and the mean defect size was 6.4 cm2 (range, 3.0-9.0 cm2). Eight flaps survived providing an adequate contour and durable coverage with a thin flap. Among 8 cases of healed flaps, 6 required secondary skin grafts while the other 2 healed spontaneously without additional operation. One patient (defect size: 3.0 cm × 3.0 cm) with underlying diabetes mellitus and peripheral arterial occlusive disease encountered flap total necrosis. Revisional flap surgery was performed to cover the flap total necrosis. In conclusion, the intrinsic adipofascial flap is a relatively simple and suitable method for complex dorsal foot defect reconstruction because it provides minimal donor site morbidity. However, relatively large defect size and comorbidities, such as underlying diabetes mellitus and vascular occlusive disease could accompany a risk of flap necrosis.

Comparative study of various dressing techniques in diabetic foot ulcers in the Indian population: a single-center experience.

A prospective randomized study was conducted to evaluate and compare the efficacy of conventional dressing, foam dressing, and vacuum-assisted closure (VAC) in the management of diabetic foot ulcers (DFUs). Ninety patients with DFU were included in the study conducted between 2018 and 2021 at a tertiary care center. Group 1 patients (n = 30) were treated with conventional dressing, group 2 patients (n = 30) with foam dressing, and group 3 patients (n = 30) with VAC dressing.The duration of treatment, number of debridement, need for the secondary procedure, cost of treatment, and duration of hospital stay were compared between the three groups. There was a significant difference in the duration of treatment among the three groups with VAC being the least(group 1, 31.17days; group 2, 24.13days; group 3, 15.17days).The mean number of debridement was also significantly less in the VAC group (2.37, 2.43, and 1.60, respectively). The need for the secondary procedure, like flap or skin graft, was also the least in the VAC group, although insignificant. The mean hospital stay of the study subjects was 31.17days, 24.13days, and 15.17days in the 3 groups, respectively. The mean cost of the treatment was 3076.67 INR, 3717.33 INR, and 10,680 INR, respectively. VAC dressing is the best option amongst the available dressing modalities in terms of faster healing and a short hospital stay. Foam dressing does provide an economically viable option with better results than conventional dressing.

Upper Extremity Wounds Treated with Biodegradable Temporizing Matrix versus Collagen-Chondroitin Silicone Bilayer

Objective This study aims to compare outcomes between Novosorb Biodegradable Temporizing Matrix (BTM) and Integra collagen-chondroitin silicone for upper-extremity wound reconstruction.Methods This retrospective study analyzed adult patients who underwent wound reconstruction with either BTM or Integra at our institution between 2015 and 2020.Results Forty-eight patients were included: 31 (64.6%) BTM and 17 (35.4%) Integra. Mean age was 44.0 (range: 18–68) years. Age, race, sex, smoking, comorbidities, and defect size were similar between groups. Wound etiologies included 12 (25.0%) burn, 22 (45.8%) trauma, and others. Median template size was 133 cm2 for BTM and 104 cm2 for Integra (p = 0.526). Skin grafting was performed after 14 (45.2%) and 14 (82.4%) wounds treated with BTM and Integra, respectively (p = 0.028). Template complications of infection and dehiscence were comparable. Skin-graft complications occurred in five (35.7%) and three (21.4%) wounds in BTM and Integra, respectively (p = 0.031). Skin-graft failure rates were comparable (p = 0.121). Mean number of secondary procedures required after template placement was higher in the Integra group (BTM, 1.0; Integra, 1.9; p = 0.090). Final healing was achieved in 17 (54.8%) BTM and 11 (64.7%) Integra wounds (p = 0.694). Median time to healing was 4.1 months after BTM and 2.6 months after Integra placement (p = 0.014).Conclusion Compared with Integra, BTM achieved comparable wound healing and complication rates. Fewer secondary procedures and skin grafts were observed in BTM wounds, likely as a result of the coronavirus disease 2019 pandemic. At our institution, 100 cm2 of product costs $850 for BTM and $3,150 for Integra, suggesting BTM as an economical alternative to fulfill the high functional and aesthetic requirements of upper-extremity wounds.

Pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) flap for perineo-scrotal reconstruction following Fournier's gangrene.

Fournier's gangrene is a form of necrotising fasciitis involving perineo-scrotal skin. It is treated with radical debridement, infection control and often leaves a large anatomical defect that is challenging to reconstruct. The anatomical location of the defect leads to faecal contamination, difficulties when mobilizing, and negative psychological impact. Traditional approaches for managing such defects have relied on either healing by secondary intention or skin grafting. There are few reported cases in the literature to cover such defects with a flap. Pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) flap reconstruction was performed in three patients who had perineo-scrotal defects following debridement for Fournier's gangrene. All flaps survived with no significant postoperative complications and good functional and aesthetic outcomes were achieved. The mean age of patient was 52 years and the largest defect measured 22 × 10 cm. The reconstruction of perineo-scrotal defects is difficult despite a range of reconstructive options. The pedicled SCIP flap offers many advantages over standard techniques. This flap is thin, pliable, and has a consistent anatomy. With continued experience, we feel that this flap could be considered the gold standard of treatment for such defects.

Outcomes and Reliability of Perforator Flaps in the Reconstruction of Hidradenitis Suppurativa Defects: A Systemic Review and Meta-Analysis.

Introduction: Hidradenitis suppurativa (HS) is a common and debilitating disease, in which the only effective treatment involves a wide excision of the affected skin. Secondary wound healing and skin grafting are two well-known options for managing these defects, but perforator flaps provide a new therapeutic alternative by ensuring reconstructions of large defects, reducing donor site morbidity, and enhancing functional recovery. The aim of this study was to achieve a systematic review of perforator flaps use in HS. Patients and Methods: PubMed and Cochrane databases were searched from 1989 to 2021. The PRISMA statement was used in the study selection process and the review was registered on PROSPERO. Furthermore, patient characteristics, operative technique, complications, and recurrences were searched. Results: Thirty-six articles were selected including 286 patients and 387 flaps. Axillary localization was mostly represented (83.2%). Direct donor site closure was achieved in 99.1% of cases. In total, 15.1% of the flaps presented at least one of the following complications: wound dehiscence (5.5%), partial necrosis (2.9%), hematoma or seroma (2.1%), infection (2.1%), venous congestion (1.8%), and nerve injury (0.3%). Two cases of total necrosis were recorded. Recurrence of the disease was observed in 2.7% of the defects. Conclusions: Pedicled perforator flaps are a reliable and reproducible technique in the reconstruction of HS defects. They are associated with a low recurrence rate while ensuring an effective reconstruction with reduced morbidity and faster recovery compared to the techniques classically used in this indication.

Two-stage skin grafting using a basic fibroblast growth factor-impregnated artificial dermis.

For traditional artificial dermises, a waiting period of approximately three weeks is required after the first implantation before they are adequately vascularized. The objective of this retrospective case series was to investigate whether full-thickness skin defects, requiring surgical reconstruction, could be successfully treated by implantation of a basic fibroblast growth factor (bFGF)-impregnated artificial dermis and secondary skin grafting with a shorter waiting period. Between January 2019 and January 2021, 19 skin defects in 14 patients (7 male and 7 female) were treated with two-stage skin grafting using bFGF-impregnated collagen-gelatin sponge (CGS). All of them were included in this case series, and the waiting period for skin grafting, success rate of skin grafting, infection during the waiting period, and scar quality 6–12 months postoperatively were retrospectively investigated. As a result, all skin grafting surgeries were successfully performed with a waiting period of 13.3 ± 4.3 days. Infection during the waiting period was observed in three lesions (15.8%); however, all infections were controllable. Postoperative scar quality was acceptable (Vancouver Scar Scale score range, 1–8). In conclusion, compared to traditional artificial dermises, bFGF-impregnated CGSs have the potential to shorten the waiting period without decreasing the success rate of skin grafting. Further studies are required to confirm this finding.

Technical details for inset of flaps in transfer of double-level gastroepiploic lymph node flaps for lower extremity lymphedema

In this study, the method that can be followed to ensure rapid and uncomplicated recovery of lymph node flap (LNF) applied in the medial of the ankle for lymphedema treatment was investigated. Thirty-seven patients with class II of lower limb lymphedema underwent transfer of gastroepiploic LNF to the medial ankle and popliteal fossa areas. At the popliteal fossa region, the wound could always be closed primarily by the advancement of neighboring skin. The wound closure could be classified into three types at the medial ankle area (A) The partially exposed LNF was covered with a split-thickness skin graft (STSG) (n=9). (B) A larger local flap was elevated, and the donor site of the local flap was covered with STSG (n=18). (C) The skin flap's donor site was treated with pre-tie sutures (n=10). In the popliteal region, there was no complication of wound healing. In the ankle region, the wound was coated by a thin layer of hematoma over the exposed LNF in 5 patients of group A. It healed secondarily except for one patient who needed a secondary skin graft. The healing was perfect in group B. In group C the healing was good, but there was a hypertrophic scar in 7 patients and required steroid injection later. To avoid complications of the gastroepiploic LNF at the medial ankle, it should be entirely covered by an anteriorly-based local flap, and the donor site defect of the local flap can be treated with either pre-tie sutures or a skin graft.

A Severe Electrothermal Ring Burn Case and a Proposed Treatment Algorithm

Ring-associated burns are infrequent comprising only a tiny fraction of burn consults. Due to the circular nature of rings, these burns are often circumferential, with an increased risk for compartment syndrome and neurovascular injury. The severity of ring burn is related to the type of material and electrical current. Low-voltage injuries are generally due to contact with batteries and household devices, while high-voltage electric injuries occur with occupation-related accidents or natural disasters. Low-voltage ring burn can be managed conservatively with close follow-up. However, high-voltage ring burn might have dramatic consequences such as finger amputation. To date, there have been few cases reported in the literature of a ring burn. Most cases were superficial burns and managed with secondary healing or skin grafting. However, the literature has not reported the management of a severe ring burn with deteriorated finger circulation. In this case report, we present a circumferential electrothermal ring burn case with resulted in total loss of a finger. Furthermore, we propose an algorithmic approach to ring burn injuries.

Effects of comprehensive treatment of infected wounds in patients with iatrogenic Cushing's syndrome

Objective: To investigate the characteristics and comprehensive treatment of infected wounds in patients with iatrogenic Cushing's syndrome. Methods: A retrospective observational study was conducted. From May 2012 to December 2021, the data of 19 patients with iatrogenic Cushing's syndrome discharged from the Department of Burns and Plastic Surgery of the First Affiliated Hospital of Guangxi Medical University were collected, including 8 males and 11 females, aged 28-71 (56±11) years, with 12 cases of infected acute wounds and 7 cases of infected chronic wounds. The lesions were located in the limbs, perianal, and sacrococcygeal regions, with original infection ranging from 9 cm×5 cm to 85 cm×45 cm. After admission, the patients were performed with multidisciplinary assisted diagnosis and treatment, and the wounds were treated with debridement and vacuum sealing drainage, according to the size, severity of infection, suture tension, and bone and tendon tissue exposure of wounds, direct suture or autologous skin and/or artificial dermis and/or autologous tissue flap transplantation was selected for wound repair. The levels of cortisol and adrenocorticotropic hormone (ACTH) of patients at 8:00, 16:00, and 24:00 within 24 h after admission were counted. After admission, the number of operations, wound repair methods, and wound and skin/flap donor site healing of patients were recorded. During follow-up, the wounds were observed for recurrent infection. Results: The cortisol levels of 16 patients at 8:00, 16:00, and 24:00 within 24 h after admission were (130±54), (80±16), and (109±39) nmol/L, respectively, and ACTH levels were (7.2±2.8), (4.1±1.8), and (6.0±3.0) pg/mL, respectively; and the other 3 patients had no such statistical results. After admission, the number of surgical operation for patients was 3.4±0.9. The following methods were used for wound repair, including direct suturing in 4 cases and autologous skin and/or artificial dermis grafting in 9 cases, of which 2 cases underwent stage Ⅱ autologous skin grafting after artificial dermis grafting in stage Ⅰ, and 6 cases had pedicled retrograde island flap+autologous skin grafting. The wound healing was observed, showing that all directly sutured wounds healed well; the wounds in 6 cases of autologous skin and/or artificial dermis grafting healed well, and the wounds in 3 cases also healed well after the secondary skin grafting; the flaps in 4 cases survived well with the wounds in 2 cases with distal perforators flap arteries circumfluence obstacle of posterior leg healed after stage Ⅱ debridement and autologous skin grafting. The healing status of skin/flap donor sites was followed showing that the donor sites of medium-thickness skin grafts in the thigh of 4 cases were well healed after transplanted with autologous split-thickness grafts from scalp; the donor sites of medium-thickness skin grafts in 3 cases did not undergo split-thickness skin grafting, of which 2 cases had poor healing but healed well after secondary skin grafting 2 weeks after surgery; the donor sites of split-thickness skin grafts in the head of 2 patients healed well; and all donor sites of flaps healed well after autologous skin grafting. During follow-up of more than half a year, 3 gout patients were hospitalized again for surgical treatment due to gout stone rupture, 4 patients were hospitalized again for surgical treatment due to infection, and no recurrent infection was found in the rest of patients. Conclusions: The infected wounds in patients with iatrogenic Cushing's syndrome have poor ability to regenerate and are prone to repeated infection. Local wound treatment together with multidisciplinary comprehensive treatment should be performed to control infection and close wounds in a timely manner, so as to maximize the benefits of patients.

Pedicled anterolateral thigh flap reconstruction in the region of the lower abdomen, groin, perineum, and hip

Soft tissue reconstruction of complex defects of the lower abdomen, groin, the perineum and the hip region present areconstructive challenge. Besides free tissue transfer, pedicled flaps may also be utilized. Harvest of the vertical rectus abdominis flap causes afunctional deficit by weakening the abdominal wall. Pedicled, perforator-based flaps minimize functional deficits by preserving muscle. Soft tissue defects with exposed vital structures, prosthetic devices or irradiated wound beds. Previous surgery at the donor site, peripheral vascular disease at the pelvic and thigh region, previous vascular interventions at the donor site. After preoperative localization of the perforators, aretrograde, intramuscular dissection of the pedicle allows sufficient length to be gained in order to transpose the flap into the defect. Tunneling of the flap beneath the rectus femoris muscle and Sartorius muscle is often required for tension-free inset. Five days of bed-rest postoperatively followed by ambulation. No complete flap loss was encountered in 13cases. In 2cases apartial tip necrosis required secondary skin grafting.