Subsequent Split-thickness Skin Grafting Research Articles

Versatility in the Use of Cadaveric Skin Grafts for Wound Management

Background. Cadaveric skin grafts were initially used for the management of acute burn wounds. The biological coverage of the wound improves the quality of the wound bed, which prepares it to receive an autologous skin graft. The benefits of cadaveric skin graft in burn wounds have led to its use in the management of acute and chronic wounds of diverse etiologies. Objective. To evaluate the use of cadaveric skin graft and subsequent autologous split-thickness skin graft (STSG) in the management of wounds of diverse etiologies at a single institution. Materials and Methods. A retrospective analysis was performed of patients with wounds of different etiologies managed with cadaveric skin grafts followed by a second procedure in which autologous STSG was performed from May 2017 through May 2022 in the Plastic and Reconstructive Surgery Department of German Hospital, Buenos Aires, Argentina. Results. A total of 25 patients with wounds of different etiologies were included. The mean affected body surface area (BSA) was 1.87%. The mean engraftment percentage of the cadaveric skin graft was 96.6%. The mean engraftment percentage of the STSG was 90.6%. All patients demonstrated improvement in local edema and inflammation, reduced secretions, and reduced pain after treatment. Two patients (8%) had complications, with 1 case of delayed healing of the donor site and 1 case of hypertrophic scarring. Conclusions. Cadaveric skin graft with subsequent STSG is a simple, safe, and effective alternative for the management of complex wounds of diverse etiologies. This technique is particularly useful in patients with multiple comorbidities who are at risk of recurrence and of developing multiple wounds during their lifetime.

E-cigarette explosions: patient profiles, injury patterns, clinical management, and outcome

BackgroundE-cigarette abuse, also known as vaping, is a widespread habit. Recently, there have been increasing reports of explosions of these devices resulting in serious burn injuries, especially to the groin, hand, and face. Overheating rechargeable lithium-ion batteries are supposed to be the responsible mechanism, especially in low quality fabrications. MethodsIn this single-center retrospective study, data of 46 patients are presented and analyzed. In addition to information on demographics, injury patterns, and treatment options, this is the first study investigating outcome after an average of 13 months via a standardized telephone interview of 31 patients (67%). Patients were specifically asked regarding their outcome, vaping habits, technical modifications to their devices and supply source. ResultsPatients were mainly male (98.2%) with a median age of 36 years. Typical injury patterns included the groin region (n = 32; 69%), hands (n = 12; 25%) and face (n = 3; 7%). All patients underwent debridement, in nine cases hydrotherapeutically. 61% (n = 28) underwent consecutive tangential necrectomy and subsequent split thickness skin graft transplantation. Wound infection was observed in 18 patients (39%), with burn depth as a significant risk factor (p < 0.001). 91% of the followed-up patients were satisfied. Surprisingly, 38% were still using e-cigarettes. 42% (n = 13) reported manual modifications of their devices to prolong battery life or increasing smoke production. ConclusionsInjuries from exploding e-cigarettes can be serious and should be treated in a specialized burn center. E-cigarette explosions lead to characteristic injury patterns and often need surgical treatment. This should be made more public to reduce their use and keep people from modifying the devices. The counterintuitive and irrational observation of a high rate of abuse even after the injury underlines their addiction potential.

Orbital Exenteration Reconstruction for Medically Complex Patients: Bilaminate Dermal Substitute as an Alternative to Major Surgery.

Reconstructive strategies after orbital exenteration range from the use of skin grafts to tissue flaps, depending on the classification of the defect, patient's goals, and tolerance for surgery. We present a case of a 68-year-old, medically complex patient who underwent orbital exenteration, radiation therapy, and reconstruction with a bilaminate dermal substitute. Despite the placement in an irradiated area without periosteum, the bilaminate dermal substitute graft demonstrated acceptable integration and provided an adequate base for subsequent split thickness skin grafting, sparing a medically fragile patient from a morbid operation. This case highlights the advantages of a less invasive reconstructive modality when managing a patient with multiple comorbidities and a significant chance of cancer recurrence.

Wound management using homemade vacuum dressing, affordable and customized (homemade vac)

Introduction: The vacuum-assisted closure (VAC) has proved to be very promising in the management of difficult to heal wounds. However, the first reports about the use of negative pressure wound device came from Argenta and Morykwas in the year 1997. Though there are various commercially prepared and manufactured vacuum assisted closure dressing materials, these are often unavailable or unaffordable to patients in third world countries. Our “homemade” vacuum dressing has been found to be, affordable for our patients and most importantly effective in wound management. Materials and methods : The homemade Vacuum Assisted closure dressing was used for the management of some wounds which presented at our centre. These wounds were irrigated and thoroughly debrided. Our homemade vacuum assisted closure dressings were subsequently applied. Results: The wounds healed well with good granulation tissue. Subsequent split thickness skin graft (SSG) done had very good take. The VAC dressing often resulted in good wound contraction with no need for SSG. Conclusion: In our practice our “home made” vacuum which was affordable and customized proved to be effective in wound management.

Review of Transmetatarsal Amputations in the Management of Peripheral Arterial Disease in an Asian Population.

Objective: To evaluate outcomes after transmetatarsal amputation (TMA) in peripheral arterial disease (PAD) limb salvage in an Asian population and identify risk factors associated with TMA failure.Methodology: A retrospective review of 147 patients with PAD, who had undergone TMA between 2008 and 2014, was carried out. Univariate and multivariate analysis were used to identify predictors of TMA failure. Kaplan–Meier survival analysis was used to calculate major amputation and all-cause mortality rates.Results: The mean age was 66 years. 92% were diabetic patients and 78% had preceded angioplasty. 56% of TMAs were healed via secondary intention, 8% required subsequent split-thickness skin graft closure, 24% required further debridement while 37% had wounds, which failed to heal and required below-knee amputations (BKA). Multivariate analysis showed that diabetes is the only independent predictor of TMA failure (odds ratio (OR) 7.11, p=0.064). Patients with TMA failure were at increased risk of developing nosocomial infections (p=0.025) and faced a higher risk of 30-day re-admission rate (p=0.002).Conclusion: The success rate for PAD limb salvage TMA was 63% and diabetes was an independent predictor of TMA failure. Patients with TMA failure were at increased risks of nosocomial infections, and 30-day re-admissions; hence the risks and benefits of TMA for diabetic foot limb salvage must be individualized for each patient.

Surgical Management and Reconstruction of Hoffman's Disease (Dissecting Cellulitis of the Scalp).

Dissecting cellulitis of the scalp, or Hoffman's disease, is a rare dermatologic condition characterized by recurrent pustules and sinus tract formation leading to scarring and alopecia. Medical management includes the use of corticosteroids, antibiotics, isotretinoin, and adalimumab. In cases where the disease is severe, refractory, and intractable, surgery is an option. We report two cases of Hoffman's disease, where medical management failed to achieve remission. Surgical treatment was undertaken with complete resection of the affected scalp in staged procedures with subsequent split-thickness skin grafting for reconstruction. Surgery achieved both disease remission and excellent aesthetic outcomes in both patients.

Treatment of chest burn contracture causing respiratory compromise with island release and grafting using cross-link collagen and Integra™ bilayer dressing

Post-burn skin contractures of the anterior and lateral abdomen and chest may result in respiratory compromise due to limitation of rib excursion. This case report describes a young man with respiratory compromise limiting his daily activity and function, as a result of a 90% burn sustained 6 years previously. Release of his chest and upper abdomen was achieved using “island” scar releases and a cross-linked bovine tendon collagen and glycosaminoglycan and a semi-permeable polysiloxane bilayer matrix dressing (Integra™) followed by subsequent split thickness skin graft. An immediate increase in maximal inspiratory volume was obtained intra-operatively and in the im­mediate post-operative period, and this improvement was sustained after healing of all wounds with subjective relief of the patient’s symptoms.

Malignant granular cell tumor of the back: a case report and review of the literature.

Malignant granular cell tumors are rare, intensely aggressive entities. This paper presents a case of a large rapidly recurrent malignant granular cell tumor with regional and distal metastases on the back of a 54-year-old Cuban man. The primary tumor recurred within six months of the original wide local excision and with satellite lesions apparent at twelve months, and the mass was diagnosed using the histological criteria established by Fanburg-Smith et al. for malignant granular cell tumors. By fifteen months, right axillary lymphadenopathy, multiple satellite lesions, pulmonary nodules, and distant metastasis in the right thigh were present. At sixteen months, wide local excision of recurrent mass and local satellite masses along with right axillary dissection and placement of Integra with subsequent split-thickness skin graft were performed by surgical oncology and plastic surgery teams. The surgical specimen measured 32.0 × 13.5 × 5.5 cm, containing multiple homogeneous masses with the largest mass 22.0 × 9.0 × 4.6 cm. Following surgery, patient was started on Pazopanib 800 mg/day based on phase III randomized trial data in the treatment of soft tissue sarcomas showing this as a potential novel therapy for malignant granular cell tumors.

Screw Fixation of Dermal Regeneration Template for Scalp Reconstruction

Despite many advances in reconstructive techniques, the full-thickness scalp defect remains a difficult problem for the reconstructive surgeon. Patient and disease-specific factors occasionally make reconstruction with a dermal regeneration template (DRT) an attractive option when other methods are less advised. Although the applicability of dermal regeneration templates has been well elucidated, the method of DRT immobilization has not been standardized. Given the difficulty of adherence and subsequent infiltration of host cells into the DRT from the underlying bone due to seroma, hematoma, or shearing forces, we propose a screw and bolster system for DRT immobilization. We present a series of 13 patients with full-thickness scalp loss who underwent reconstruction with DRT and a subsequent split-thickness skin graft. All 13 patients were treated with the screw-bolster method of DRT fixation before a vacuum-assisted closure dressing. The average surface area of the defect was 96 cm. The mean time interval between the application of DRT and skin graft was 28 days. At a mean of 9-month follow-up, all patients achieved a well-vascularized neodermis, and progressed to complete, stable wound healing following application of a split-thickness skin graft. We propose that a screw-bolster system of fixation is a safe and effective method of immobilizing DRT in full-thickness scalp defects.

Der temporoparietale Faszienlappen zur Rekonstruktion von Weichteildefekten

Soft tissue reconstruction with a temporoparietal fascial flap (TPFF). Defect coverage with thin, pliable, and well-vascularized tissue. A bilayered TPFF provides a gliding surface in tendon reconstruction. Further options include TPFF harvest with overlying skin or subjacent bone for composite tissue reconstruction or the application as a sensate local fascial flap. Maximum defect dimensions: 17 × 14cm. Absolute: prior injury to the flap or flap pedicle, temporal arteritis, Moyamoya syndrome, defects with volume deficit. Relative: alopecia along the planned incision. Pedicle location is outlined using Doppler ultrasound. Injection of the incision line with diluted epinephrine solution. Skin incision with subsequent visualization of the temporoparietal fascia and supplying vessels. Skin flaps are raised carefully paying special attention to the hair follicles (CAVE: postoperative alopecia). Primary closure of the donor site. Defect coverage with pedicled or free TPFF with subsequent full or split-thickness skin grafting. Dressing: Bolster or V.A.C. Immobilization/elevation in the setting of extremity reconstruction. Removal of bolster dressing or V.A.C. on postoperative day5. Dangling protocol instituted on postoperative day7. Removal of sutures/staples at the donor site on postoperative day5-7 and at the recipient site on postoperative day12-14. The TPFF was utilized for soft tissue reconstruction in 8patients. A pedicled TPFF was used in 2patients. Mean time to healing was 16.3days. Mean follow-up was 13.4months. Successful reconstructive results with satisfactory functional and aesthetic appearance were obtained in all patients. Complications were encountered in 3patients and included alopecia at the donor site and iatrogenic injury to the frontal branch of the facial nerve. Vascular compromise was observed in the early postoperative period in a third patient. However, operative revision resulted in successful flap salvage.

Management of severe hand wounds with integra® dermal regeneration template

We report our experience with the use of Integra® for the management of severe traumatic wounds of the hand. Fifteen patients were treated with follow-up ranging from 10 to 37 months. Wounds were associated with an osseous and/or joint and/or tendon exposure. Following Integra® placement, patients were managed with dressings and subsequent split-thickness skin grafting an average of 26 days later. Integra® was successful in achieving durable, functional and aesthetic definitive coverage in 13 of 15 applications while allowing a satisfying pollicidigital prehension. Regarding our clinical experience, Integra® is an effective technique to deal with severe wounds of the hand with exposed tendon and/or bone and/or joint, even in the absence of paratenon or periosteum. This can potentially lessen the need for local rotational or free flap coverage and should be taken into consideration as a viable alternative in traumatic reconstruction of the hand.

Plantar Reconstruction Using the Medial Sural Artery Perforator Free Flap

Free flaps are usually required rather than local flaps for large plantar defects, due to a lack of locally available tissue. The medial sural artery perforator free flap, recently introduced clinically by several authors, is a noticeable option for soft tissue coverage, but it has still not been widely used for the reconstruction of various large plantar defects. Between 2005 and 2007, medial sural artery perforator free flaps were used to reconstruct soft tissue defects in plantar areas in 11 patients at our institute. Patient ages ranged from 10 to 68 years (mean, 43 years), and follow-up periods ranged from 7 to 22 months (mean, 13 months). Flap sizes ranged from 10 to 14 cm in length and from 5 to 7 cm in width. Flaps survived in all patients. Marginal loss over the distal flap region was noted in 1 patient, and this was treated successfully with a subsequent split-thickness skin graft. In another one case, venous insufficiency developed, but salvage was successful with leech application. Long-term follow-up showed good flap durability with a protective sensation. The medial sural artery perforator flap provides sufficient durability for weight-bearing areas, even though it is a thin cutaneous flap. The authors recommend that this flap be considered as a reliable alternative for the reconstruction of large plantar defects.

Coverage of Exposed Bones and Joints in Critically Ill Patients: Lower Extremity Salvage with Topical Negative Pressure Therapy

Soft tissue defects of the limb with exposure of tendons and bones in critically ill patients usually lead to extremity amputation. A potential treatment with topical negative pressure may allow split-thickness skin grafting to the bone, which leads to limb salvage. We report on 21 multimorbid patients, 46 to 80 years of age, with severe lower limb soft tissue loss and infection with exposed bone following débridement with critical limb ischemia. Attempts to salvage the extremities were undertaken with repeated surgical débridement followed by vacuum-assisted closure therapy and subsequent split-thickness skin grafting procedures. Infection control and limb salvage were achieved in all cases with multiple débridements, topical negative pressure therapy, and skin grafts. In all patients, the exposure of tendons and bones was reversible by this strategy without a free flap transfer. The patients described in this study were severely compromised by systemic and vascular disorders, so extremity amputation had been considered owing to the overall condition and the exposure of tendons and bones. Since it was possible to salvage the affected limbs with this straightforward and simple procedure, this type of treatment should be considered as a last attempt to prevent amputation.

Bioartificial Dermal Substitute: A Preliminary Report on Its Use for the Management of Complex Combat-Related Soft Tissue Wounds

To report our institutional experience with the use of a bioartificial dermal substitute (Integra) combined with subatmospheric pressure [vacuum-assisted closure (VAC)] dressings followed by delayed split-thickness skin grafting for management of complex combat-related soft tissue wounds secondary to blast injuries. Retrospective review of patients treated December 2004 through November 2005. Military treatment facility. Integra grafting was performed 18 times in 16 wounds at our institution. Indications for Integra placement were wounds not amenable to simple split-thickness skin grafting, specifically those with substantial exposed bone and/or tendon. Patients underwent an average of 8.5 irrigation and debridement procedures and concurrent VAC dressings prior to placement of the Integra. Following Integra grafting, all patients were managed with VAC dressings, changed every 3 to 4 days at the bedside or in clinic, with subsequent split-thickness skin grafting an average of 19 days later. The mechanism and date of injury, size of residual soft tissue deficit, indication for Integra placement, number of irrigation and debridement procedures prior to Integra placement, days from injury to Integra placement, days from Integra placement to split-thickness skin grafting, and clinical outcome were recorded. Integra placement and subsequent skin grafting was successful in achieving durable and cosmetic definitive coverage in 15 of 16 wounds with two of these patients requiring repeat Integra application. Two patients with difficult VAC dressing placement had early Integra graft failure but successfully healed following repeated Integra application and skin grafting. Bioartificial dermal substitute grafting, when coupled with subatmospheric dressing management and delayed split-thickness skin grafting, is an effective technique for managing complex combat-related soft tissue wounds with exposed tendon. This can potentially lessen the need for local rotational or free flap coverage.

Enhanced Dermal Regeneration using Modified Collagen Scaffolds: Experimental Porcine Study

Ongoing research has achieved much progress towards the development of new artificial skin substitute products. However, effective implant material for correcting full-thickness defects (such as those arising from extensive burns, tumor resection, hereditary or congenital defects and chronic wounds) has not yet become available. Following split-thickness skin grafting, contraction and scar formation are unavoidable. These phenomena are believed to be due to poor dermis regeneration. Collagen dermis substitute has been developed for the treatment of deep, poorly vascularized tissue defects. However, their application is problematic, because scaffolds of this kind fail to adequately induce the neoangiogenesis needed for regeneration. To overcome these shortcomings a number of matrices have been chemically modified. Furthermore, these matrices first require implantation and follow-up by skin grafting 3 to 5 weeks later. In this article we describe new materials made of modified collagen which enhance dermal regeneration and neoangiogenesis. The procedure was applied in successfully dealing with full-thickness defects in pigs, with subsequent split-thickness skin grafting being performed immediately afterwards. Histological findings revealed that the neodermis obtained resembles a normal dermis structure. These scaffolds have the potential of serving as an off-the-shelf skin replacement in the reconstruction of deep wounds, thus supporting wound-healing processes.

Laparoscopic Greater Omentum Harvesting with Split-Thickness Skin Grafting for Sternal Wound Dehiscence

Sternal wound dehiscence is a serious complication occasionally requiring soft tissue coverage. The greater omentum typically has been used as a last resort because of the underlying morbidity from a laparotomy. We present a case in which a laparoscopically created omental flap with subsequent split-thickness skin grafting was used to correct a large soft tissue defect that occurred after sternal wound dehiscence developed. A nonambulatory 49-year-old man who underwent coronary artery bypass grafting developed sternal wound dehiscence. Because a large soft tissue defect developed after multiple debridements, soft tissue coverage was required. A laparoscopically harvested omental flap spared this man's upper extremity musculature and provided a soft tissue bed for split-thickness skin grafting. This case helps to establish the role of laparoscopically harvested omentum. If the results suggested by this case are confirmed in a large series, omental flaps should be considered as options of first choice in the management of sternal wound dehiscence.

Radial Midpalmar Island Flap

Although defects and contractures of the first web space and the thumb base can be a difficult problem, several local flaps have been used to reconstruct them. However, as most of these flaps are raised from the dorsal aspect of the thumb and the index finger, they may be unsuitable for reconstruction when defects or contractures of the first web space and the thumb base involve the dorsal skin. In an attempt to resolve this problem, an island flap harvested from the radial aspect of the midpalm and based on the terminal branch of the superficial palmar arch was developed at Chonnam National University Medical School. From 1998 to 2003, this flap was used in 15 patients. The sizes of these flaps ranged from 2 to 3 cm in width and from 2.5 to 5 cm in length. All the flaps survived completely. The donor site was covered with a skin graft in six patients and closed primarily in nine. Healing of most donor sites was uncomplicated. However, in one patient, the skin graft on the donor site did not take completely as a result of subgraft hematomas and a subsequent split-thickness skin graft was required to cover the defect. Although there may be some variations of the vascular pedicle, the radial midpalmar island flap is reliable using careful dissection. This new flap may offer an alternative for reconstructing the first web space and the thumb base in selected patients.

Vacuum-assisted closure – a management option for the burns patient with exposed bone

Exposed bone, secondary to debridement of severe burns to the lower limb, presents a challenge to the plastic surgeon. Techniques to provide soft tissue cover, such as local tissue advancement are limited, due to the severe thermal damage to the tissue surrounding the wound. Free tissue transfer may be relatively contraindicated by the patient’s systemic problems. Until such soft tissue cover can be provided, split thickness skin grafting will not be successful. Limb amputation is sometimes the only option available to this group of patients. The advent of vacuum-assisted closure (VAC) devices has changed many wound management practices. This technique, first described by Argenta and Morykwas [1,2], involves the insertion of a foam sponge into the wound cavity and achieving an airtight seal with the adhesive covering. Subatmospheric pressure is then applied. Wound healing is thought to be promoted by the removal of interstitial oedema, the increase in local blood flow and stimulation of granulation tissue formation secondary to negative pressure application [1–3]. Tissue bacterial counts have also been shown to be reduced [1,2]. We present a series of three patients, all of whom had severe lower limb burns with exposed bone following debridement, in whom vacuum-assisted closure dressings were applied and helped achieve soft tissue cover. Subsequent split thickness skin grafting was possible for wound closure, and limb salvage was achieved in each case.

Distally based dorsal forearm fasciosubcutaneous flap.

Use of a local flap is often required for the reconstruction of a skin defect on the dorsum of the hand. For this purpose, a distally based dorsal forearm fasciosubcutaneous flap based on the perforators of the posterior interosseous artery was developed. From 1997 until 2002, this flap was used to reconstruct skin defects on the dorsum of the hand in nine patients at Chonnam National University Medical School. The sizes of these flaps ranged from 10 to 14 cm in length and from 5 to 7 cm in width. The flaps survived in all patients. Marginal loss over the distal edge of the flap was noted in one patient. Three flaps that developed minimal skin-graft loss were treated successfully with a subsequent split-thickness skin graft. The long-term follow-up showed good flap durability and elasticity. The distally based dorsal forearm fasciosubcutaneous flap is a convenient and reliable alternative for reconstructing skin defects of the dorsum of the hand involving vital structure exposure. It obviates the need for more complicated and time-consuming procedures.

Absorbable mesh and skin flaps or grafts in the management of ruptured giant omphalocele

Purpose: The authors report the use of absorbable mesh closure with subsequent skin graft or skin flap coverage for giant ruptured omphalocele. Methods: Retrospective review of a single surgeon's experience was conducted from 1996 through 2001. Results: Four infants were identified presenting an average of 4 weeks prematurely. All patients had an initial attempt at silo reduction but had either infection or respiratory compromise. The silo was removed, and the defect was covered with polyglycan mesh followed by subsequent skin coverage. In 2 patients, final coverage was obtained using skin flaps, whereas in 2 patients, split-thickness skin grafts were required. All patients were noted to have a distinct narrow chest contour with evidence of pulmonary hypoplasia. Three patients had respiratory failure requiring tracheostomy and prolonged ventilation. Two children were decannulated after one and 2 years, respectively; the third child is booked for decannulation at age 12 months. Although these children have required multiple reoperations, they are all presently doing well with an average of 4 years of follow-up. Conclusions: Patients with giant omphalocele have associated pulmonary hypoplasia, which limits the ability to reduce the abdominal contents. Absorbable mesh coverage followed by split-thickness skin graft or skin flap coverage provides a viable biological coverage and minimizes ongoing pulmonary morbidity. The authors recommend a minimally aggressive attempt at sac reduction in the initial treatment of giant omphalocele and, if necessary, the use of absorbable mesh as a staged coverage with subsequent split-thickness skin grafting to minimize the pulmonary effects of the abdominal operation. J Pediatr Surg 38:725-728. © 2003 Elsevier Inc. All rights reserved.