Split-thickness Graft Research Articles

Epithelial Rate Difference on Donor Wound of Split Thickness Skin Graft in the Thigh Area by Applying Leukocrepe® and Medicrepe®

Background: applying split thickness graft (STSG) is as one of the reconstruction techniques and it is often conducted. Applying the technique creates superficial wound on the donor wound or it is known by donor site. The elastic bandage usage is one of the tools which is used in giving treatment to donor site as a standard operational procedure treatment at Dr. Moewardi hospital (RSDM) Surakarta. RSDM Surakarta has not had clinic test yet to compare between applying elastic bandage Leukocrepe® and Medicrepe® on wound care STSG on the thigh area. Subject and Method : The study used post-test only control group design with the total of the sample was 18 patients. The study was conducted in intermediate STSG donor wound with 0.018 inches thickness on the lateral thighs. By dividing two donor wounds, a half-sided of upper part was bandaged by applying Leukocrepe® and the other half of the lower part was bandaged by Medicrepe®. After that, epithelialization score was conducted on the seventh day. All the data then were collected and after that the data were tested by applying Wilcoxon rank test. Result: according to the study conducted to 18 patients of plastic surgery section at RSUD Dr. Moewardi during November 2016-Juni 2017, the result showed that the epithelialization chart was approximately 61.39 ± 30.05% for STSG donor wound on the lateral thighs part and it was done on the seventh day by applying Leukocrepe, meanwhile applying Medicrepe, the result was approximately 43.67 ± 30.69 %. The mean score of epithelialization applying Medicrepe® was more significant than applying Leukocrepe® and it showed that there was significantly different statistically with the score (p<0.001). Conclusion: According to the result above, it can be seen that the STSG donor wound care on the thighs using Medicrepe® is more effective in accelerating epithelialization process than the one which is applied by Leukocrepe®. Key Word: Epithelization, Elastic Bandage, Medicrepe®, Leukocrepe® Correspondence: Ivan Rinaldi. Public Surgery Resident of Medical Faculty of UNS. Email: ivanmudfin@gmail.com. Indonesian Journal of Medicine (2017), 2(3): 146-153 https://doi.org/10.26911/theijmed.2017.02.03.01

Doppler Comparative Measurements in the Reconstruction of Limbs with Flaps and Grafts

Abstract Doppler technique was first described by the Australian physicist and mathematician Christian Doppler. Doppler effect is defined as a reflection of high frequency sound waves of different frequency when they come in contact with the movable structure in the blood vessel. Waves that go to transducers are coded red, while waves that move away from the transducer are coded blue. Doppler main types can be classified as following: continuous wave (CW) Doppler, spectral Doppler, color Doppler and Power Doppler color. The study was realizedat the University Clinic for Plastic and Reconstructive Surgery. It is a randomized prospective study. During the study two groups of 30 patientseach were formed. Each patient was required a permission for reconstructive surgery procedure and an informed consent for participation in the study. For all patients a specially designed questionnaire (non-standardized) was filled out. 1. First (I) group of patients treated with flaps. In this group a type of reconstructive technique with skin or complex flapshas been applied. 2. Second group (II) of patients treated with grafts (split thickness grafts). In this group applied reconstruction comprised application of skin grafts with partial thickness. The study included patients with defects of the skin and soft tissues, whohad an indication for reconstructive surgery procedure. Exclusion criteria of patients for participation in the study were: children under 14 years of age, adults over 75 years, people with systemic diseases that can affect the results of reconstructive intervenetions and patients who have without periosteum bone-like surface defect as contraindication for skin grafting. The results of the reconstructive procedures according to the objectives set were investigated clinically into three time periods: preoperative, postoperative day 7 and day 30 postoperatively. The following investigations were carried out: determination of the circulation levels by means of Doppler; determination of the levels of limbs circulation is distal to the site of reconstruction in the pre-and postoperative period (day 7 and day 30); For the evaluation of blood flow the following parameters were used: • PSV-Peak systolic velocity • PI - Pulsatility index RI - Resistance indexPI and RI were calculated using the formula: • PI = PSV - EDV / Vmean • RI = PSV - EDV / PSV EDV indicates the flow velocity in late diastole and V mean, the average speed of blood flow through the artery. By assessment of arterial status before and after surgery through the analysis ofvascular waves at different locations of the vascular tree of the upper and lower extremities, we registered significant difference between the two examined groups, which speaks in favor of the use of flaps in reconstruction of the lower limbs.

Harvesting split thickness costal cartilage graft.

Aim:There are few complications associated with harvesting of full thickness coastal cartilage grafts i.e., pneumothorax (0.9%), contour deformities and prolonged post-operative pain. To address these issues, authors devised special scalpel to harvest split-thickness costal cartilage grafts.Materials and Methods:Standard inframammary incision was used for harvesting rib. Incision was made directly over the desired rib. Specially designed scalpel was used to cut through the rib cartilage to the half of the thickness. The study was conducted in two parts – cadaveric and clinical.Results:There was significantly less pain and no pneumothorax in the patients in whom the split thickness graft was harvested. Wounds healed without any complication.Discussion:Thus, newly devised angulated scalpel used in the current study, showed the potential to supply the reconstructive surgeon with split thickness rib graft without risk of complications such as pneumothorax or warping contour deformities and post-operative pain.

Surgical management of nonmelanomatous malignant cutaneous lesions of the face

Objective The aim of the present study was to evaluate the esthetic and functional outcomes after surgical excision of nonmelanomatous malignant lesions of the face, followed by a suitable tool of reconstruction. Background Neoplasm of the skin is found most often on the face. Cosmetically, the face is the most important anatomic area for most patients. Because of this, malignant tumors of the facial skin pose a great challenge in treatment, prohibiting compromises between oncologically responsible surgery and functional and cosmetic outcomes. Patients and methods This prospective study included 25 patients, all of them suffering from nonmelanomatous skin cancer and managed at Menoufia University Hospitals and Damanhur Oncology Center by different modalities of reconstruction during the period from April 2012 to December 2014. The appropriate technique was selected for every patient, taking in consideration the location and size of the lesion. Results Eighteen cases had reconstructive procedures with local flaps only, five cases had more combined reconstructive tools in the form of local flaps (rotational flaps) plus split-thickness graft to close the secondary defect, and two cases required reconstruction with a full-thickness graft. Conclusion Our experience showed that the postoperative defects gave the best cosmetic results when reconstructed by using a nearby tissue, fulfilling all patient and surgeon expectations with a minimum rate of morbidity. Clear guidelines and a multidisciplinary approach for the treatment of skin cancer are important to ensure that patients receive optimal care with satisfactory end results for tumor control as well as reconstructive esthetic outcome.

Wound Care: What the Medical Director Needs to Know

Wound Care: What the Medical Director Needs to Know

Novel technique for harvesting the sternoclavicular graft.

Originally introduced for mandibular reconstruction more than 40 years ago, the sternoclavicular graft (SCG) has gained widespread popularity for the reconstruction of the ramus-condyle unit (RCU) owing to its anatomic and histological likeness to the normal mandibular condyle. Conventional longitudinal osteotomy design for its harvest has been fraught with considerable complications at the donor site including fracture clavicle and major neurovascular injury. In an attempt to alleviate these ill effects, a new technique for procuring the sternoclavicular graft is presented. A split-thickness cortico-cancellous graft was harvested form the sternal end of the clavicle along with the articular disk with the osteotomy cut oriented parallel to the coronal plane, with limited soft tissue dissection. Donor site complications were assessed in terms of incidence of clavicle fracture, neurovascular injury, pleural tear and radiographic healing as seen in the six-month postoperative chest radiograph. 17 patients suffering from unilateral temporomandibular joint ankylosis underwent SCG harvesting for RCU reconstruction following osteoarthrectomy. No adverse events were seen in the intra- and post-operative period in any patient and satisfactory radiographic osseous healing was observed after six months. The proposed harvest technique for SCG results in reduced donor site morbidity and favourable healing and greater patient comfort.

A Case Series of Complex Recalcitrant Wounds Treated with Epidermal Grafts Harvested from an Automated Device.

Introduction: Epidermal grafting has several advantages over full-thickness or split-thickness grafts in the treatment of complex non-healing wounds. These include the low risk of donor site complications, minimal patient discomfort, and abstention from the operating room. Traditionally, the lack of reliable epidermal harvesting techniques has limited its clinical utilization. The development of an automated suction blister epidermal graft (SBEG) harvesting device may facilitate clinical utilization of this technique. The authors present a case series of multimorbid patients who were poor surgical candidates and were treated with this technique.Methods: A retrospective review of all patients treated with CelluTome™​ Epidermal Harvesting System (KCI, an Acelity company, San Antonio, TX) prior to May 2016 at our institution was conducted.Results: A total of 12 patients underwent 14 epidermal grafting procedures. Multiple comorbidities were identified, including smoking (33%), immunosuppression by immunotherapy or steroids (25%), chronic venous insufficiency (25%), diabetes mellitus (25%), malignancy (25%), polysubstance abuse (17%), HIV/AIDS (17%), and peripheral artery disease (8%). Among the two acute wounds (≤ 3 months) and 10 chronic wounds, the average wound size was 49.1 cm2 (± 77.6 cm2) and the median wound duration was 5.7 months (interquartile range: 4.1 - 15.8 months) before SBEG was attempted. These complex wounds had failed prior therapies, such as local wound care (100%), incision and drainage (58%), vacuum-assisted closure (33%), split-thickness skin graft (16%), and hyperbaric oxygen (8%). Following the procedure, all donor sites healed within one week. Three patients were lost to follow-up. Of the remaining nine patients, four patients had complete resolution of their wounds at a median follow-up of 13.1 weeks (interquartile range: 6.8-17.3 weeks). Among those with partial resolutions, the average wound size was 4.2 cm2 (± 2.1 cm2) with an average wound reduction of 79% (± 23%). No donor or recipient site complications were observed.Conclusions: The automated SBEG harvesting device is an effective and safe option for treating complex non-healing wounds in multimorbid patients who may be poor surgical candidates. This procedure demonstrates minimal contraindications to its use and donor or recipient site complications.

Randomized control trial to compare the efficacy of split thickness transplant versus autologous melanocyte transplant in the management of stable vitiligo

Background: Stable cases of vitiligo can be managed surgically and over the years there has been a shift in the management protocol from the time tested epidermal tissue grafting techniques to the newer melanocyte or cellular transplant techniques. This randomized control trial has evaluated the relative efficacy of both the transplant techniques in the management of stable cases of vitiligo with at least one year of stability. Methods: Epidermal split thickness grafts were harvested from medial aspect of thigh. In the split thickness epidermal grafting technique the donor tissue was directly transplanted on the dermabraded vitiliginous areas. In the autologous melanocyte transplant technique melanocytes were harvested from a donor split thickness graft as a melanocyte rich cell suspension, which was then transplanted to the recipient area that had been superficially dermabraded. 50 patches of vitiligo in patients were randomly allocated into 2 groups to receive either of the two interventions. Results: An excellent response was seen in 64% cases with the melanocyte cell suspension technique and in 52% with the split thickness epidermal grafting technique. Conclusion: Both the surgical techniques are effective in obtaining re-pigmentation in recalcitrant but stable lesions of vitiligo. Large areas of skin can be covered with a smaller donor skin using melanocyte transfer technique; however melanocyte transplant method is more time consuming, and a labor intensive process, requiring state of the art equipments with a sterile laboratory and dermato-surgery setup.

Collagen structural alterations contribute to stiffening of tissue after split-thickness skin grafting.

The gold standard treatment for full thickness injuries of the skin is autologous split-thickness skin grafting. This involves harvesting the epidermis and superficial dermis from healthy skin and transplanting it onto the prepared wound bed. The donor site regenerates spontaneously, but the appendages and cellular components from the dermal layer are excluded from the graft. As a result, the new tissue is inferior; the healed graft site is dry/itchy, has decreased elasticity, increased fragility, and altered sensory function. Because this dermal layer is composed of collagen and other extracellular matrix proteins, the aim was to characterize the changes in the dermal collagen after split thickness grafting that could contribute to a deficit in functionality. This will serve as a baseline for future studies designed to improve skin function using pharmacological or cell-based therapies for skin repair. A xenograft model whereby human split-thickness grafts were implanted into full-thickness defects on immunocompromised (athymic Nu/Nu) mice was used. The grafts were harvested 4 and 8 weeks later. The collagen microstructure was assessed with second harmonic generation with dual-photon microscopy and light polarization analysis. Collagen fiber stiffness and engagement stretch were estimated by fitting the results of biaxial mechanical tensile tests to a histo-mechanical constitutive model. The stiffness of the collagen fibril-proteoglycan complex increased from 682 ± 226 kPa/sr to 1016 ± 324 kPa/sr between 4 and 8 weeks postgrafting. At the microstructural level there were significant decreases in both thickness of collagen fibers (3.60 ± 0.34 μm vs. 2.10 ± 0.27 μm) and waviness ratio (2.04 ± 0.17 vs. 1.43 ± 0.08) of the collagen fibers postgrafting. The decrease of the macroscopic engagement stretch from 1.19 ± 0.11 to 1.09 ± 0.08 over time postgrafting mirrored the decrease in waviness measured at the microscopic level. This suggested that the integrity of the collagen fibers was compromised and contributed to the functional deficit of the skin postgrafting.

Surgical management of recurrent oral submucous fibrosis (a collagen metabolic disorder due to the continuation of habitual factor) by split thickness skin graft from thigh: A clinical challenge

Usage of betel quid with areca nut is commonly seen in South Asian population. Most important premalignant condition, oral submucous fibrosis, arises due to this habit. The pathognomonic feature is characterized by higher intensity of submucosal collagen, inflammatory process, and palpable fibrotic bands intraorally, restricting the mouth opening. Management of this condition is of either medical or surgical means. Various grafts in surgical method are palatal island flaps, temporalis muscle flap graft, split-thickness skin graft, buccal fat pad graft, bilateral nasolabial flap, and tongue flap. Most serious complication of oral submucous fibrosis is oral carcinoma. Common site of involvement is of buccal mucosa which sometimes might extend up to pharynx. In our case report, we present a 35-year-old male with oral submucous fibrosis, previously treated by buccal fat pad and coronoidectomy, which recurred due to habits, currently managed by split-thickness graft from thigh. Postoperative outcome was good.

The assessment of the clinical applications of propeller flaps of the lower leg

Objective The aim of the present study was to assess the clinical applications of the various propeller perforator flaps for the leg in an attempt to evaluate the results and propose an algorithm for the management of various defects of the lower-third of the leg. Background The ideal method for the soft-tissue reconstruction of the leg should be reliable, relatively easy to perform, offer viable tissues similar in skin texture and thickness to the lost ones (replace like with like), leave the most inconspicuous donor-site defect possible, and be performed without compromising other body parts. The perforator-based propeller flaps have all these advantages. Patients and methods This study included 34 patients who presented with moderate-sized leg defects from August 2013 to June 2015. Out of the 34 patients, 24 were males and 10 were females. Their ages varied from 5 to 50 years with an average age of 27 years. There were 19 posterior tibial artery perforator flaps. There were 12 flaps based on perforators of the peroneal artery. Lastly, there were three anterior tibial artery perforator flaps. Duplex ultrasonography was carried out for 25 patients preoperatively. Results All flaps were based on a single perforator except three cases in which the flaps were based on two adjacent perforators. Fourteen of the flaps were proximally based and 20 were distally based. All flaps were designed as propeller flaps and were rotated from 70° to 180°. The donor site was closed by using split-thickness grafts in all except three cases in which the donor site was closed primarily. Out of the 19 flaps of the posterior tibial artery, 11 (57.5%) healed uneventfully and eight (42.5%) cases were complicated. Out of the 12 peroneal artery propeller flaps, nine (75%) flaps healed uneventfully and three (25%) cases were complicated. Lastly, out of the three cases of the anterior tibial artery propeller flaps, one (33%) healed uneventfully and two (66%) were complicated. Conclusion Propeller flaps based on perforator vessels are raising interest in the reconstructive surgery of the limbs. These flaps allow efficient coverage of large wounds without the need to sacrifice a major vascular axis. The operative technique does not require microvascular anastomosis and allows the reconstruction of soft-tissue defects using nearby similar tissues. The aim of this study was to evaluate the clinical results of propeller perforator flaps in the treatment of various lower-leg defects.

Wound-healing improvement by resurfacing split-thickness skin donor sites with thin split-thickness grafting

IntroductionSplit-thickness skin graft (STSG) donor site dressing has been controversial until now. Our study aimed to assess the patient comfort and wound-healing efficacy with the application of thin split-thickness skin grafts regrafting on STSG donor sites. MethodsOne hundred ninety-two consecutive patients undergoing split-thickness skin grafting were included in the study, and the participants were randomly divided into the following three groups: group A was regrafted with thin STSGs and groups B and C were covered with occlusive hydrocellular dressing and paraffin gauze, respectively. The participants were compared according to the epithelialization time, pain and scar formation. ResultsThe average time of epithelialization was 6.2±1.1 days in group A, 11.1±2.1 days in group B and 13.5±2.5 days in group C. The pain scores on days 2 and 5 after operation were 2.3±0.8 and 1.9±0.8 in group A, 2.5±1.1 and 3.9±1.3 in group B, and 3.8±1.4 and 5.9±2.1 in group C. The scar scores at half a year and one year after operation were 4.3±0.6 and 2.50±0.6 in group A, 7.4±0.6 and 6.2±0.6 in group B, and 11.8±0.4 and 10.9±1.0 in group C, separately. The difference in the three groups was significant. ConclusionUtilizing thin STSGs regrafting on donor sites could significantly shorten the epithelialization time, reduce pain and prevent hyperplastic scar formulation.

Use of a Barbed Suture Tie-Over Technique for Skin Graft Dressings: A Case Series

BackgroundA tie-over dressing is the accepted method to secure skin grafts in order to prevent haematoma or seroma formation. We describe the novel application of a barbed suture tie-over for skin graft dressing. The barbs act as anchors in the skin so constant tensioning of the suture is not required.MethodsFrom January 2014 to August 2014 we used the technique in 30 patients with skin defects requiring split-thickness or full-thickness grafts. Patient demographics, clinicopathological details and graft outcome were collected prospectively.ResultsThe majority of cases were carried out for split-thickness skin grafts (n=19) used on the lower limb (n=20). The results of this novel technique were excellent with complete (100%) graft take in all patients.ConclusionsOur results demonstrate the clinical application of a barbed device for securing skin grafts with excellent results. We find the technique quick to perform and the barbed device easy to handle, which can be applied without the need for an assistant.

Thickness of calvarium and diploic space in children ages 0 to 17 as assessed by computed tomography

The thickness of the calvarium and presence of the diploic space in children can aid surgical planning for split-thickness calvarial bone grafting when needed in calvarial reconstruction. However, the normal anatomical characteristics of calvarial thickness and the diploic space in children are poorly defined. Computed tomography scans of pediatric heads over a 2-year period were culled from a large, urban pediatric referral hospital. Subjects with a craniofacial/developmental abnormality or history of surgery were excluded. 104 scans met inclusion criteria. Each skull was marked at 40 locations over the frontal, parietal, and occipital bones. At each location, thickness measurements of the calvarium and the diploe were taken. The left posterior parietal region was thicker than the right in both skull and diploic thickness. Over 90 % of subjects had diploe demonstrable on CT in the frontal and posterior parietal regions by age 3–5. In all ages, the diploe was thickest in the frontal bone and in posterolateral parts of the parietal bones. The skull and the diploe are bilaterally symmetric except in the posterior parietal region, where the left is thicker than the right. The presence of a diploe in surgically important regions can be reliably demonstrated using CT by age 3–5. Level IV, diagnostic study.

Prompt diagnosis and management of cervical necrotizing fascitis.

Necrotizing fasciitis is a rapidly progressing inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissue. It is uncommon and difficult to diagnose, and it causes progressive morbidity until the infectious process is diagnosed and treated medically and surgically [1]. Smith et al., stated that the mortality rate of necrotizing fasciitis can be upto 34%. Monomicrobial necrotizing fasciitis is caused by the betahemolytic streptococcus normally seen in healthy persons with the previous history of wound infection [2]. Necrotizing fasciitis is also known as Flesh eating disease, Gangrenous erysipelas, Hospital gangrene, Non-closteroidal crepitant cellulitis, Streptococcal gangrene, Meleney’s cellulitis [3]. A 50-year-old male was admitted with history of pain and swelling of cervical and temporal region since four days. The patient presented with cervical and temporal abscess upon physical examination [Table/Fig-1]. The overlying skin showed multiple haemorrhagic areas [Table/Fig-2] varying in size from 2 cm to 4 cm. Computerized Tomography (CT scan) of the head and neck region [Table/Fig-3] showed collection of air in the pretracheal, retrotracheal regions. A diagnosis of cervical necotizing fasciitis along with temporal abscess secondary to grossly decayed 48 was made. The following differential diagnoses were considered, Necrotizing fasciitis, Ludwig’s angina, Erysipelas, Progressive bacterial gangrene. Microbiolgical analysis of the pus revealed staphylococcus aureus. Intravenous antibiotic therapy consisted of Injection cefotaxime with salbactum (1.5 gm eight hourly) and Injection levofloxacin 100 ml 24 hourly. Incision and drainage of the cervical and temporal abscess was done followed by vigorous debridement of fascia, subcutaneous tissue and necrotic skin [Table/Fig-4]. Neomycin and cutacill dressing was done [Table/Fig-5]. Reconstruction was done after three weeks using split thickness graft from the thigh region [Table/Fig-6,​,77]. [Table/Fig-1]: Swelling of cervical region with multiple haemorrhagic areas [Table/Fig-2]: Swelling of the temporal region, [Table/Fig-3]: CT scan showing air spaces [Table/Fig-4]: Debridement of fascia & subcutaneous tissue [Table/Fig-5]: Neomycin and cutacill dressing [Table/Fig-6]: Healing after three weeks [Table/Fig-7]: Healing one month after the graft placement

A Novel Technique of Defattening Large Full Thickness Skin Grafts.

Sir, Full Thickness Skin Graft (FTSG) holds an irreplaceable position in a reconstructive and aesthetic surgeon’s armamentarium. Particularly for coverage of defects over face and hands, FTSG provides superior aesthetic and functional result as compared to the split thickness graft. FTSG is harvested free hand with a scalpel and invariably tends to include some of the underlying fat with it. Defattening of the graft is an important step to avoid fat necrosis [1] and to facilitate approximation of the dermis to wound bed which is essential for the revascularisation of the graft and eventually affects the ‘take’ [2]. Placing the skin graft under tension over a convex surface is a prerequisite for optimal defattening. As originally described in text [3] and as per the conventional teaching, the FTSG has always been defattened by stretching it upside down over the tip of surgeon’s index finger of non dominant hand while cutting with a sharp scissors [Table/Fig-1] [3]. This may at times lead to inadequate or irregular defattening, may also cause buttonholing and may be quite time consuming for large area grafts. [Table/Fig-1]: Conventional technique of defattening of FTSG We have tried a novel way of defattening of a large FTSG by placing it over the dorsum of the non dominant hand of the assistant with dermal side facing upwards and defattening by using sharp scissors [Table/Fig-2a,b]. This technique has been particularly found useful for the large FTSG required for resurfacing of extensive facial post burn scars as the sheer size of the graft renders it unmanageable to defattening by conventional technique. Other advantages are that it is easier and faster and provides better outcome in terms of more uniform defattening of the FTSG and also prevents any inadvertent buttonholing of the precious graft. It is worth noting that this technique keeps both hands of the surgeon free to work. [Table/Fig-2a,b]: Our technique for defattening of large grafts placing the graft on back of the assistant’s hand: a) relative position of surgeon and assistant; b) the way graft is held over back of the hand of assistant while fat is trimmed off In our practice we cover large post burn scars over face and neck with large FTSGs harvested from lower abdomen with or without the use of tissue expansion. These grafts may sometimes be of dimensions upto 25 x 10 cm. As the surgery is being done for aesthetic effect, buttonholing and graft necrosis due to inadequate defattening is not acceptable. Defattening of such large grafts proves to be a challenge. The authors have been using this technique routinely for the cases requiring large size full thickness grafts (in more than 100 patients till now) with excellent outcomes and never had complications associated with the conventional technique as discussed above [Table/Fig-3]. [Table/Fig-3]: Cases of post burn scar over face resurfaced with large FTSG from lower abdomen Thus we see that with this modified technique, one can defatten FTSG with precision in just few minutes and it makes the surgeon’s life easier while also giving a superior aesthetic result as compared to the conventional technique.

Aerobic Fitness Is Disproportionately Low in Adult Burn Survivors Years After Injury.

A maximal aerobic capacity below the 20th percentile is associated with an increased risk of all-cause mortality (Blair 1995). Adult Adult burn survivors have a lower aerobic capacity compared with nonburned adults when evaluated 38 ± 23 days postinjury (deLateur 2007). However, it is unknown whether burn survivors with well-healed skin grafts (ie, multiple years postinjury) also have low aerobic capacity. This project tested the hypothesis that aerobic fitness, as measured by maximal aerobic capacity (VO2max), is reduced in well-healed adult burn survivors when compared with normative values from nonburned individuals. Twenty-five burn survivors (36 ± 12 years old; 13 females) with well-healed split-thickness grafts (median, 16 years postinjury; range, 1-51 years) covering at least 17% of their BSA (mean, 40 ± 16%; range, 17-75%) performed a graded cycle ergometry exercise to test volitional fatigue. Expired gases and minute ventilation were measured via a metabolic cart for the determination of VO2max. Each subject's VO2max was compared with sex- and age-matched normative values from population data published by the American College of Sports Medicine, the American Heart Association, and recent epidemiological data (Aspenes 2011). Subjects had a VO2max of 29.4 ± 10.1 ml O2/kg body mass/min (median, 27.5; range, 15.9-53.3). The use of American College of Sports Medicine normative values showed that mean VO2max of the subjects was in the lower 24th percentile (median, 10th percentile). A total of 88% of the subjects had a VO2max below American Heart Association age-adjusted normative values. Similarly, 20 of the 25 subjects had a VO2max in the lower 25% percentile of recent epidemiological data. Relative to nongrafted subjects, 80 to 88% of the evaluated skin-graft subjects had a very low aerobic capacity. On the basis of these findings, adult burn survivors are disproportionally unfit relative to the general U.S. population, and this puts them at an increased risk of all-cause mortality (Blair 1995).

The donor site pain assessment of the patients who were reconstructed split-thickness graft

In this study we examined the donor site pain intensity of the patients who were reconstructed by split thickness skin graft (STSG) due to tissue defect. This descriptive study was performed in a Plastic and Reconstructive Surgery Clinic of a State Hospital in Istanbul. Sampling selection wasn't made, all (31) cases were studied with STSG in 2013. As data collection forms, we used Patient Information Form and Visual Analog Scale (VAS). In the analysis of the data percentage, Kruskal-Wallis and Mann-Whitney-U tests were used. 38.71% of the patients were female and 61.29% were male. It was determined that grafting application was mostly made in the lower extremity and 61% of the patients were able to perform individual functions independently. It was observed that pain intensity increased as the donor area expanded. It was also determined that semi-dependent patients' pain intensity was higher than independent patients'. In 64.52% of the patients graft donor area was wider than 10cm². The postoperative pain intensity of the patients who were reconstructed by STSG in the lower extremity was higher than patients who were reconstructed by STSG in the upper extremity area. It was observed that the donor area pain intensity of patients was the most severe on the first day after surgery and the least severe on the sixth day after surgery. In conclusion, the pain evaluation of the donor area has to be assessed by the nurse on the first day after surgery.

Laser-Assisted Indocyanine Green Dye Angiography Accurately Predicts the Split-Thickness Graft Timing of Integra Artificial Dermis

The use of an artificial dermal substitute such as Integra-a bilaminate combination of thin silicone and cross-linked bovine tendon collagen and chondroitin-6-sulfate-has become a popular method to address large surface area wounds or smaller, complex wounds devoid of a vascular bed. The incorporation of Integra depends on a vascular wound bed or periphery and can take 4 weeks or longer to occur. If the Integra has not fully incorporated at the time of placement of the split-thickness graft, complete graft loss may result. The availability of a minimally invasive method to assess the incorporation of Integra would be of great value. Two 5 × 10-cm paraspinal full-thickness wounds were created on 3 female swine. Wounds were randomly assigned full-thickness skin graft or Integra (Plainsboro, NJ) treatment. Both types of grafts were placed after the application of fibrin glue (Tisseel, Deerfield, Ill) to the wound bed. Laser Doppler imaging (LDI) (Moor), indocyanine green dye (ICG) angiography (LifeCell SPY), and clinical scoring were performed weekly for a period of 8 weeks after grafting. At 4 weeks, the silicone layer of the Integra was removed, and a culture of autologous keratinocytes was applied. A 4-mm punch biopsy sample of each graft was taken 1, 2, 4, 6, 7, and 8 weeks postoperatively for histologic analysis. Both ICG angiography and LDI perfusion measurements noted an increase in perfusion at the Integra graft site that peaked 3 weeks after grafting, corresponding with the start of neovascularization and the optimal time for the application of a split-thickness skin graft. indocyanine green dye angiography measurements exhibit greater reproducibility between animals at late time points as compared with LDI. This decrease in LDI precision is directly related to increases in scar tissue thickness of greater than 5 mm as determined via histologic analysis and corresponds with the accepted maximum penetration depth of the LDI laser. Indocyanine green dye angiography may provide valuable information as to graft integrity and split-thickness skin graft timing at late time points. Range of LDI seems to be insufficient for split-thickness graft timing or late time point accuracy. Future exploration of ICG angiography potential will involve tracking Integra graft delay in porcine models.

Total scalp reconstruction following a dog bite in a pediatric patient.

The purpose of this case report is to present the reconstruction of a full-thickness scalp defect in a 2-year-old Hispanic male mauled by a dog, which was performed by a novel technique. After the scalp defect was debrided multiple times and treated with greater than 600 cm2 of cryopreserved human skin allograft, Integra was applied to the scalp defect following debridement and burring-out the outer bony cortex to promote bleeding and integration, followed by the application of a VAC dressing. Four weeks later, the mature Integra was grafted with split-thickness grafts. One year after the original injury, the patient demonstrated 98% take of the skin grafts to the calvarium. The resultant soft-tissue cover was supple, pliable, uniform in texture, and stable. The proposed technique of reconstruction of large full-thickness scalp defects in pediatric patients is easily reproducible, involves a short operative time, and produces satisfying cosmetic results.