Split Skin Graft Research Articles

25, 50 & 75 years ago

25, 50 & 75 years ago

Reconstruction of complex oro-mandibular defects by four different modifications of free fibula osteomyocutaneous flap: A prudent alternative to multiple flaps

Resection of advanced oral squamous cell carcinoma results in complex oro-mandibular defects involving external skin, oral mucosa, and bone. Reconstruction of such defects by a single free fibula flap (FFF) is limited by the lack of soft tissue bulk and adequate skin paddle for both intra- and extra-oral coverage. In this study, the reconstruction of large defects was achieved by four modifications of free fibula osteomyocutaneous flap as an alternative to multiple flaps. In this prospective study, 29 patients with complex oro-mandibular defects were reconstructed by FFF from December 2018 to October 2020. Reconstruction was done with any one of the four FFF modifications involving large proximal skin paddle from lateral leg: Strip de-epithelialization (De-Ep), chimeric bipaddle (Ch-Bp), muscle orally and skin extra-orally (Mo-Se), and double microvascular (Db-Mi). Outcome variables assessed were functional and esthetic results, early/late complications, donor site morbidity, and operative time. An algorithm based on Cordeiro's classification is proposed to assist in the selection of appropriate FFF modification. Among 29 patients, De-Ep was used in 13, Ch-Bp in 8, Mo-Se in 7, and Db-Mi in 1 case. None of the flaps underwent total loss. Two cases required re-exploration. The median operative time was 775min. Wound dehiscence and oro-cutaneous fistula were common early and late complications, respectively. Partial split skin graft loss (SSG) was the most common donor site morbidity. Functional and facial aesthetics were acceptable at the end of follow-up. Specific FFF modifications can be recommended in selected scenarios. It is reliable for single-stage reconstruction with satisfactory esthetic and functional outcomes. When used for reconstruction in first primary tumors, the second donor site is preserved, which can prove valuable in the event of a recurrence or second primary.

VACUUM-ASSISTED CLOSURE AND MUSCLE FLAP AS AN ALTERNATIVE MODALITY FOR INFECTED WOUND AFTER ORIF OF TIBIAL FRACTURE: CASE REPORT

Background: The blood supply of a bone can be decreased due to the use of an implant, leading to wound-bed bacterial colonization and the development of the SSI. The principle of vacuum-assisted closure (VAC) is to use a negative pressure environment in the wound to promote increased wound healing. The case shows that VAC application and muscle flap therapy provide the definitive healing of infected wounds after ORIF. Case Report: A 45 years-old male presented with a close comminuted proximal third right tibia fracture and tense skin. The fracture was openly reduced and internally fixated with plate fixation and a skin flap on the fracture area. Still, the wound could not be closed due to difficulty covering the wound, so a counter incision was made. After four days, the patient developed necrosis in the post-operation wound and subsequently underwent debridement and muscle flap with VAC application. Discussion: SSI can be treated by applicating of appropriate antibiotic and surgical procedures. In this case, the infection was treated using third-generation cephalosporin antibiotic, debridement, dissection, and re-elevation of gastrocnemius muscle flap covering the exposed plate area in inferior, split skin graft above the muscle flap and VAC above skin graft with 75 mmHg pressure. Conclusion: Debridement with muscle flap and application of VAC in the deep infected wound of open reduction and internal fixation was found to be successful methods in minimizing complications and obtaining an optimal outcome. This finding was associated with accompanying morbidities or a good wound healing process.

Features of autodermoplasty in traumatic wounds of the skin and soft tissues

Autodermoplasty with a skin flap is the main surgical solution for traumatic wounds of the skin and soft tissues. Split-skin grafting is a routine reconstructive technique associated with large variation in practice. To date, the technique of skin grafting with a skin flap has been brought to perfection mainly by the efforts of specialists – combustiologists. The authors have identified a number of features of autodermoplasty with a skin flap. Split-skin grafting for complex traumatic wounds of the skin and soft tissues was performed in 50 patients, good functional and cosmetic results were obtained.

A prospective comparative study on the effectiveness of two different non-adherent polyurethane dressings on split-thickness skin graft donor sites

AimTo analyze differences in re-epithelization, exudate absorbency, ease and pain on dressing removal between ALLEVYN™ Non-Adhesive and Betaplast™ N. MethodologyPatients admitted to the general ward undergoing split skin grafting were recruited. Allevyn and Betaplast were applied on the donor site. Exudate absorption was assessed daily using an absorbency grading chart. Dressing change was done on post-operative day five. Ease of dressing removal and pain score using the Wong-Baker Pain Scale was assessed. The percentage of re-epithelization for each dressing was assessed. Results30 patients were recruited. There was a statistically significant difference in exudate absorption on post-operative day 3 (z = −2.006, p = 0.045, T = 236) and post-operative day 4 (z = −2.026, p = 0.0143, T = 188), pain score (z = −2.861, p = 0.004, T = 180), ease of removal (z = −2.668, p = 0.008, T = 126) and re-epithelization (z = −2.566, p = 0.009, T = 336) between Betaplast and Allevyn. ConclusionBetaplast may have faster re-epithelization, better exudate absorption, and is easier to remove while minimizing discomfort as compared to Allevyn.

Applying the modified Meek technique to heal smaller burns: a retrospective review

Deep dermal and full thickness burns are typically closed with split thickness skin grafting. In less extensive burns where donor skin is readily available healing is usually achieved with meshed split skin grafting. Meek micrografting is an alternative technique that is well-recognised for more extensive burns, but can also have a place in managing smaller total body surface area (TBSA) burns primarily to minimise donor site size and its associated morbidity.We present our 9-year experience of using Meek grafting in a series of 11 cases involving ≤20% TBSA burn injuries, and describe our method for minimising theatre time. We achieved 80.7% graft take at 4 weeks post-grafting and demonstrated 100% healing of all wounds at an average of 58.1 (31–83) days after the final Meek grafting operation. Our results demonstrated that Meek grafting achieves comparable healing to conventional grafting with a similar surgical time and reduced donor size.

Physiotherapy succeeding split skin grafting in a case of degloving injury of hand and keloid formation

Physiotherapy succeeding split skin grafting in a case of degloving injury of hand and keloid formation

Covering of large scalp defects prior to postoperative irradiation.

After R0 resection of extensive cutaneous squamous cell carcinoma of the scalp with indication for postoperative radiotherapy, closure techniques should be chosen that allow rapid initiation of radiotherapy. The aim of this retrospective analysis is to evaluate defect coverage by transverse transposition flap and split skin grafting of the donor site in such a scenario with regard to oncologic safety (recurrence rate) and permanence of wound closure. Eleven patients were identified who had histologic cutaneous squamous cell carcinoma treated by microscopically controlled excision and defect coverage using a transverse transposition flap and split skin grafting of the donor site and who received postoperative radiotherapy. Patients were evaluated for recurrence, wound healing disorders and side effects of radiotherapy. The mean age was 81 years. Follow-up time averaged 1.4 years after the last radiotherapy session. Wound healing disorders of the transposition flap or graft necrosis were not detected. All therapy-associated side effects had resolved at follow-up. Local recurrence or metastasis did not occur. Combined transverse transposition flap plasty with split-skin grafting of the donor site is a safe treatment concept with few side effects for large scalp defects with exposed calvaria requiring postoperative radiotherapy.

Fixation of split skin graft using cyanoacrylate tissue adhesive versus skin stapling: A comparative study

Fixation of split skin graft using cyanoacrylate tissue adhesive versus skin stapling: A comparative study

722 Collagen-elastin matrix for defect coverage in exposed bradytrophic tissue after severe burn and degloving injuries

IntroductionDespite successful defect coverage by means of complex skin or muscle flaps, particularly large and deep problematic wounds with exposed bradytrophic tissues after soft tissue loss are very susceptible to surgical revision.A dermal matrix, consisting of native collagen (collagen type I, III and V) supplemented by an elastin hydolyzate was first used for the treatment of burns, predominantly those that were full-thickness. Subsequently, its use was extended to defect coverage especially after soft tissue loss caused by degloving injuries.Methods52 patients with exposed bradytrophic tissues caused by severe burn or degloving injuries were treated the same way.In all patients operative debridement showed soft tissue loss with free bone or free periostal structures, exposed tendons or joint capsules.In all patients after accurate wound bed preparation defect coverage was performed with collagen-elastin matrix and unmeshed split skin grafts in combination with negative pressure wound therapy for fixation of dermal matrix and split skin grafts.ResultsTwo-years follow up of these collagen-elastin matrix procedures in defect coverage showed an excellent functional outcome:Up until now, no areas with unstable scars have occurred, no surgical scar revisions were required. The patients were still able to wear normal footwear, clinical gait analysis showed perfect functional outcome.ConclusionsThe application of collagen-elastin matrix in patients with exposed bradytrophic tissues after severe burn or degloving injury treated so far represents an excellent reconstruction method, from initial coverage to scar development.

Open lower limb fractures in the elderly

ObjectiveThe aim of this study was to assess the outcomes of open lower limb fractures in patients aged 65 and over. The primary outcome was mortality at 30 days, and the secondary outcome was reoperation. MethodsThis study retrospectively identified patients aged 65 and over, presenting with an open tibia or ankle fracture, over a two-year period. Patient demographics, injury characteristics and surgical interventions were documented. The 30-day and one-year mortality was recorded, as well as any complications encountered. ResultsThere were 88 patients included in the study, with a mean age of 78 years and 66% of patients were female. Of this cohort, 67 patients (76%) had low energy injuries and 64 patients (73%) had Gustillo-Anderson type IIIB injuries. Treatment consisted of a one-stage surgical procedure in 49 patients (56%) and a two-stage procedure in 37 patients (42%), with two patients dying before definitive treatment. Primary wound closure was performed in 23 patients (26%), four patients (5%) had a split skin graft alone, 35 patients (40%) had local flaps, 21 patients (24%) were managed with free flaps and three patients (3%) had primary below knee amputations. The 30-day mortality rate was 10%, the one-year mortality rate was 19% and the reoperation rate was 8%. ConclusionOpen lower limb fractures in the elderly are a life and limb threatening injury, with a similar demographic and mortality profile to hip fracture. This study demonstrates that limb salvage can be achieved in 93% of cases, with treatment performed as a one-stage procedure in 56% of cases.

Hydrosurgical and conventional debridement of burns: randomized clinical trial.

Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting. A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation. Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P = 0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001). One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis. Trial NL6085 (NTR6232 (http://www.trialregister.nl)).

Лечение последствий ранений голени: продолжение развития технологии Илизарова

Introduction Severe open injuries and wounds of the tibia refer to the topical problem of traumatology due to the difficulties in the functional restoration of the segment when there is a bone and soft tissues defect. Material and method The treatment of 11 patients with soft tissue and tibial defects was analyzed. At the time of reconstruction, the age of male patients ranged from 20 to 52 years (mean age 34.2 ± 3.2 years). Gunshot wounds of tibia occurred in 7 injured and tibial injury was observed in 4 cases. Segmental defects of the tibia ranged from 6 cm to 18 cm, mean 12.6 ± 4.4 cm, myocutaneous defects ranged from 20 cm2 to 112 cm2, mean 74.4 ± 22.4 cm2. Results In seven cases, the wounds healed by primary intention, the signs of infection and marginal necrosis of the soft tissue component of the flap were observed in 4 (36.4 %) cases and were addressed conservatively (dressings and debridement), but in one case, necrosis was excised (on day 21) and autodermoplasty was performed using split skin graft. We had no problems with the transport (distraction) of bone regenerates, since the rib cage of the flaps protected the soft tissues and the vascular pedicle of the flap, despite the early start of distraction (mean period 7.3 ± 2.1 days) and the length of treatment, when averaged, was 163.2 ± 8.7 days. Support function was restored in all patients and the functional results were satisfactory. Discussion The combination of Ilizarov distraction osteogenesisand soft tissue reconstruction using free vascularized flap grafting makes it possible to invalidate the short-comings of both, i.e. to lighten up the bone transfer, to avoid damage to the scarred skin of the anterio-medial surface of tibia and to preserve the axial circulation of the graft. The inclusion of a rib fragment provided the required conditions for application the Ilizarov distraction method. The rib, not being a supportive bone tissue, protected the soft tissue component of the flap and its vascular pedicle from deformity and participated in the formation of callus. Conclusions Plastic filling in the extensive tibial defects using free vascularized myocutaneous flap with rib fragments and Ilizarov distraction osteogenesis provides favorable conditions for acute surgical intervention allowing to save the limb, restore the support ability and return the patients to work.

Multimodal management of Fournier’s gangrene with subsequent wound closure techniques

Fournier’s gangrene (FG) is a fulminant and lethal condition usually occurring in the immunocompromised, first described in 1883 by the French dermatologist Jean Alfred Fournier. It is a form of necrotizing fasciitis of the perineal, genitourinary and perianal regions mostly in males with a mortality of nearly 20-50%. It is a surgical emergency and requires early diagnosis aided by scores such as laboratory risk indicator for necrotising fasciitis (LRINEC) and FG severity index (FGSI), extensive debridement combined with supportive procedures to manage associated complications and broad-spectrum antibiotics. Management of FG thus required a multimodal approach and emphasis on reconstruction after recovery in patients who survive was crucial to improving the quality of life in these patients. Here we were presenting 7 cases of FG successfully managed at our institution, grouped under the four methods by which wound closure was achieved: fecal diversion and split skin grafting of scrotum, urinary diversion and penoscrotal split skin grafting, delayed primary closure (with and without orchidectomy) and wound healing by secondary intention.

Improvement in functional and aesthetic outcome in postburn contracture of neck following split skin grafting using goniometer

Introduction: Although the mortality and morbidity from burns have diminished significantly over the last few decades, these do not truly reflect whether the victim could lead a normal life, owing to postburn contractures (PBCs) and other deformities, which have functional and aesthetic implications. Objective: The main objective of this study was to compare the improvement in cervico-mental angle after surgery, using a goniometer; and to assess the postoperative complications, cosmetic outcome and patient satisfaction after contracture release and split-thickness skin grafting. Methods: In this prospective study, we have studied a total of 20 patients with PBCs of neck, who underwent contracture release and split skin grafting. The preoperative cervico-mental angles were compared to postoperative measurements using a goniometer. Results: In this study, we observed that the mean cervicomental angle before the surgery was 85.5° ± 12.8° and after the surgery was 106.4° ± 7.8°. The percentage improvement was 24.3% which was found to be statistically significant (P &lt; 0.001). Patients were also classified based on age, gender, mechanism and classification of burns, time elapsed since burn injury. Postoperative complications, cosmetic outcome and patient satisfaction were also studied. Conclusion: PBCs can affect a patient's life functionally, aesthetically, and psychologically. Split-thickness skin grafting is a safe and reliable option for PBC neck. This causes improvement in cervicomental angle and thus range of movements of the neck in different axes (as measured by a goniometer). lthough the mortality and morbidity from burns have diminished significantly over the last few decades, these do not truly reflect whether the victim could lead a normal life, owing to postburn contractures (PBCs) and other deformities, which have functional and aesthetic implications. In this prospective study, we have studied a total of 20 patients with PBCs of neck, who underwent contracture release and split skin grafting. The preoperative cervico-mental angles were compared to postoperative measurements using a goniometer, and a significant improvement was noted. Overall patient satisfaction was also very good. Hence, split thickness skin grafting is a safe and reliable option for PBC neck.

RECONSTRUCTION OF TWO DISCRETE SURGICAL DEFECTS IN HEAD AND NECK IN THE ABSENCE OF FREE FLAPAVAILABILITY-AN INSTITUTIONAL EXPERIENCE

Introduction: Operable oral and oropharyngeal tumors with extra nodal extension inltrating the skin at level II to V require resection of primary and extended radical neck dissection can result in a defect at both primary and neck with intervening normal tissue. Ideally they need to be reconstructed with a chimeric free ap but in cases where it was not possible, locoregional aps were utilized. Aim-To discuss and compare our experience with various methods to reconstruct two discrete defects. Materials And Methods: This is a retrospective study from the Head Neck Oncology Dept of a Kidwai Memorial Institute Of Oncology, Bangalore, India between March 2016 – August 2021. A total of 14 were included in this study and divided into 3 groups. Group-1 included Pectoralis Major Myocutaneous Flap (PMMC) in a dual island technique, group-2 included reconstruction with combination of two locoregional aps. Group-3 included reconstruction with PMMC with split skin graft(SSG) covering for external defect. Results: The time taken to raise a dual-islanded PMMC and for PMMC with split thickness skin grafting an average is 50minutes compared to group-2- 90minutes. The time for insertion into the defects were one-and-a -half times more in the group-2 than other groups. No patients in group 1 and group 2 had a delay in receiving adjuvant treatment, whereas 50% of patient in group-3 could not receive adjuvant radiotherapy on time due to delayed wound healing. Conclusion- any of the three options can be considered for reconstruction of two discrete defects. PMMC with dual island technique found to be the most effective one with shorter operating time and with the least complication rate.

Congenital atresia of external auditory canal with choristoma: A rare case report

Congenital aural atresia (CAA) is the abnormality of the auricle and/or external auditory canal where there is closure of the external auditory canal which may be associated with microtia and anomalies in the middle ear, inner ear, or temporal bone. It can be solid or membranous type of atresia. To identify the type of defect, high-resolution computed tomography (HRCT) temporal bone is useful. After identifying the defect, the patient can be planned for canaloplasty or atresiaplasty with split skin graft. A 6-year-old boy was brought to the otorhinolaryngology outpatient department with complaints of deformity of the left ear since birth. HRCT temporal bone showed isolated left external auditory canal atresia. Echocardiogram showed dextrocardia with situs solitus and USG abdomen revealed situs inversus of the abdominal organs with no significant abnormality. After proper evaluation of the child, after obtaining preanesthetic fitness, the child had undergone atresiaplasty with split skin graft under general anesthesia. Soft tissue that was excised from the external auditory canal was sent for histopathological examination, which revealed the presence of salivary gland tissue with lymph nodes showing reactive changes. These features were suggestive of possibility of choristoma of the left external auditory canal. CAA occurs in the defect during embryological development which may result in deformity of the auricle and external auditory canal. The surgical management of congenital external auditory canal atresia is atresiaplasty, and hearing rehabilitation (bone anchored hearing aid) should be given in case of no improvement in hearing. The surgery will be challenging because of altered anatomy of surgical landmarks. Choristoma is a tumor-like growth of normal tissue in an abnormal place. It is a benign condition, which may be found commonly in the head-and-neck region such as presence of salivary gland tissue in the middle ear, presence of gastric mucosa in the tongue and presence of osseous or cartilaginous masses in the intraoral soft tissues. Total excision can be done for small and pedunculated tumors, and care should be taken not to injure facial nerve. CAA may not necessarily present with deformities in the external ear (pinna), but Congenital aural atresia cases may not always present with deformities of the pinna,but it is crucial not to miss such cases. These patients may be evaluated by doing High Resolution Computed Tomography temporal bone and audiometric assessment such as. Pediatric evaluation is equally important to rule out for any syndromic association. Atresiaplasty or canaloplasty has shown great result for correcting the cosmetic defect. Hearing can be facilitated further using bone anchored hearing aids or cochlear implantation.

Distally Based Peroneus Brevis Muscle Flap for Soft Tissue Reconstruction in Lower Third of Leg: A Case Series

Covering soft tissue defects in the distal part of leg and ankle is difficult. Most of the flaps used in reconstructing these defects are bulky and aesthetically unpleasing. The peroneus brevis muscle flap is ideal for covering these defects and providing an aesthetically better outcome. Peroneus brevis is a muscle located in the lateral compartment of the leg. It can be used for covering defects over the ankle and distal part of the leg without causing loss of function. This study was done to assess the surgical technique and clinical outcomes in the use of this muscle flap. This case series presents the authors’ experience of six cases of distally based peroneus brevis muscle flap. Three of the six patients were found to have superficial flap necrosis. Two of these three was treated with debridement and Split Skin Grafting (SSG) while one was managed conservatively with daily dressings. This flap is simple, easy to rise and useful in covering small defects of 3-4 cm width in the distal part of the leg and ankle. The donor site to be closed primarily leaving behind only a thin linear scar. Overtime the flap thins down and gives good cosmetic results. Donor site morbidity is minimal as the peroneus longus muscle is preserved and thus the function of the foot (plantar flexion and foot eversion) is intact. The distally based peroneus brevis flap is a reliable flap for covering defects over the distal one third of the leg, the upper half of the medial and lateral malleoli and the posterior aspect of the heel.

Malignant Peripheral Nerve Sheath Tumour of the Scalp with Bone Metastasis

Introduction: Malignant Peripheral Nerve Sheath Tumour (MPNST) is a malignant tumour arising from a peripheral nerve or showing a nerve sheath differentiation, with the exception of tumours originating from the epineurium or the peripheral nerve vasculature. Most of these tumours arise on the trunk, extremities, or head and neck regions. MPNST of the scalp is very rare. Case Report: We, report the case of a 71-year-old woman with a lesion in the scalp over the occipital region with FNAC showing the features of MPNST. Wide local excision and split skin grafting were done. Histopathological analysis of the resected specimen strongly supported the diagnosis of MPNST. The patient received adjuvant radiotherapy and was disease-free for 2 years and later presented with bone metastasis. Discussion: MPNSTs are rare soft tissue tumours that arise in proximity to large peripheral nerves and account for 3-10% of all soft tissue sarcomas. Primary MPNST of the scalp is extremely rare and very few cases have been reported in the literature. In this report, we have described the clinical and pathological characteristics of this rare tumour. We have also discussed the various treatment options offered. Conclusion: Scalp MPNSTs are aggressive lesions, and multimodality approaches including surgery and adjuvant radiation are necessary to optimize outcomes. Every attempt should be made to obtain wide and negative margins since positive margins are significantly associated with a poor outcome.

Abstract- Poster

Introduction:Tapentadol is a centrally acting synthetic opioid analgesic which has partial opioid agonist and norepinephrine reuptake inhibitor action with a relatively higher μ-affinity. It has abuse potential, and classified as scheduled drug, yet currently it is not known to be an opioid which is widely misused in India.Case report:A 22yr old male was introduced to Tablet tapentadol by his friends. Initially he started taking 2-3 tablets(50mg) per day orally. Later he was suggested by his friend to try intravenous route and as it was more pleasurable he continued to use the drug intravenously. His opioid use gradually increased from 5 tablets per day to a maximum of 10 tablets per day(max dose upto 600mg) with craving, tolerance, withdrawal symptoms, loss of control within the initial 1-2yrs.He also occasionally used heroin whenever he got access to it. History of occasional use of alcohol, tobacco and cannabis was present. He presented to OPD with withdrawal symptoms and a blister in the left forearm which within few days became an abscess and he was referred to a surgeon and was diagnosed as Necrotizing fasciitis, which was surgically corrected and split skin grafting was done. He was later started on opioid substitution therapy with tablet buprenorphine and is currently maintaining abstinence.