Split-thickness Autograft Research Articles

Human Skin Cell Fractions Fail to Self-Organize Within a Gellan Gum/Hyaluronic Acid Matrix but Positively Influence Early Wound Healing

Split-thickness autografts still are the current gold standard to treat skin, upon severe injuries. Nonetheless, autografts are dependent on donor site availability and often associated to poor quality neoskin. The generation of dermal-epidermal substitutes by tissue engineering is seen as a promising strategy to overcome this problematic. However, solutions that can be safely and conveniently transplanted in one single surgical intervention are still very challenging as their production normally requires long culture time, and graft survival is many times compromised by delayed vascularization upon transplantation. This work intended to propose a strategy that circumvents the prolonged and laborious preparation period of skin substitutes and allows skin cells self-organization toward improved healing. Human dermal/epidermal cell fractions were entrapped directly from isolation within a gellan gum/hyaluronic acid (GG-HA) spongy-like hydrogel formed from an off-the-shelf dried polymeric network. Upon transplantation into full-thickness mice wounds, the proposed constructs accelerated the wound closure rate and re-epithelialization, as well as tissue neovascularization. A synergistic effect of the GG-HA matrix and the transplanted cells over those processes was demonstrated at early time points. Despite the human-derived and chimeric blood vessels found, the proposed matrix did not succeed in prolonging cells residence time and in sustaining the self-organization of transplanted human cells possibly due to primitive degradation. Despite this, the herein proposed approach open the opportunity to tackle wound healing at early stages contributing to re-epithelialization and neovascularization.

Parental allografts in the management of Adams–Oliver syndrome

Dear Editor: We read with interest the report of Udayakumaran et al. [5]. The case they present is strikingly similar to that of a girl with Adams–Oliver syndrome (AOS) who has been under our care since 2005. Our patient was born with a 10×12 cm full-thickness scalp defect with present but abnormal underlying dura. We elected to cover the defect with a scalp transposition flap but, as in Udayakumaran’s case, the flap failed. Likewise, we covered the defect with a paternal split thickness skin graft which was repeated on three occasions over the following 2 months until the wound had developed a sufficiently robust vascularised connective tissue bed to receive a meshed split thickness autograft. The graft matured well and over the following 7 years, new bone continues to form beneath it, closing the calvarial defect. Both cases illustrate key points in the management of this very rare condition which we wish to emphasise. Although scalp flaps appear to be an attractive option for achieving rapid closure of aplasia cutis congenita and AOS scalp defects, they are prone to a high rate of failure probably due to abnormal vascular anatomy [4]. Although free transfer techniques would avoid this problem, successful microsurgery in the neonate remains a considerable challenge. Conservative approaches employing repeat dressings are well described [3], but are slow to achieve epithelialisation in large defects. Repeated dressing changes risk infection and haemorrhage [1], which may be fatal, as well requiring extended nursing involvement and likely distress to the infant. Early skin grafting offers a middle course between these two approaches but can be impeded by the lack of available donor skin. Further, the initial wound bed may well be fragile and poorly vascularised, resulting in a poor quality, unstable graft with likely areas of loss, if an autograft is applied immediately. Allografts initially survive and provide temporary wound closure, reducing dressing demands along with the associated risk of bleeding and serious infection. Further, allografts promote development and maturation of the underlying wound bed [2]. Temporising with parental allografts also allows the infant to grow sufficiently to provide an adequate autograft. Overgrafting the final autograft with parental allograft also enables a thin widely meshed autograft to be used, minimising donor site morbidity. In retrospect, we would suggest that in patients with a large scalp defect, parental allografts should be considered as a first-line measure rather than as a salvage procedure pending definitive autografting. Lastly, we note the authors’ plan to evaluate the need for cranioplasty at a future date. Our and others’ [6] experience of new bone formation beneath skin grafts in calvarial defects in young children with intact dura suggests that a cranioplasty may well not be required.

Application of acellular dermal xenografts in full-thickness skin burns

The aim of this study was to explore the clinical value of the porcine acellular dermal xenograft (ADX) in combination with autologous split-thickness skin and pure autologous split-thickness skin grafting applied in deep full-thickness burns and scar wounds. A total of 30 patients with deep burns were randomly divided into experimental and control groups following escharectomy. The patients were separately treated with porcine acellular dermal xenograft (ADX) in combination with autologous split-thickness skin and pure autologous split-thickness skin graft. The wound healing was observed routinely and the scores were evaluated using Vancouver scar scale at different times following transplant surgery. The samples of cograft regions and the control group (pure transplant split-thickness skin autograft) were observed using light microscopy and electron microscopy, and the follow-up results were recorded. No conspicuous rejections on the cograft wound surface were observed. Compared with the control group, the cograft wounds were smooth, presented no scar contracture and exhibited good skin elasticity and recovery of the joint function. The cografted skin combined well and displayed a clear and continuous basal membrane, as well as gradually combined skin structure, a mature stratum corneum, downward extended rete pegs, a mainly uniform dermal collagen fiber structure, regular alignment, and fewer blood capillaries. Clear desmosome cograft regions were identified among heckle cells, as well as a clear and continuous basal membrane. The cografted skin of the combined split-thickness autograft and the acellular heterologous (porcine) dermal matrix showed an improved shape and functional recovery compared with the pure split-thickness skin autograft. The combination of the meshed ADX and the split-thickness skin autograft applied in deep full-thickness burns and scar wounds may induce tissue regeneration via dermis aiming. This method also has superior shape and functional recovery, and has an extensive clinical application value.

The roles of knitted mesh-reinforced collagen–chitosan hybrid scaffold in the one-step repair of full-thickness skin defects in rats

Full-thickness skin defects represent a significant and urgent clinical problem. Dermal substitutes serving as a regenerative template to induce dermal reconstruction provide a promising method to treat serious skin defects. Although collagen–chitosan dermal scaffolds display good biocompatibility and a suitable porous structure for angiogenesis and tissue regeneration, their poor mechanical properties compromise their application. To develop a well-supported dermal substitute, a poly(l-lactide-co-glycolide) (PLGA) knitted mesh was fabricated and integrated with collagen–chitosan scaffold (CCS) to obtain a PLGA knitted mesh-reinforced CCS (PLGAm/CCS). The morphology of this PLGAm/CCS was investigated in vitro. To characterize the tissue response, specifically angiogenesis and tissue regeneration, the PLGAm/CCS was transplanted in combination with thin split-thickness autografts to repair full-thickness skin wounds using a one-step surgical procedure in Sprague–Dawley rats. These results were then compared with CCSs. At weeks 2, 4 and 8 after the operation, the healing wounds were imaged to analyse wound changes, and tissue specimens were harvested for histology, immunohistochemistry, real-time quantitative polymerase chain reaction and Western blot analysis. The results demonstrated that collagen–chitosan sponge in the PLGAm/CCS remained porous, interconnected and occupied the openings of PLGA mesh, and the incorporation of the PLGA knitted mesh into CCS improved the mechanical strength with little influence on its mean pore size and porosity. Following transplantation, PLGAm/CCS inhibited wound contraction, and effectively promoted neotissue formation and blood vessel ingrowth. In conclusion, the mechanical strength of the scaffolds plays an important role in the process of tissue regeneration and vascularization. The ability of PLGAm/CCS to promote angiogenesis and induce in situ tissue regeneration demonstrates its potential in skin tissue engineering.

The Use of Integra® Dermal Regeneration Template in the Reconstruction of Traumatic Degloving Injuries

Traumatic soft tissue, or "degloving" injuries from trauma are common. These injuries are a result of shearing and disrupt tissue planes, such as the junction between muscle and bone. Traditional repair involves debridement followed by skin grafting or flap reconstruction. Many degloving injuries, however, extend to bone or tendon and the decreased vascularity of the wound bed can compromise the success of traditional repairs. Additionally, medical comorbidities make some patients poor candidates for flap reconstruction. The purpose of this study was to evaluate the success of a dermal regeneration template in the treatment of complex traumatic degloving injuries at an American College of Surgeons verified Level 1 Trauma Center. A retrospective review was conducted on all patients sustaining traumatic degloving injuries from January 2009 to July 2010, who were treated with Integra Dermal Regeneration Template followed by split-thickness autografting. Medical records were reviewed and patient demographics, injury characteristics, comorbidities, hospital course, and outcomes were summarized. Ten patients were studied. All had traumatic degloving injuries of an extremity ranging from 50 to 1000 cm. Nine had injuries extending to bone and/or tendon. After debridement, patients underwent placement of Integra followed by a split-thickness skin graft. Of the 10 patients nine had complete take of their grafts with excellent cosmetic and functional results. Degloving injuries are common in trauma. These injuries often extend to tendon and bone, which poses challenges to repair because of decreased vascularity. Placement of a dermal regeneration template followed by a split-thickness autograft is a viable alternative to traditional methods of repair.

Ultrasound guided lateral femoral cutaneous nerve (LFCN) block: Safe and simple anesthesia for harvesting skin grafts

Many burn patients experience more intense pain from the split thickness skin donor site than in the grafted burn wound in their postoperative period. Often, split thickness autografts are harvested from the lateral thigh area, which is innervated by the lateral femoral cutaneous nerve (LFCN). Sonographic nerve localization has been an increasingly popular technique to provide regional nerve blocks and we explore its role in improving pain control during skin harvesting. The LFCN was identified and blocked using ultrasound in 16 patients with a variety of wounds. The donor site was tested and marked after the injection. General anesthesia or sedation was administered after markings were completed. A postoperative survey was performed to assess the return of sensation at the donor site. All blocks were successful with adequate visualization of LFCN using ultrasound. Full anesthesia at the donor site, defined as absence of pain in response to a sharp object prick, was tested at 15min and confirmed at 20min after the block. The size of the anesthetized field ranged from 119 to 630cm2, with a mean surface area of 268.5cm2. Donor site sensation returned within 5–16h with a mean time of 9.1h. Ultrasound guided LFCN block provides a simple and safe choice of anesthesia for harvesting skin from the lateral thigh.

Morphogenesis and Biomechanics of Engineered Skin Cultured Under Uniaxial Strain

Split-thickness autograft is the standard wound treatment for full-thickness burns. In large burns, sparse availability of uninjured skin prevents rapid closure of the wound, resulting in increased scar tissue formation or mortality. Tissue-engineered skin (ES) offers promise when autografts are not available. ES, constructed from a polymeric scaffold and skin cells, has been shown to reduce donor site area required to permanently close wounds, mortality, and morbidity from scarring but cannot restore all skin functions. Current generations of ES are orders of magnitude weaker than normal human skin, leading to difficulty in surgical application, greater susceptibility to mechanical damage during fabrication and application, and less elasticity and strength once engrafted. Previous studies to improve ES biomechanics focus on altering the scaffolding material, which resulted in modest improvements but often inhibited proper skin development. As the skin is naturally under static strain, adding these mechanical cues to the culture environment is hypothesized to improve ES biomechanics. ES was cultured under applied static strains ranging from 0% to 40% strain for a total of 10 days. Strain magnitudes of 10% and 20% strain resulted in significantly stronger ES than unstrained controls, showed upregulation of many genes encoding structural extracellular matrix proteins, and exhibited increased epidermal cell proliferation and differentiation. Enhanced biomechanical properties of ES can allow for facile surgical application and less damage during dressing changes. These findings suggest that mechanical cues play a significant role in skin development and should be further explored.

Treatment outcomes for keloid scar management in the pediatric burn population

IntroductionKeloids scars are challenging problems facing many reconstructive surgeons and have proven to be resistant to many treatments. This is evident by the broad range of treatments available and implemented with inconsistent results. We reviewed our experience to better define the disorder and to evaluate the impact of specific treatment options as related to our patient population. MethodsAfter obtaining Institutional Review Board approval, we examined the medical records of pediatric patients who were evaluated at our pediatric burn center between 2000 to 2008. All study subjects were identified as having keloid scars confirmed by clinical evaluation (raised scar extending beyond the margins of the original wound [1,2]). Treatments included excision and grafting [split thickness autograft (STAG) or full thickness autograft (FTAG)], excision and grafting with steroid injection, excision and primary closure, or excision and primary closure with steroid injection. Patients were included only if there was follow-up of 12 months or greater. ResultsOne hundred and ten subjects with a diagnosis of a keloid scar were identified. Twenty-six were treated with excision and skin grafting and 8 were treated with a steroid and surgery regimen. Of the patients treated with surgery and steroids, the treatment varied from an intra-operative injection to post-operative injections at 6-week intervals. The number of injections was determined by the administering surgeon and varied from one to three. Clinical end points were determined by the administering surgeon and included: (1) no further improvement in scar maturation or (2) absence of improvement. Recurrence was defined as return of a raised scar consistent with a keloid scar. The recurrence rate was 87.5% for patients treated with surgery and steroids and 80.0% for surgery only. This difference was not statistically significant. ConclusionsOur data demonstrate that steroids do not significantly decrease recurrence in pediatric burn related keloids as compared to previously published series involving non-burn related keloids [3,5]. This further emphasizes that burn related keloids respond differently to conventional treatments that have proven successful in keloid scars from other mechanisms of injury. A consistent and effective treatment algorithm should be implemented in treating keloid scars from burn wounds.

Levamisole-Induced Necrosis of Skin, Soft Tissue, and Bone

This represents the largest case of skin necrosis related to levamisole, a common cocaine contaminant, requiring closure with skin grafts, and is the only case resulting in nasal amputation, central upper lip excision, extremity bone necrosis, and above knee amputation. The case report is followed by a review of the literature. Unique considerations for the full-thickness necrosis induced by levamisole vasculitis are highlighted, including antibody level monitoring, need for multiple excisions, timing of skin grafting, and potential for soft tissue and bone necrosis as well. A 54-year-old man presented to an outside facility with fever, generalized weakness, and agranulocytosis, with a history of cocaine use 3 weeks before. After admission, he developed generalized violaceous lesions and an elevated p-antineutrophilic cytoplasmic antibody and was diagnosed with disseminated vasculitis and agranulocytosis secondary to levamisole-contaminated cocaine exposure. On transfer to the authors' facility, 52% TBSA was involved with violaceous, nonblanching lesions, which progressed to full-thickness necrosis. Local wound care continued until necrotic areas fully demarcated and progressive necrosis stabilized, and skin grafting for closure was not performed until antibody levels normalized. Current treatment of levamisole-induced skin rash or necrosis focuses on discontinuation of levamisole. As demonstrated by this case, extensive necrosis secondary to levamisole-induced vasculitis can be successfully treated with multiple excisions until necrosis stabilizes, and then, split-thickness autografts may be applied. In areas with poor vascular supply or areas with poor functional prognosis, amputation may ultimately be required.

The scalp or how to reduce the scarring associated with the harvesting of a split-thickness skin graft in head and neck surgery

Skin grafts are commonly used in head and neck recon-struction surgery. Muscle flap coverage [1] or closure ofa flap harvesting site [2] (e.g., antebrachial radial flap)may require split-thickness autograft. Harvesting, however,involves considerable postoperative pain, and healing islong, often leaving an unsightly or pathological scar outsideof the head-and-neck region [3].Reducing the scars left by reconstruction surgery shouldbe a constant concern. It helps improve patients’ quality oflife. In this perspective, we here present a harvesting tech-nique for split-thickness skin graft from the scalp in headand neck surgery.The scalp is routinely used as a split-thickness skin graftdonor region in burn surgery [4]. It avoids leaving an extrascar, which is completely hidden and invisible once the hairgrows back.

Skin substitutes for burn wound healing: current and future approaches

Partial-thickness burn wounds can heal spontaneously, but full-thickness burns require skin grafting for definitive wound closure. Historically, the gold standard for closure of excised full-thickness burns is split-thickness skin autograft. Patients with very large burns have limited donor sites for harvesting of autograft and may benefit from the use of skin substitutes. Engineered skin substitutes that may provide temporary wound coverage until donor sites are ready to be reharvested for autograft, or if they contain autologous cells, may provide permanent wound closure. Relatively few permanent skin substitutes are currently available, but developments in tissue engineering of human skin are expected to soon provide improved models for increased availability and enhanced healing of burn wounds

Use of an autologous bioengineered composite skin in extensive burns: Clinical and functional outcomes. A multicentric study

Objective We report clinical and functional outcomes obtained after application of an autologous bioengineered composite skin (ABCS) produced in a single Spanish tissue-engineering unit. Materials/methods Twenty-five burned patients treated with ABCS from 1999 to 2007 in five burn centres were included in the study. Mean age was 29 years (SD 11), with mean total body surface area (TBSA) burned being 74% (SD 17) and mean full-thickness injury of 61% (SD 19) of TBSA. Results The mean area initially engrafted with ABCS was 24% (SD 13) of TBSA, with a final take of 49% (SD 30, range 0–100%). ABCS achieved permanent coverage of a mean of 11% (SD 8) of TBSA. In subset analyses, lack of pre- and post-application wound bed infection and lack of serious acute systemic complications at the time of engraftment were significantly associated with better ABCS take. Conclusions Final take obtained with ABCS could be improved with the use of non-cytotoxic topical antibiotics following engraftment. The use of plasma to prepare ABCS reduces production costs: cost-effectiveness ratio is not a limitation for its use. In terms of patient satisfaction, cosmetic/functional outcomes (general appearance, texture, flexibility, sensitivity and colour) of ABCS and split-thickness autografts are not different statistically.

Terapia de vacío como adyuvante para el uso de sustitutos dérmicos monocapa

Split thickness autografts are the gold standard for wound coverage. However, scars and retractions are frequent after skin grafts, and would be severe over ...

Clinical Application and Long-Term Follow-Up Study of Porcine Acellular Dermal Matrix Combined With Autoskin Grafting

The purpose of this study was to investigate the clinical effects of porcine acellular dermal matrix combined with autoskin grafting on full-thickness skin defects using long-term clinical follow-up study and histologic examination. One hundred fifty-two patients with deep burn or trauma hospitalized from February 2000 to July 2003 were repaired with porcine acellular dermal matrix and split-thickness autoskin graft. Take rate of the grafts was calculated on 1 week after operation. Scar hyperplasia was examined on 1, 3, 6, and 12 months after operation. At the same time, the contracture rates of grafted areas were also calculated. Skin biopsy was performed on five patients for histologic examination, as well as transmission electron microscopy 78 months after operation. The take rate of grafts of 116 patients (76.3%) was 100%, and the take rate of the rest of the patients (36 patients, 23.7%) was more than 95%. No one needed skin transplantation for the second time. One hundred twenty-seven patients were followed up on 1 month after operation; grafts showed mild contraction. There was slight cicatricle at skin junction with tender texture. There was no obvious pruritus and blister. One hundred one patients were followed up on 3 months after operation. The graft contraction showed obvious relief with good articular function. Eighty-two patients were followed up on 6 months after operation. The color and texture of the grafts were similar to normal skin without obvious cicatricial hyperplasia. Fifty-eight patients were followed up on 12 months after operation. The grafts were similar to normal skin without obvious rejection. There were no significant differences between the contracture rates at 3, 6, and 12 months and 1 month after the second surgery. Sixteen patients were followed up on 78 months after operation. The appearance of grafts was slightly dry compared with normal skin. Tissue structure of grafts was similar to normal skin with sweat gland-like structure, and sweat gland cells were shown in the dermis. Xenogenic acellular dermal matrix combined with split-thickness autograft can repair full-thickness skin defects and inhibit scar proliferation without obvious immune rejection for long time. Newly formed sweat gland-like structure and sweat gland cells in the dermis may be a new research point for reconstruction of skin function.

The Effectiveness of Basic Fibroblast Growth Factor in Fibrin-based Cultured Skin Substitute In Vivo

Cultured skin substitute (CSS), comprised keratinocytes and fibroblasts in a biopolymer matrix, is useful for adjunctive burn therapy. However, the vascularization of CSS is much slower than split-thickness autografts, because it lacks a vascular plexus. This study evaluated the influence of basic fibroblast growth factor (bFGF) on fibrin-based CSS grafting in vivo. Fibrin-based CSS treated with 0, 0.26, 1.3, 6.5, 13, or 130 microg/cm bFGF was transplanted into athymic mice, and macroscopic and histologic examinations of the graft were performed on day 21 posttransplantation. Engrafted CSS of the 0.26 to 6.5 microg/cm bFGF treatment groups were similar to the untreated control. However, the engrafted area was significantly suppressed in the 13 microg/cm bFGF treatment group, and the 130 microg/cm bFGF treatment group was not engrafted. Neovascularization of CSS was significantly increased in the 1.3 microg/cm bFGF treatment group compared with the control (P < .05). The number of human fibroblastic cells in CSS that were positive for vimentin increased significantly in the 0.26 and 1.3 microg/cm bFGF treatment groups (P < .01). CSS treated with 0.26 to 6.5 microg/cm bFGF showed normal epidermis with keratinizing stratified squamous epithelium, whereas the thickness of the epidermis and proliferation of keratinocytes in the basal layer was decreased. These results demonstrated that bFGF treatment (1.3 microg/cm) in fibrin-based CSS may enhance angiogenesis and fibroblast proliferation after transplantation.

Use of Integra® in the Treatment of Third Degree Burns to the Penile Shaft: A Case Series With 6-Month Follow-Up

Third-degree burns to the penile shaft are serious injuries sometimes accompanied by poor healing, hypertrophic scar formation, painful erections, and dyspareunia. At this burn center, three patients with penile shaft burns have been treated successfully with Integra followed by thin, split-thickness skin grafting. Allowing a scar-free foundation for skin grafting to the penile shaft, in combination with early excisions and split-thickness autografting, Integra application facilitated the early return of near-normal skin quality, no contractures, and pain-free erectile function. With innovative management techniques, functional outcomes were obvious throughout the 6-month follow-up period.

Hyalomatrix: A Temporary Epidermal Barrier, Hyaluronan Delivery, and Neodermis Induction System for Keratinocyte Stem Cell Therapy

Keratinocyte stem cell technology provides at least an adjuvant therapy to clinically close large cutaneous wounds (e.g., burn wounds). Here, the performance of keratinocyte cultures depends primarily on the quality of the bed to which they are applied. Clinical take rates for cultured keratinocyte grafts are optimal when applied to a vascularized dermal bed with minimal bacterial colonization. In the absence of autologous dermis, staged reconstruction with a dermal equivalent or dermal regeneration template is required. A novel product, Hyalomatrix, is a bilayer of an esterified hyaluronan scaffold beneath a silicone membrane. The scaffold delivers hyaluronan to the wound bed, and the silicone membrane acts as a temporary epidermal barrier. The product has been investigated in a controlled, porcine, acute full-thickness excisional wound model. Cultured autologous keratinocytes (CAKs) were delivered on Laserskin to acute full-thickness wounds treated with Hyalomatrix within chambers, and graft take rates were assessed longitudinally using image analysis. In the absence of chambers, wound contraction was assessed. Clinical CAK take rates fall sequentially with delay in application post-Hyalomatrix pre-treatment, but repeated pre-treatment removed this, with maximal take of 57.2% at 5 weeks post-wounding. In the absence of chambers, more-complete wound closure resulted from edge re-epithelialization and contraction, by a factor of 5 at 1 month, and was achieved at least 2 weeks sooner in the gold standard controls of split-thickness autograft to an acute or pre-treated wound bed. Wound contraction and late neodermal morphology (1 year) were similar in pre-treated CAKs and split-thickness autograft wounds. In this model, the Hyalomatrix wound bed pre-treatment increase in CAK take appeared to be dose dependent. The product appeared to act as a hyaluronan delivery system rather than a dermal regeneration template. The silicone membrane may limit wound bed colonization, and the combination of this temporary barrier with hyaluronan delivery and neodermis induction has been termed a barrier-delivery-induction system. The development of similar systems for serial application offers an alternative to a dermal regeneration template when CAKs are engrafted in the hostile, colonized environment of large burn wounds.

Uniplanar External Fixation for Care of Circumferential Extremity Burn Wounds in Adults

The optimal management of circumferential extremity burns remains a challenge. Elevation of the extremity to decrease wound swelling and avoid pressure at the point of contact on new skin grafts is a standard objective but can be frequently difficult to accomplish. Although various forms of elevation have been proposed, our purpose was to evaluate the safety and efficacy of the uniplanar external fixation (UEF) device in providing extremity elevation and stabilization while optimizing skin grafting. Intraoperative application of either upper or lower extremity UEF was performed at the time of eschar excision and application of split-thickness autografts. Inclusion criterion was that patients should be over 16 years of age with third-degree circumferential extremity burns that were planned for autologous skin grafting within 48 hours after their injury. Patient consent was obtained in every case. Eight patients aged 17 to 62 with circumferential extremity burns were reviewed. No pin-tract infections were observed, nor were any of the skin grafts lost due to shearing. Peripheral nerve and arterial injuries were not encountered. Only one patient with an oversized arm secondary to morbid obesity had a pin pull-out. No other patient developed adverse sequelae from the surgery or from the placement of the UEF device. The UEF device provides a safe and effective means for elevation of extremites in patients with circumferential extremity burns undergoing skin grafting. This allows for optimal access for skin grafting, dressing changes, and postoperative positioning. Shear injury and pressure necrosis of the fresh grafts is minimized. Increasing the number of pins in obese patients should be considered to avoid the complications of pin pull-out.

Preparation of laser micropore porcine acellular dermal matrix for skin graft: An experimental study

In our previous study, we used composite grafts consisting of meshed porcine acellular dermal matrix (PADM) and thin split-thickness autologous epidermis to cover full thickness burn wounds in clinical practice. However, a certain degree of contraction might occur because the distribution of dermal matrix was not uniform in burn wound. In this study, we prepare a composite skin graft consisting of PADM with the aid of laser to improve the quality of healing of burn wound. PADM was prepared by the trypsin/Triton X-100 method. Micropores were produced on the PADM with a laser punch. The distance between micropores varied from 0.8, 1.0, 1.2 to 1.5mm. Full thickness defect wounds were created on the back of 144 SD rats. The rats were randomly divided into six groups: micropore groups I-IV in which the wound were grafted with PADM with micropores, in four different distances, respectively and split-thickness autograft; mesh group rats received meshed PADM graft and split-thickness autograft; control group received simple split-thickness autografting. The status of wound healing was histologically observed at regular time points after surgery. The wound healing rate and contraction rate were calculated. The wound healing rate in micropore groups I and II was not statistically different from that in control group, but was significantly higher than that in mesh group 6 weeks after grafting. The wound healing rate in micropore groups III and IV was lower than that in mesh and control groups 4 and 6 weeks after grafting. The wound contraction rate in micropore groups I and II was remarkably lower than that in control group 4 and 6 weeks after surgery and it was significantly much lower than that in mesh group 6 weeks after surgery. Histological examination revealed good epithelization, regularly arranged collagenous fibers and integral structure of basement membrane. Laser micropore PADM (0.8 or 1.0mm in distance) grafting in combination with split-thickness autografting can improve wound healing. The PADM with laser micropores in 1.0mm distance is the better choice.

Complete intracranial autolysis after thermal injury

A 41-year-old male electrician presented to our Burn Center after being rescued from the bottom of a manhole where a fire broke out as he was laying cables. Investigators did not believe the fire was electrical in origin and may have been related to a flammable gas leak. He had no past medical or surgical history, had no allergies, and took no prescription medications. He had no history of tobacco or illegal drug use, although he did socially use alcohol. Upon arrival at our institution, he was awake, alert, and communicative with a Glasgow Coma Score of 15. There was no loss of consciousness. He was hemodynamically stable, but in respiratory distress. The trauma evaluation revealed no additional injuries other than the burn wounds. Evaluation of his thermal injuries revealed a 51% total body surface area involvement, including the entire anterior torso, face, bilateral arms, and the back of one leg. The majority of these burn wounds were deep partial and full-thickness. The patient was immediately intubated and resuscitated. Over the next several days, the patient underwent escharotomy of his upper extremity near-circumferential wounds, tracheostomy, and tangential excision and splitthickness autografting of his extremity wounds, as well as tangential excision of the thoracic burn.