Split Skin Graft Research Articles

Efficacy of collagen and elastin matrix in the treatment of complex lower extremity wounds

Successful engraftment of skin grafts highly depends on the quality of the wound bed. Good quality of blood vessels near the surface is critical to support the viability of the graft. Ischemic, irradiated scar tissue, bone and tendons will not have the sufficient blood supply. In such situations flaps are to be resorted. However, the flaps also need to have good vascularity over the limbs. The introduction of dermal substitutes has provided a novel method for repairing various severe skin defects. These substitutes act as dermal regenerative templates, which facilitate dermal reconstruction and regeneration. This study was done to ascertain the effectiveness of these substitutes in the treatment of complex wounds. Between January 2022 and June 2023, 20 patients who had complex wounds, which could not be treated with simple skin grafting and who were treated with collagen and elastin matrix and split skin grafting (SSG) were retrospectively studied. The percentage of SSG take as per the records was noted at a 10-day post-operative period. Patient characteristics, comorbidities, duration and outcomes of the treatment were noted. Twenty patients were included in the study. The minimum size of the ulcer was 5 × 4 cm (area of 20 cm2) and the maximum size of the ulcer was 15 × 15 cm (225 cm2). Average take of skin graft was 93.7% at 10th post-operative day. Recurrence at 6 months was nil. The scar quality was assessed by patient and observer at 3 months and 6 months post-operatively. The lower-limb ulcers with compromised surrounding tissue are complex. The major goal in these cases is to do simple surgery and prevent recurrence. The collagen and elastin matrices provide structural support for cellular infiltration, which helps maximize a SSG take and a stable long-term scar.

The Correlational Study of Percentage of Heamoglobin in Patients who are Undergoing Split Skin Graft Procedure

The Correlational Study of Percentage of Heamoglobin in Patients who are Undergoing Split Skin Graft Procedure

Suprathel Versus Hypafix in the Management of Split-Thickness Donor Site Wounds in the Elderly: A Randomised Controlled Trial

(1) Background: Effective wound management aims for expedited healing, improved functional and scar outcomes, and reduced complications including infection. Delayed wound healing remains a prevalent problem in the elderly. Suprathel is a synthetic absorbable skin substitute and an attractive option in partial thickness wounds. The objective of this randomised controlled study was to assess the effect of skin substitute dressings on elderly split-skin graft (STSG) donor sites, evaluating time to heal, pain, itch and scar outcome. (2) Methods: 40 patients over 65 undergoing split-thickness skin grafting for non-melanoma skin cancer excision were randomised to STSG donor site dressings with either Suprathel or Hypafix. Patients were followed up weekly until healed and at 13 weeks post-procedure. (3) Results: There was no significant difference in time to healing, pain, itch, or scar outcome at 13 weeks between the two groups. The mean time to healing was 31.7 days for the skin substitute group and 27.3 days for the adhesive tape control group (p = 0.182). (4) Conclusions: Both dressings are appropriate for STSG donor sites. Hypafix remains a cost-effective dressing of choice for donor sites. Benefits demonstrated in other studies using skin substitutes have not translated into the elderly population. There remains scope in developing dressings that reduce elderly donor site morbidity.

Evaluation of a Kenaf Nanocrystalline Cellulose-based Hydrogel Containing Platelet Lysate for Full-thickness Wound Healing

Introduction: Healing full-thickness wounds is often challenging and time-consuming, with complications such as scarring and infections. The standard treatment, split skin grafting, has limitations due to the availability of healthy donors and suitability for immunocompromised patients. Method: Autologous platelet lysate (PL) has been popular for tissue regenerative potential because it contains growth factors (GF) and is a safer option for bedridden patients with weak immune systems. However, PL has inconsistent clinical efficacy, high costs, and a short half-life. To address these issues, this study explores a novel delivery system by fabricating a chitosan/nanocrystalline cellulose (CS/NCC) hydrogel to sustainably deliver autologous PL to the wound site. Notably, NCC was prepared from kenaf bast fibers using acid hydrolysis and integrated into the CS matrix through physical entrapment without any chemical crosslinkers. The composite hydrogel was then enriched with autologous PL and further characterized for its physicochemical properties, in vitro GF release, and compatibility with skin cells. At the molecular level, gene expression of wound healing genes was facilitated using qPCR, revealing that the PL-supplemented hydrogel upregulated the expression of extracellular matrix genes. An in vivo study using a full-thickness wound model demonstrated that the CS-NCC-PL hydrogel dressing achieved 81.8% wound closure within 14 days, compared to the control groups. Result: Histological analysis indicated enhanced re-epithelialization, angiogenesis, and collagen deposition. Particularly, the CS-NCC-PL hydrogel group showed a significantly higher hydroxyproline content (60.62 ± 11.46 μg/100 mg) by day 14. Immunohistochemistry results revealed elevated levels of α-SMA and CD31, markers of myofibroblast presence and angiogenesis, peaking at day 7. Conclusion: These findings suggest that the CS-NCC-PL hydrogel is a promising personalized wound dressing for bedridden patients, offering improved healing outcomes in hospital settings.

Individualized surgical treatment using decellularized fish skin transplantation after enzymatic debridement: A two years retrospective analysis

Over the past few years, treatment of burn injuries has evolved beyond primary surgical therapy with the development of enzymatic debridement and new types of skin replacement materials by providing complex personalized therapy concepts aimed at preserving and replacing the dermal layer of the skin.The aim of our study was to develop an individualized treatment algorithm for mixed depth burn wound and evaluate the outcomes of individualized combined treatment of mixed depth burn wounds with enzymatic debridement and decellularized fish skin.A total of 18 patients with a mean age of 34.8 years and mean follow-up of 447.6 days were included. The mean total burn surface area was 12.3%. All patients received enzymatic debridement and an average area of 247.2 cm2 of decellularized fish skin. Days until complete epithelization were 49.4 ± 25.79 days. No patient developed scar contracture or keloid. The Patient and Observer Scar Assessment Scale (POSAS) observer scale showed an overall impression average of 2.2 ± 0.83. The POSAS patient scale showed an overall impression average 2 ± 0.7. The Vancouver Scar Scale showed an average score of 1.89 ± 1.45. In conclusion, combined treatment using enzymatic debridement and decellularized fish skin, polylactide membrane, or split skin grafts allows for a more individualized therapy for mixed depth burn wounds. Fish skin was found to provide a satisfying result in terms of the overall outcome of the developed scar tissue and could lead to a reduction in the area that requires autologous transplantation.

Bullous pemphigoid after Split Skin grafting in vitiligo patient

Bullous pemphigoid (BP) is an autoimmune condition characterized by tense subepidermal blisters commonly seen in old age. Vitiligo is another autoimmune disease associated with loss of melanocytes. Very few cases of coexistence of vitiligo and BP are reported. A split skin graft (SSG) is a surgical options for stable vitiligo. BP over the SSG is a rare occurrence. We present the case of an elderly individual who developed BP at the site of SSG for vitiligo. Postmanagement of BP the lesion healed with recurrence of vitiligo patch at the same site. This case highlights that surgical intervention without ascertaining the stability of the disease activity may not only preclude the patient to the development of the primary disease but also lead to development of other autoimmune illnesses at the surgical site due to unmasking of the epitope to already circulating antibodies.

Train Climbing-A new old trend in adolescents: Treatment of high voltage injuries and planning of a pilot project to raise awareness.

An increasing number of high voltage electric burn injuries in atypically younger patient collective of train surfers and climbers at our levelI center for burns was recognized. The purpose of this study was aretrospective data evaluation and as aconsequence the implementation of an awareness program against train surfing. In aretrospective analysis of prospectively collected data, 17patients with high voltage injuries, who had been treated at our unit between January 2022 and January 2023, were identified. Of these patients seven were treated for injuries due to train surfing or climbing and therefore included in this study. The patients were assessed clinically for total burn surface area (TBSA), degree of burn, associated Injuries, hospital length of stay, number and type of surgeries (fasciotomy, minor/major amputations, defect coverage split skin graft or flaps). Atotal of seven males formed the basis of this report with an average age of 17.7 years (range 14-21years). The highest ABSI (Abbreviated Burn Severity Index) score was 12, leading to the death of the 21-year-old patient who had 80% TBSA as well as multiple comorbidities including severe brain damage. The mean duration of stay at the intensive care unit (ICU) was 24.8 days and the mortality rate was 14.29%. This study highlighted the severity of injuries, with amean TBSA of 41.42% and amortality rate of 14.29% among the study population. Train climbing and surfing patients presented with severe injuries and fatal long-term consequences. Apilot project involving several stakeholders was initiated in order to raise awareness of the dangers of electric arcs and the risk involved.

Efficacy of tranexamic acid versus placebo in reducing blood loss during burn excisional surgery: a multi-center, double-blind, parallel, randomized placebo-controlled clinical trial (TRANEX)

BackgroundDespite an increase in knowledge, blood loss during burn excisional surgery remains a major challenge and is an independent predictor of mortality. During burn surgery, limited measures are available to control the bleeding. Increased fibrinolysis could be one of the contributing factors of blood loss during burn excisional surgery. Tranexamic acid inhibits the fibrinolytic response, and a small body of evidence shows positive effects of tranexamic acid on the volume of blood loss.MethodsThe main objectives of this study are twofold, (1) to investigate whether tranexamic acid reduces blood loss and (2) to investigate the changes in coagulation after burn trauma and during burn excisional surgery. This study is a multicenter double-blind randomized clinical trial in patients scheduled for burn excisional surgery within the Dutch burn centers. All adult patients scheduled for burn surgery with an expected blood loss of ≥ 250 are eligible for inclusion in this study. The study is powered on a blood loss reduction of 25% in the intervention group. In total, 95 subjects will be included. The intervention group will receive 1500 mg tranexamic acid versus placebo in the other group. Primary endpoint is reduction of blood loss. Secondary endpoints include occurrence of fibrinolysis during surgery, graft take of the split skin graft, and differences in coagulation and blood clot formation.DiscussionThis protocol of a randomized controlled trial aims to investigate the efficacy of tranexamic acid in reducing blood loss during burn excisional surgery. Furthermore, this study aims to clarify the coagulation status after burn trauma and during the surgical process.Trial registrationEudraCT: 2020-005405-10; ClinicalTrial.gov: NCT05507983 (retrospectively registered in August 2022, inclusion started in December 2021).

Dynamic optical coherence tomography for imaging acute wound healing.

The aim of this study was to investigate acute wound healing with dynamic optical coherence tomography (D-OCT). From 22 patients with 23 split skin graft donor sites, vessels at four wound edges, the wound bed, and adjacent and unaffected skin of the contralateral leg were measured by D-OCT at six time points from surgery to 4 weeks of healing. Changes in vessel orientation, density, diameter, morphology and pattern in horizontal, vertical and 3D images were analysed for wound healing and re-epithelialization. At 300 μm depth, there were significant differences of blobs and serpiginous vessels between normal and wounded skin. The wound had significantly more vertically oriented vessels, a higher degree of branching, vessel density and diameter compared with healthy skin. 3D images showed increased angiogenesis from healthy skin towards the wound centre, significantly higher vessel density at the wound than at normal skin and the highest at the interface. During wound healing blobs, coils and serpiginous vessels occurred significantly more frequently in lesional than healthy skin. Vessel density was greatest at the beginning, decreased and then increased by 4 weeks post-surgery. D-OCT helps to evaluate acute wound healing by visualizing and quantifying blood vessel growth in addition to re-epithelialization.

An Exasperating and Unusual Presentation of Buschke-Lowenstein Tumor in an Adolescent Girl: Case Report with Review of Literature

AbstractGiant condylomata acuminata of Buschke-Löwenstein (GCBL) is a benign condition with a high recurrence rate and a remote possibility of developing into cancer. It is characterized by excessive proliferation of verrucous lesions on the genitalia and/or perianal region, and is frequently linked to human papillomavirus (HPV) subtypes 6 and 11. With the exception of a few case series, case reports make up the majority of the literature. Despite the literature's support for surgical excision, the current evaluation reveals a lack of clarity regarding the disease's diagnosis and best course of action. Better assessment and management of these patients are necessary to prevent any progression/recurrence of disease.Here, we present a case of a GCBL of the vulva in an 18-year-old girl, who was effectively treated with a simple vulvectomy and split skin graft reconstruction. The reported case is one of the rarest presentations of Buschke-Löwenstein tumor as it is not associated with any of the HPV subtypes and is seen in an 18-year-old girl, one of the youngest patients reported till date. This case report is followed by a brief review of the literature on GCBL, which will add to our understanding of this entity and the most effective therapy to treat the disease.

Extensive Fournier’s Gangrene Due to Delayed Management of Perianal Abscess in Uncontrolled Diabetes: A Case Report

Abstract Fournier’s gangrene is a rapidly spreading gangrene predominantly affecting the genital and perianal region. It has the highest mortality and is more common in immunocompromised and diabetic patients. Poorly controlled diabetes is one of the common risk factors for Fournier’s gangrene. Delayed diagnosis and treatment increase mortality by nearly 100%. In our case, the patient was initially managed for a perianal abscess and later progressed to Fournier’s gangrene. A 48-year-old male diabetic presented with erythematous swelling in the right-side scrotal region for one-week duration. He had a recent perianal abscess and underwent incision and drainage at another hospital He also reported fever with chills and rigors for the past two days. The patient is now in a state of septic shock. He has a history of irregular medication for type 2 diabetes mellitus. Clinical examination confirmed Fournier’s gangrene resulting from a perianal abscess in the context of uncontrolled diabetes. The patient underwent an emergency wound debridement under spinal anesthesia. Extensive wound debridement was performed on the right hemiscrotum. Necrotic tissue was debrided on the right perianal region. The patient was initiated on empirical antibiotics, receiving a calculated dose of cefoperazone with sulbactam and metronidazole. Additionally, the patient underwent sitz baths and received regular wound dressing. Following wound debridement and glycemic control with insulin, the patient showed signs of improvement. Four weeks post-debridement, the patient underwent split-skin grafting for the raw area on the scrotum, while the fistula site was allowed to heal by secondary intention. The cornerstone in managing perianal abscess with Fournier’s gangrene in diabetic patients is extensive wound debridement, antibiotic coverage, and proper management of diabetes. Early diagnosis and prompt surgery of perianal abscess can reduce the risk of developing Fournier’s gangrene in diabetic patients. Post-surgical raw areas can be effectively managed with split-skin grafts.

Double opposing five flaps as an easy way to correct post burn band contracture

Post burn contracture usually need interference mostly for functional or cosmetic correction. Release and skin graft is the first option in the reconstructive ladder; it has its drawbacks either re-contracture or pigmentation of the graft. Release and flap coverage when available is the best. Free flaps, at a time, was the best and last option in the reconstructive ladder. Still, it is the most expensive surgery that consumes a long time for flap raising, anastomosis of its vessels, in addition to donner site morbidity, the need for stages of defatening and the possibility of failure.Local flaps if available is the easiest technique for all plastic surgeons even the beginners. Back to basic: advancement, transposition and rotation flap are easy for any plastic surgeon. Linear scaring or contracture usually can be corrected by Z plasty or multiple Z if long. Sometimes double opposing Z plasties (5 flaps release) is used if one side of the line is healthy and the other is scared.Z plasty and its varieties are not enough to correct very broad band contracture since its release usually develops large defect. In that case even the free flap alone is not enough; split skin graft is mandatory to complete the defect coverage.Our technique is only for band contracture that neither very broad nor linear, and is surrounded by healthy skin, that technique is double opposing 5 flap (DO5F) release.

The minimal important change (MIC) and minimal clinically important difference (MCID) of the patient and observer scar assessment scale (POSAS) 2.0

BackgroundThe Patient and Observer Scar Assessment Scale (POSAS) is frequently used to assess scar quality after burns. It is important to be aware of the minimal important change (MIC) and the minimal clinically important difference (MCID) to establish if a POSAS score represents a clinically relevant change or difference. The aim of this study is to explore the MIC and MCID of POSAS version 2.0. MethodsThis prospective study included 127 patients with deep dermal burns that underwent split thickness skin grafting with a mean age of 44 years (range 0 – 87) and total body surface area burned of 10 % (range 0.5 – 55). POSAS data was obtained for one burn scar area at three, six, and 12 months after split skin grafting. At the second and third visits, patients rated the degree of clinical change in scar quality in comparison to the previous visit. At 12 months, they completed the POSAS for a second burn scar area and rated the degree of clinical difference between the two scar areas. Two anchor-based methods were used to determine the MIC and MCID. ResultsMIC values of the patient POSAS ranged from − 0.59 to − 0.29 between three and six months and from − 0.75 to − 0.38 between six and 12 months follow-up. Both had a poor discriminatory value. MCID values ranged from − 0.39 and − 0.08, with a better discriminatory value. ConclusionResults suggest that patients consider minor differences (less than 0.75 on the 1–10 scale) in POSAS scores as clinically important scar quality changes. MCID values can be used to evaluate the effects of burn treatment and perform sample-size calculations.

Case Report ‘Layer of Hope’: Managing Large Surface Wounds on Frontal Bare Bone in a Challenging Patient

This was a case of an elderly gentleman with large bleeding basal cell carcinoma occupying almost three quarter of the forehead managed with adjunct usage of integra acellular dermal regeneration template after lesion’s wide local excision despite challenged with patient’s newly diagnosed bicytopenia to rule out haematological malignancy. Standard management of tissue reconstruction with purely living tissue (split skin grafting) has higher risk of graft rejection due to bare bone as wound bed. This limits the neo-graft ability to achieve optimal potential of imbibition and inosculation. Thus, dermal matrix usage makes split skin grafting difficult wound bed has higher chance of surviving and hence shortens healing time and reduces hospital stay.

Multiple squamous cell carcinomas of temporal bone years after radiotherapy for malignancy glottis-report of a rare case with review of literature

Larynx is unique in its anatomy. It is critical to map the lesions accurately so that the patient may benefit from the strategy most likely to preserve a functional larynx with the lowest likelihood of recurrence and the least morbidity. We describe a case of 60-year-old male with malignancy glottis diagnosed at the age of 43, treated with external beam radiotherapy, presented 15 years after with swelling in the right upper part of the face, lateral to the eye. Radiological investigations suggested neoplasm in the skin over the right zygomatic part of the temporal bone. Biopsy confirmed malignancy, basal cell carcinoma type. Wide local excision of the lesion with split skin grafting was done. After 2 years, he presented with right ear pain, discharge, and hard of hearing. Examination and radiological investigations confirmed a mass in the external auditory canal, infiltrating through the temporal bone. Biopsy revealed an acantholytic variant of squamous cell carcinoma (SCC). The patient was advised about treatment options and radiotherapy was chosen. Further, a literature search was conducted to detect similar cases. We describe the incidence and prevalence of radiation-induced temporal bone malignancy, an exceedingly rare and late complication of head and neck irradiation. Radiation induced SCCs are highly malignant secondary neoplasms in the head and neck region. It constitutes a therapeutic challenge because of its anatomy and the known side effects of radiation. Timely intervention with a multidisciplinary approach is necessary.

Giant pretibial cellular fibrous histiocytoma colliding with an epidermal cyst

Histiocytomas are common benign tumors of the skin. In contrast, giant histiocytomas are a rarity. We report a 43-year-old male patient, who presented with a 7 × 6 cm large firm tumor on his left lower leg. This was a long-standing lesion, but within the last three months, the tumor developed an exophytic nodule. A skin biopsy revealed an atypical spindle-cell tumor. We decided to perform a complete excision with a safety margin. Complete histopathological analysis confirmed the diagnosis of a collision tumor composed of a cellular fibrous histiocytoma and an epidermal cyst. The resulting defect was temporarily closed by vacuum-assisted closure before eventually a meshed split skin graft was transplanted. Proliferating fibrohistiocytic lesions should be surgically removed, and a careful histopathologic analysis is necessary to avoid delayed diagnosis of possible malignant lesions.

Study on Management of Diabetic Foot Ulcer in a Rural Tertiary Care Hospital

Abstract Background: Diabetic foot ulcer is a common complication among diabetic patients. Diabetes is prone to multiple complications related to microvascular, macrovascular, and metabolic etiologies. Diabetic foot ulcers can ultimately lead to infection, gangrene, amputation, and even death. Methods: This is a prospective observational study, that was carried out on 100 adult patients between July 2022 and January 2023 diagnosed with diabetic foot ulcer, treated at MVJ Medical College and Research Hospital. Inclusion criteria were all patients aged above 18 years. Exclusion criteria were patients with peripheral vascular disease not arising due to diabetes, patients with varicose veins, and patients who are undergoing chemotherapy or immunocompromised and in sepsis. Routine blood investigation, blood sugar levels, and liver function test were done. Specific investigation including discharge from wound/biopsy for culture, urine routine, x- ray of foot and doppler studies was done. The patient underwent standard surgical procedure and was followed up. The collected data were analyzed using SPSS-21 software. Results: The data collected were analyzed and documented. In our study, we noted that male cases were about 64% and female cases were about 36%, and the ratio of male:female is 1.7. The maximum number of cases were observed in the age group of more than 65 years, and the most common site of involvement was right foot. Conservative treatment involved diabetes control with drugs and insulin followed by wound management by dressing, debridement, amputation, and split skin grafts. Conclusion: Foot ulcer is preventable, and relatively simple interventions can reduce the risk of amputations by 80%. Management is primarily concerned about wound healing, and stopping the spread of infection, this is achieved by various methods such as split skin grafting, amputations, and conservative methods like dressing.

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.

Comparison of Ba-Hao burn ointment gauze and petrolatum gauze in split graft donor site healing: A randomized, prospective, and self-control study.

To assess patient comfort, wound healing, and scarring at the 6-month follow-up of split-skin graft donor sites treated with Ba-Hao burn ointment (BHBO) gauze, a compound preparation of traditional Chinese medicine since 1970s, compared with petrolatum gauze. Thirty patients admitted to the Department of Burns of the First Affiliated Hospital of Anhui Medical University between September 2021 and September 2022 participated in this randomized, prospective, self-control clinical study. After harvesting the split skin, donor sites were divided into two parts along the midline. BHBO gauze was applied to half of the donor wounds, and petrolatum gauze was applied to the other half. The wound healing time, pain scores on the postoperative Days 3, 6, and 9, and Vancouver Scar Scale (VSS) score at the 6-month follow-up were assessed. The wound healing time was significantly shorter in the BHBO group than in the control group (10.07 ± 1.48 days vs. 11.50 ± 1.74 days, p < 0.001). On postoperative Days 3 and 6, the pain scores quantified by visual analog scores were significantly lower in the BHBO group than in the control group (5.33 ± 1.54 and 4.17 ± 1.51, respectively vs. 7.57 ± 1.41 and 5.20 ± 1.47, respectively). The difference in the visual analog scale score on postoperative Day 9 between the groups was not significant (p > 0.05). Microbiological assessment revealed the absence of bacterial contamination in both groups. At the 6-month follow up, the VSS score was significantly lower in the BHBO group (6.67 ± 1.92) than in the control group (9.57 ± 1.55). BHBO resulted in faster donor-site healing, reduced postoperative pain, and improved scar quality at the 6-month follow-up than petrolatum gauze alone.

Duragen: A dermal substitute for the management of suboptimal wounds.

Using a flap in a large wound with a very small area of exposed vital structures may be an excessive intrusion and cause unnecessary donor site morbidity. Dermal matrix (DuraGen) was applied onto critical areas where bone or tendons were exposed and a split skin graft was placed thereon. All patients had satisfactory wound closure without the need for a flap. DuraGen appears to be a safe, single-stage alternative, to a flap for the healing of complex wounds.