Skin Grafting Techniques Research Articles

Particularités de la greffe cutanée en chirurgie plastique pédiatrique

Skin graft is a skin tissue fragment transferred from a donor site to a receiving site with a spontaneous revascularization. Basic process of plastic surgery, skin graft known in children, specific, warnings and refinements. It finds its indication in many pediatric cases: integumental diseases (neavus, hamartoma), acute burns and scars, traumatic loss of substance or surgically induced, congenital malformations of the hands and feet, etc. Specific skin graft techniques in children are developed: donor sites, sampling technique and procedure, early postoperative care. Especially in children, the scalp is a perfect site for split skin graft and technique is actively developed. Refinements and special cases are discussed: use of dermal matrices, allografts, xenografts, negative pressure therapy, prior skin expansion of the donor site. Results of skin graft in children are exposed: taking of graft, growth and shrinkage, pigmentation. Skin graft sometimes allows to stay the complex movement and get the best final benefit, permanent or at least temporary, in a growing being.

A new method for skin grafting in murine model.

Skin transplantation provides an excellent potential model to investigate the immunology of allograft rejection and tolerance induction. Despite the theoretical ease of performing skin transplantation, as well as the potential of directly observing the reaction to the transplanted tissue, the poor reliability of skin transplantation in the mouse has largely precluded the use of this model. Furthermore, there is controversy regarding the most appropriate skin graft donor site due to poor success of back skin transplantation, as compared with the thinner ear or tail skin. This study demonstrates a reliable method to successfully perform skin grafts in a mouse model, as well as the clinical and histologic outcome of syngeneic grafts. A total of 287 grafts were performed (in 126 mice) utilizing donor skin from the ear, tail or back. No graft failure or postoperative mortality was observed. Comparison of this technique with two previously established protocols of skin transplantation (5.0 absorbable Suture + tissue glue technique and no-suture technique) demonstrates the significant improvement in the engraftment success of the new technique. In summary, a new technique for murine skin grafting demonstrates improved reliability across donor site locations and strains, increasing the potential for investigating interventions to alter the rejection process.

Individualized therapy for burn wound

Individualized therapy denotes that a suitable treatment project is chosen according to specific conditions of the patients with full benefit and minimal damage, and it is one of the contemporary surgical procedures that surgeons are looking for. But certain difficulties still exist in the treatment of burn patients, as well as repair of refractory or chronic wound as performed by burn surgeons. In this issue of the journal, application of individualized therapy in burn wound was discussed from various angles. For instance, through using Meek skin grafting technique, large sheets of skin graft could be saved for repair of wound on special body part of patients with severe burn, and combined flaps surgery could be applied to repair skin and soft tissue defects.

A new strategy for total auricular reconstruction using prelamination of an extended retroauricular flap with tissue expansion

To accomplish total ear reconstruction with aesthetic appearance is a great challenge for plastic surgeons worldwide due to insufficient skin coverage. A retroauricular fascial flap and skin graft technique are commonly used, but the results obtained are not satisfactory due to color mismatch, severe edema, and donor-site morbidity. Here, we describe a novel strategy for total ear reconstruction, utilizing an extended retroauricular flap prelaminated with tissue expansion to obtain enough skin for ear reconstruction. About 2 months before ear reconstruction, a kidney-shaped tissue expander was inserted at the mastoid region subcutaneously. The retroauricular skin became enlarged and thinner in 2 months after expansion. Next, the expander was removed and the retroauricular flap was extended by dissecting the surrounding scalp subcutaneously. By mobilizing the scalp-extended retroauricular flap, we could encapsulate the entire framework with thin and non-hair-bearing skin. From August 2014 to September 2015, 36 microtia patients had undergone ear reconstruction using the novel strategy. Satisfactory aesthetics along with fine structure, symmetry, and maintenance of the auriculocephalic angle was achieved in all patients. Using our novel strategy, we can obtain satisfactory aesthetic outcomes by fully mobilizing the expanded skin without additional morbidities of the donor sites. Patients are satisfied with the vivid ear contour and lack of groin scar.

A Skin Graft Technique for Reconstructing Full-Thickness Scalp Defects

A Skin Graft Technique for Reconstructing Full-Thickness Scalp Defects

Fibrin gel as a scaffold for skin substitute – production and clinical experience.

The purpose of this study was to create a fibrin-based human skin substitute in vitro with epidermal and dermal component and to assess its healing potential in deep partial and full thickness burns. Fibrin scaffolds were prepared from commercial fibrin glue kits. Human fibroblasts were cultured in fibrin gel. Human keratinocytes were seeded on the top of the gel. Viability of cells was determined fluorimetrically. Scanning electron microscope and immunocytochemistry analysis of cultured cells were performed. After hydrosurgical preparation of deep burn necrotic tissue, wound bed was prepared for skin substitutes. Progress of healing was documented using visual estimation and photos. Scanning electron microscope images showed good cell attachment and colony spreading of keratinocytes and fibroblasts on fibrin scaff old. Immunofluorescent staining of cell cultures on fibrin scaffold showed expression of vimentin, a marker of fibroblast cells, cytokeratin 19, a marker of epithelial stem cells, as well as involucrin, a marker of differentiated keratinocytes. Clinical results clearly showed that appearance of the skin did not differ significantly from the areas of transplanted skin using split-thickness skin graft techniques. In conclusion, using these fibrin-cultured autografts on massive full-thickness burn resulted in good healing.

A systematic review on skin complications of bone anchored hearing aids in relation to surgical techniques

A systematic review to study the skin complications associated with the bone-anchored hearing aid in relation to surgical techniques. The following databases have been searched: MEDLINE, EMBASE, the Cochrane Library , Google scholar and the PubMed. The literature search date was from January 1977 until November 2013. Randomised controlled trials and retrospective studies were included. Initial search identified 420 publications. Thirty articles met the inclusion criteria of this review. The most common surgical techniques identified were full-thickness skin graft, Dermatome and linear incision techniques. The result shows that dermatome technique is associated with higher rate of skin complications when compared to linear incision and skin graft techniques. Based on the available literature, the use of a linear incision technique appears to be associated with lower skin complications; however, there is limited data available supporting this. Higher quality studies would allow a more reliable comparison between the surgical techniques.

A comparison of fasciotomy wound closure methods following extremity compartment syndrome at a regional trauma centre

Background Extremity fasciotomy wound closure following acute compartment syndrome is often prohibited by residual swelling, producing wounds that significantly contribute to patient morbidity. The aim of this study was to assess patient and fasciotomy wound outcomes associated with dynamic closure (DYN), delayed primary closure (DPS) and split skin grafting (SSG) techniques.

Challenging the Conventional Therapy: Emerging Skin Graft Techniques for Wound Healing.

Split-thickness skin grafting is the current gold standard for treatment of major traumatic skin loss. However, split-thickness skin grafting is limited by donor-skin availability, especially in large burns. In addition, the donor-site wound is associated with pain and scarring. Multiple techniques have been developed in the past to overcome these limitations but have been unable to achieve clinical relevance. In this study, the authors examine the novel emerging skin grafting techniques, aiming to improve the utility of split-thickness skin grafting. An extensive literature review was conducted on PubMed, MEDLINE, and Google Scholar to look for new skin grafting techniques. Special focus was given to techniques with potential for large expansion ratio and decreased donor-site pain. The new modalities of modified skin grafting technique, discussed in this article, include (1) Xpansion Micrografting System, (2) fractional skin harvesting, (3) epidermal suction blister grafting, and (4) ReCell technology. These techniques are able to achieve significantly increased expansion ratios compared with conventional split-thickness skin grafting and also have decreased donor-site morbidity. These techniques can be used separately or in conjunction with split-thickness skin grafting to overcome the associated pitfalls. Further studies and clinical trials are needed to define the utility of these procedures and where they fit into routine clinical practice.

A Rare Case of Penile Lymphangioma Circumscriptum Treated with the Split-Thickness Skin Grafting Technique

A Rare Case of Penile Lymphangioma Circumscriptum Treated with the Split-Thickness Skin Grafting Technique

Non-healing wounds of the equine distal limb — effective field surgery techniques

Management of a chronic wound presents a common challenge in equine practice. Thorough evaluation of the animal and wound is required to identify intrinsic and extrinsic factors that can prevent healing. Additional investigation may require radiography, ultrasonography, bacterial culture and histopathology in order to identify underlying complicating factors. External factors such as ongoing trauma, bacterial colonisation and excess movement require management utilising debridement, coaptation and appropriate use of antimicrobial therapy. Wound specific factors such as bone sequestra and the propensity for exuberant granulation in the distal limb require careful evaluation and proactive management. Once inhibitory factors have been addressed, second intention healing can be optimised through the principles of moist wound healing and by the use of skin grafting techniques. Island grafting techniques can be performed in the field and should be considered as a cost-effective method of improving the quality and speed of wound healing.

Promising long-term outcomes of the reused skin-graft technique for chronic gluteal hidradenitis suppurativa

BackgroundThe reused skin-graft technique can be used to treat chronic gluteal hidradenitis suppurativa, but long-term outcomes and the reliability of the technique have not been reported. MethodsIn a retrospective review of 18 men with chronic gluteal hidradenitis suppurativa (age range, 18–68 years) treated with a reused skin graft between June 2004 and March 2012, we evaluated disease severity (Hurley classification system), skin-graft thickness, the need for an additional normal skin graft, histological findings and recurrence rate at the surgical site. ResultsThe mean duration of follow-up was 61.3 months (range, 17–113 months). Five cases were classified into severity group I, 12 cases into severity group II and one case into severity group III. The range of skin-graft thicknesses was 0.013–0.020 inches. An additional donor site was unnecessary in 10 cases (three cases in group I (60%) and seven cases in group II (58.3%)). Histological examination indicated that a buried epidermal cyst could cause chronic gluteal hidradenitis suppurativa recurrence, although none of the patients experienced recurrence at the surgical site during follow-up. ConclusionThe reused skin-graft technique is reliable for chronic gluteal hidradenitis suppurativa resection, and it shows promising long-term outcomes.

Hair follicles and their potential in wound healing.

Hair follicles and their potential in wound healing.

A systematic review on skin complications of bone-anchored hearing aids in relation to surgical techniques.

A systematic review to study the skin complications associated with the bone-anchored hearing aid in relation to surgical techniques. The following databases have been searched: MEDLINE, EMBASE, the Cochrane Library , Google scholar and the PubMed. The literature search date was from January 1977 until November 2013. Randomised controlled trials and retrospective studies were included. Initial search identified 420 publications. Thirty articles met the inclusion criteria of this review. The most common surgical techniques identified were full-thickness skin graft, Dermatome and linear incision techniques. The result shows that dermatome technique is associated with higher rate of skin complications when compared to linear incision and skin graft techniques. Based on the available literature, the use of a linear incision technique appears to be associated with lower skin complications; however, there is limited data available supporting this. Higher quality studies would allow a more reliable comparison between the surgical techniques.

Effect of Mixed Transplantation of Autologous and Allogeneic Microskin Grafts on Wound Healing in a Rat Model of Acute Skin Defect

The treatment of extensive thermal injuries with insufficient autologous skin remains a great challenge to burn surgeons. In this study, we investigated the influence of the ratio of autologous and allogeneic tissue in mixed microskin grafts on wound healing in order to develop an effective method for using limited donor skin to cover a large open wound. Four different mixtures were tested: autologous microskin at an area expansion ratio of 10∶1 with allogeneic microskin at an area expansion ratio of 10∶1 or 10∶3 and autologous microskin at an expansion ratio of 20∶1 with allogeneic microskin at an expansion ratio of 20∶3 or 20∶6. Wound healing, wound contraction, and integrin β1 expression were measured. Mixed microskin grafting facilitated wound healing substantially. The mixture of autologous microskin at an expansion ratio of 10∶1 with the same amount of allogeneic microskin achieved the most satisfactory wound healing among the 4 tested mixtures. Histological examination revealed the presence of obviously thickened epidermis and ectopic integrin β1 expression. Keratinocytes expressing integrin β1 were scattered in the suprabasal layer. Higher levels of integrin β1 expression were associated with faster wound healing, implying that ectopic expression of integrin β1 in keratinocytes may play a pivotal role in wound healing. In conclusion, this study proves that this new skin grafting technique may improve wound healing.

External wire-frame fixation of digital skin grafts: A non-invasive alternative to the K-wire insertion method

Background and AimThe current skin graft fixation methods for digits, including the Kirschner wire insertion technique, can be limited by inadequate or excessive fixation and complications such as infection or secondary injuries. Therefore, the external wire-frame fixation method was invented and used for skin grafting of digits. This study aimed to investigate external wire-frame fixation of digital skin grafts as a non-invasive alternative to the K-wire insertion method. MethodsIn 2005–2012, 15 patients with burn scar contractures on the hand digits received a skin graft that was then fixed with an external wire frame. The intra-operative time needed to make the wire frame, the postoperative time to frame and suture removal, the graft survival rate, the effect of contracture release and the complications were recorded. ResultsIn all cases, the contracture release was 100%. The complete graft survival rate was 98.6%. Four patients had epithelial necrosis in <5% of the total area. There were no other complications such as pressure ulcer or hypoxia of fingers. ConclusionsExternal wire-frame fixation is simple, minimally invasive and a custom-made technique for skin grafting of the fingers. It was designed for its potential benefits and the decreased risk it poses to patients with scar contractures on their fingers. It can be implemented in three phases of grafting, does not affect the epiphyseal line or subsequent finger growth and is suitable for children with multi-digit involvement.

BAHA implant: Implantation technique and complications

BAHA implants have been shown to be effective in certain forms of conductive hearing loss, but the presence of the titanium abutment is responsible for sometimes severe skin reactions. The objective of this study was to compare two operative techniques: skin flap, and full-thickness skin graft. Between January 2004 and January 2011, 72 patients were treated by BAHA implant and 32 of these patients (total of 41 implants) were included in the study. Two surgical techniques were used: full-thickness skin graft (n=21) and skin flap (n=20). Four types of skin complications were observed: necrosis, inflammation/infection, hypertrophic scar, and fixture loss due to inadequate osseointegration. Complications requiring surgical revision were observed in 20% of cases with the skin flap method and 38% of cases with the skin graft technique, with no significant difference between the two groups (P=0.31). The skin graft technique appears to be associated with a higher rate of major complications. The most common complication is hypertrophic scar. The apparently high complication rate in this series can be explained by a selection bias (exclusion of a large number of complication-free patients).

Widespread Cutaneous Necrosis and Antiphospholipid Antibody Syndrome

Sir: Antiphospholipid antibody syndrome is an autoimmune disease characterized by the presence of arterial/venous thrombosis and thrombocytopenia. Specific hematologic indicators of antiphospholipid antibody syndrome include elevated titers of lupus anticoagulant and/or anticardiolipin antibodies. Elevated levels of these enzymes detected on two separate occasions at least 12 weeks apart are necessary for the diagnosis.1–3 Widespread cutaneous necrosis secondary to thrombosis of dermal microvasculature is an exceedingly rare manifestation of antiphospholipid antibody syndrome and has been reported in only 23 cases worldwide to date.3 We present a patient with recurrent widespread cutaneous necrosis secondary to antiphospholipid antibody syndrome. A 40-year-old woman presented with a painful, swollen, discolored left breast with the absence of trauma or other inciting events. The patient had a significant history of coronary artery disease, myocardial infarction, deep vein thrombosis, pulmonary embolism, and arterial thrombosis resulting in a below-knee amputation. She had been taking warfarin for 8 years with variable compliance. She was started on intravenous heparin. Demarcation of the breast was complete by hospital day 3 (Fig. 1).Fig. 1: Cutaneous necrosis and dense eschar of the left breast.A left mastectomy was performed, and the breast reconstructed with a split-thickness skin graft. The patient did well and was discharged on therapeutic dabigatran (Pradaxa). A diagnosis of warfarin-induced cutaneous necrosis was made based on wound appearance, wound location, warfarin noncompliance, histological analysis, and timing of presentation. Three weeks after discharge she presented with a painful discolored upper back. She was started on systemic lepirudin therapy and repletion of protein C (Fig. 2).Fig. 2: Cutaneous manifestation of widespread cutaneous necrosis caused by antiphospholipid antibody syndrome.Hypercoagulation panels revealed a positive result for heparin-induced thrombocytopenia (anti-heparin-PF4 enzyme-linked immunosorbent assay, immunoglobulin G 0.809 O.D.). Additional serum testing was consistent with antiphospholipid antibody syndrome (diluted viper venom screening test confirmed with elevated anticardiolipin immunoglobulins G, M, and A). Serial operative débridement of the full-thickness necrosis was performed with wound vacuum-assisted closure stabilization. The patient remained fully anticoagulated on lepirudin but sustained a cardiorespiratory arrest and passed away. Full-thickness cutaneous necrosis secondary to microvascular thrombosis is a rare clinical manifestation of antiphospholipid antibody syndrome, with only 23 cases reported worldwide. This manifestation is more commonly associated with warfarin-induced skin necrosis, but antiphospholipid antibody syndrome should be suspected in patients with recurrent skin necrosis despite warfarin cessation and alternative anticoagulation. The presence of elevated titers of lupus anticoagulant and/or systemic lupus erythematosus is diagnostic. No specific mechanism of thrombosis caused by antiphospholipid antibody syndrome has been determined; however, it is hypothesized that the antibodies have a direct effect on coagulation. Antiphospholipid antibodies have been shown to directly cause endothelial injury and activation, modulation of protein C and S pathways, activation of platelets, inhibition of the phospholipid placental anticoagulant protein-1, interference with antithrombin III, and/or fibrinolytic impairment.1,3,4 Management of patients with widespread cutaneous necrosis and antiphospholipid antibody syndrome involves local treatment of cutaneous infarction and systemic anticoagulation for long-term minimization of thrombotic recurrence. Initial administration of high-dose systemic steroids may be considered to reduce concurrent vasculitis. Plasmaphoresis has also been reported to successfully remove present aPL.1–3 Treatment for widespread cutaneous necrosis is conservative and involves local antiseptic therapy, including serial débridement of the necrotic eschar. The resulting ulceration is then either healed by secondary intention or corrected surgically by skin flap or grafting techniques.1 DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. J. Walter Dutton, M.D. West Virginia University School of Medicine Morgantown, W.Va. R. Wesley Vosburg, M.D. West Penn Allegheny Health System Pittsburgh, Pa. W. Thomas McClellan, M.D. Plastic and Reconstructive Surgery West Virginia University Morgantown, W.Va.

Human hair follicle dermal sheath and papilla cells support keratinocyte growth in monolayer coculture

Traditional skin grafting techniques are effective but limited methods of skin replacement. Autologous transplantation of rapidly cultured keratinocytes is successful for epidermal regeneration, but the current gold-standard technique requires mouse fibroblast feeders and serum-rich media, with serum-free systems and dermal fibroblast (DF) feeders performing relatively poorly. Here, we investigated the capacity of human hair follicle dermal cells to act as alternative supports for keratinocyte growth. Dermal papilla (DP) dermal sheath (DS), DF and 3T3 cells were used as inactivated feeder cells for human keratinocyte coculture. Under conditions favouring dermal cells, proliferation of keratinocytes in the presence of either DS or DP cells was significantly enhanced compared with DF cells, at levels comparable to keratinocytes cultured under gold-standard conditions. Secreted protein acidic and rich in cysteine (SPARC) expression increased DS and DP cells relative to DFs; however, further experiments did not demonstrate a role in keratinocyte support.

Skin grafting for venous leg ulcers

Venous leg ulceration is a recurrent, chronic, disabling condition. It affects up to one in 100 people at some time in their lives. Standard treatments are simple dressings and compression bandages or stockings. Sometimes, despite treatment, ulcers remain open for months or years. Sometimes skin grafts are used to stimulate healing. These may be taken, or grown into a dressing, from the patient's own uninjured skin (autografts), or applied as a sheet of bioengineered skin grown from donor cells (allograft). Preserved skin from other animals, such as pigs, has also been used (xenografts). To assess the effect of skin grafts for treating venous leg ulcers. For this update we modified the search strategies and conducted searches of The Cochrane Wounds Group Specialised Register (searched 27 July 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (2008 to July Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 26, 2012); Ovid EMBASE (2008 to 2012 Week 29); and EBSCO CINAHL (2008 to 26 July 2012). We did not apply date or language restrictions. Randomised controlled trials (RCTs) of skin grafts in the treatment of venous leg ulcers. Two review authors independently undertook data extraction and assessment of study quality. For this update of the review, we identified one new trial, bringing the total to 17 trials (1034 participants) - all of which were generally at moderate or high risk of bias. In 12 trials participants also received compression bandaging.Eleven trials compared a graft with standard care in which no graft was used. Two of these trials (102 participants) compared a dressing with an autograft; three trials (80 participants) compared frozen allografts with dressings, and two trials (45 participants) compared fresh allografts with dressings. Two trials (345 participants) compared tissue-engineered skin (bilayer artificial skin) with a dressing. In two trials (97 participants) a single-layer dermal replacement was compared with standard care.Six trials compared alternative skin grafting techniques. The first trial (92 participants) compared autografts with frozen allograft, a second (51 participants) compared a pinch graft (autograft) with porcine dermis (xenograft), the third (110 participants) compared growth-arrested human keratinocytes and fibroblasts with placebo, the fourth (10 participants) compared an autograft delivered on porcine pads with an autograft delivered on porcine gelatin microbeads, the fifth trial (92 participants) compared a meshed graft with a cultured keratinocyte autograft, and the sixth trial (50 participants) compared a frozen keratinocyte allograft with a lyophilised (freeze-dried) keratinocyte allografts.Significantly more ulcers healed when treated with bilayer artificial skin than with dressings. There was insufficient evidence from the other trials to determine whether other types of skin grafting increased the healing of venous ulcers. Bilayer artificial skin, used in conjunction with compression bandaging, increases venous ulcer healing compared with a simple dressing plus compression. Further research is needed to assess whether other forms of skin grafts increase ulcer healing.