Split-thickness Skin Graft Research Articles

Carbon footprint of non-melanoma skin cancer surgery.

Climate change poses a significant global health threat and healthcare, including surgery, contributes to greenhouse gas emissions. Efforts have been made to promote sustainability in surgery, but the literature on sustainability in plastic surgery remains limited. A life-cycle analysis was used to assess and quantify the environmental emissions associated with three distinct reconstructive methods utilized in non-melanoma skin cancer surgery: direct closure, split-thickness skin graft, and full-thickness skin graft. Analyses were conducted in March 2023 in Morriston Hospital, Swansea, UK. The carbon footprints for non-melanoma skin cancer surgery in England and Wales were then estimated. The mean carbon emissions for non-melanoma skin cancer surgery ranged from 29.82 to 34.31 kgCO₂eq. Theatre energy consumption (4.29-8.76 kgCO₂eq) and consumables (16.87 kgCO₂eq) were significant contributors. Waste produced during non-melanoma skin cancer surgery accounted for 1.31 kgCO₂eq and sterilization of reusable surgical instruments resulted in 1.92 kgCO₂eq of carbon emissions. Meanwhile, transportation, dressings, pharmaceuticals, and laundry accounted for 0.57, 2.65, 1.85, and 0.38 kgCO₂eq respectively. The excision of non-melanoma skin cancer with direct closure (19.29-22.41 kgCO₂eq) resulted in the lowest carbon emissions compared with excision with split-thickness skin graft (43.80-49.06 kgCO₂eq) and full-thickness skin graft (31.58-37.02 kgCO₂eq). In 2021, it was estimated that non-melanoma skin cancer surgery had an annual carbon footprint of 306 775 kgCO₂eq in Wales and 4 402 650 kgCO₂eq in England. It was possible to predict that, by 2035, carbon emissions from non-melanoma skin cancer surgery will account for 388 927 kgCO₂eq in Wales and 5 419 770 kgCO₂eq in England. This study highlights the environmental impact of non-melanoma skin cancer in plastic surgery departments and emphasizes the need for sustainable practices. Collaboration between surgeons and policymakers is essential and further data collection is recommended for better analysis.

Effectiveness of negative pressure wound therapy as a fixator in split thickness skin graft applied diabetic patients: evaluation of 25 cases

Objective: Microangiopathies expose diabetic patients to lower extremity wounds at certain stages of their lives. Split-thickness skin grafting (STSG) has an important place in the surgical treatment of such wounds. The aim of the present study is to evaluate the effects of negative pressure wound therapy (NPWT) on STSG survival. Methods: A total of 25 diabetic patients (M = 20, F = 5) with acute or chronic lower extremity open wounds were included in the study. All patients underwent wound debridement under regional anesthesia. STSG was applied after wound debridement. NPWT was applied to STSG to increase graft survival. Results: The hospitalization times of the patients ranged from 1 to 2 weeks. The mean follow-up period of the patients was 6 months. All wounds healed on the 14th postoperative day. There was no recurrence in the 6-month follow-up period. Conclusion: We objectively demonstrated the positive effects of NPWT application on STSG and graft survival.

Fournier's Gangrene reconstruction in black patients using SCIP flap and split thickness skin graft: 2 case reports and a literature review

Fournier's gangrene is a potentially life-threatening infectious disease involving the perineum and genitals. Aggressive surgical and medical management is often required, leaving the patient with large integumentary defects. The multiplicity of reconstructive options reported highlights the lack of consensus on the best covering option. Functional and aesthetic considerations are in play, and the literature is scarce on male black patients. We report here two cases of dark-skinned patients presenting with scrotal and penile integumentary defects that were respectively reconstructed with a superficial circumflex iliac artery propeller perforator flap and a split-thickness meshed skin graft and discuss the available literature on the topic.

Recent Updates on the Management of Split-thickness Skin Graft Donor Sites.

This article is a narrative review of split-thickness skin graft donor site (STSG-DS) management since the international guidelines were created in 2018. Although many new interventions have been developed, there is a lack of quality, multicentered clinical trials to produce updated evidence-based recommendations. Electronic databases, including Google Scholar, Web of Science, Medline, and PubMed, were searched by two independent researchers for literature regarding STSG-DS management published from 2018 through 2022, using specific terms in the text, title, and abstract. The primary endpoint assessed was STSG-DS healing, as measured by wound epithelialization. Thirty-one articles were selected, including three systemic review/meta-analyses, five case series, 14 randomized controlled clinical trials, six observational studies, and three nonrandomized trials. Novel interventions for STSG-DS management included in this article describe applications of human amniotic membranes, acellular dermal matrices, cell suspensions and growth factors, biomaterials, electromagnetic radiation, and natural products. Various interventions have shown promise for STSG-DS management since the creation of the 2018 international guidelines; however, studies with more standardized protocols and endpoints are needed to produce up-to-date, evidence-based recommendations and improve outcomes for patients undergoing split-thickness skin grafting.

Benefits of Aerosolized, Point-of-care, Autologous Skin Cell Suspension (ASCS) for the Closure of Full-thickness Wounds From Thermal and Nonthermal Causes: Learning Curves From the First 50 Consecutive Cases at an Urban, Level 1 Trauma Center.

To determine the utility of Autologous Skin Cell Suspension (ASCS) in closing full-thickness (FT) defects from injury and infection. Although ASCS has documented success in closing partial-thickness burns, far less is known about the efficacy of ASCS in FT defects. Fifty consecutive patients with FT defects (burn 17, necrotizing infection 13, crush 7, degloving 5, and other 8) underwent closure with the bilayer technique of 3:1 widely meshed, thin, split-thickness skin graft and 80:1 expanded ASCS. End points were limb salvage rate, donor site reduction, operative and hospital throughput, incidence of complications, and re-epithelialization by 4, 8, and 12 weeks. Definitive wound closure was achieved in 76%, 94%, and 98% of patients, at 4, 8, and 12 weeks, respectively. Limb salvage occurred in 42/43 patients (10 upper and 33 lower extremities). The mean area grafted was 435cm 2 ; donor site size was 212cm 2 , representing a potential reduction of 50%. The mean surgical time was 71 minutes; the total operating room time was 124 minutes. The mean length of stay was 26.4 days; the time from grafting to discharge was 11.2 days. Four out of 50 patients (8%) required 6 reoperations for bleeding (1), breakdown (4), and amputation (1). Four out of 50 patients (8%) developed hypertrophic scarring, which responded to silicone sheeting (2) and laser resurfacing (2). The mean follow-up was 92.7 days. When used for the closure of FT wounds, point-of-care ASCS is effective and safe. Benefits include rapid re-epithelialization, high rate of limb salvage, reduction of donor site size and morbidity, and low incidence of hypertrophic scarring.

Analysis of the Radial Forearm Phalloplasty Donor Site: Do Dermal Matrices Improve Donor Site Morbidity?

The radial forearm free flap is frequently chosen for phalloplasty; however, flap size required for phalloplasty is associated with a large scar burden and functional concerns. We sought to investigate donor site functionality, aesthetics, and volume deficits in a cohort of individuals who underwent radial forearm phalloplasty (RFP) with donor site skin grafting alone or dermal substitute and subsequent skin grafting. Donor site functionality was assessed using the quick Disabilities of Arm, Shoulder, and Hand (qDASH). Patient- and clinician-reported aesthetics were assessed using the Patient and Observer Scar Assessment Scale (POSAS). An Artec Leo three-dimensional scanner was used to measure volumetric differences from the donor site forearm and contralateral forearm. Fifteen patients who underwent RFP agreed to participate. No statistically significant differences were identified between different donor site closure methods regarding qDASH, patient-reported POSAS, or total volumetric deficits. A blinded clinician reported that POSAS approached significance at 4.7 for biodegradable temporizing matrix (BTM), 4.2 for Integra, and 3.0 for split-thickness skin graft (P = 0.05). No statistically significant differences were identified regarding distal, middle, or proximal volume deficits; however, a trend was observed regarding total volumetric deficits with BTM experiencing the lowest deficit (10.3 cm3) and skin graft experiencing the highest deficit (21.5 cm3, P = 0.82). The addition of dermal matrix (BTM or Integra) to the treatment algorithm for RFP did not show statistically significant improvement in donor site volume deficits, patient-reported scar appearance (POSAS), or functionality (qDASH).

THE BENEFITS OF PLASTIC AND RECONSTRUCTIVE SURGERY IN THE MANAGEMENT OF AN EAR HAMARTOMA

Hamartomas of the ear in children present significant aesthetic and functional challenges, requiring a precise surgical approach to achieve optimal results. We report the case of a 6-year-old child treated for a hamartoma of the left ear with resection of the lesion followed by a split-thickness skin graft. This article describes in detail the patients clinical presentation, the surgical technique used, and the post-operative results and discusses the efficacy of this approach.

COMPARATIVE STUDY BETWEEN THE EFFECTIVENESS OF AMNION-CollaGee [COLLAGEN–GELATIN–ELASTIN] AS A BIOLOGICAL PRODUCT WOUND DRESSING AND CONVENTIONAL DRESSING ON THE DONOR SITE OF THE SPLIT THICKNESS SKIN GRAFT IN ANIMALS MODEL (RATS)

Abstract Background The clinical application of amniotic membrane wound healing products is limited partially due to handling challenges. Amnion-CollaGee sponge dressing (ACS) provides better alternatives to traditional therapy in facilitating wound healing. Objective To optimize the effectiveness of ACS as a healing agent in donor-site split-thickness skin graft (STSG) based on in vitro outcomes. Followed by comparing wound healing rates, pain sensitivity, and risks of infection between investigator ACS dressing with currently conventional Duoderm dressing (DD) via in vivo analysis. Materials and methods Seven male Sprague-Dawley rats underwent STSG harvesting, with 1x1cm grafts taken from both the right and left sides of the animals' backs. The wounds on the right side (Group 1) were dressed with ACS, while the wounds on the left side (Group 2) were dressed with DD. The donor site wounds were assessed on the seventh, fourteenth, and twenty-first days of the experiment. Primary outcomes measured were rate of healing, pain sensitivity, potential risks of infection. Secondary outcomes were lesion vascularity, pigmentation and histopathological features. Results The size of the wounds treated with ACS was statistically smaller compared to that treated with DD. On day 21st, both types of dressings showed complete healing, thus, contributing to better aesthetic value. Additionally, superior pain suppression was witnessed at ACS-treated graft sites compared to DD. Histopathological reports displayed better post-traumatic wound site inflammatory control, less tissue scarring, and abundant collagen growth in the ACS wing compared to the DD counterpart. Conclusion The biological ACS dressing appeared to facilitate rapid wound healing rates, reduce the risk of exposed wound infections, and enhance pain suppression in rodent models. ACS based dressing agents are future interventional breakthroughs in graft donor site wound management.

The Largest Phyllodes Breast Tumor in The World: A Case Report

Phyllodes tumor of the breast is an uncommon fibroepithelial neoplasm constituting 0.3% to 0.5% of female breasttumors. Complete wide local excision is frequently used for treatment and risk reduction in local recurrence. This article aims to report the largest phyllodes breast tumor ever reported worldwide. We report the case of a 24-year-old Thai woman was admitted to our hospital with a massive ulcerofungating right breast mass. Her physical examination revealed a 59 cm diameter mass over her right upper body, in which most parts were infected and ulcerated. A right mastectomy was then performed after the patient had already been treated with intravenous antibiotics for infection control and when her nutrition status had improved. This was followed by Vacuum-Assisted closure of the wound, and split-thickness skin graft, which could be performed after there was a good granulation growth at the wound base. Additionally, after histopathology examination, a 59x53x26 cm malignant Phyllodes tumor with free margins, weighing 14,500 grams, in which there was around 20% tumor necrosis, 12/10 high power fields (HPFs) of Mitosis, and the unaffected nipple was observed. The patient was discharged from the hospital after 45 days, and there was no evidence of local and distant recurrence after a one-year follow-up. Phyllodes tumors are considered unusual fibroepithelial breast tumors that have various biological behaviors, in which surgical resection is a major option for treatment.

Update burn surgery: overview of current multidisciplinary treatment concepts

Abstract The treatment of severe burn injuries is an essential part of plastic-reconstructive surgery. Severe burned patients are treated in burn centers, which have highly specialized technical and personnel equipment. In addition to clear recommendations for prehospital management, intensive care therapy is usually required for extensive burn wounds. Shock therapy in burns primarily involves balanced fluid resuscitation according to hemodynamic monitoring, vasopressor support, pain management, temperature regulation, oxygen therapy, and comprehensive supportive care to stabilize the patient’s condition. Surgical treatment is still based on wound debridement and the gold standard of autologous split-thickness skin grafting. Besides skin transplantation, surgical management of burns may also involve the application of various topical therapies to promote wound healing, reduce pain, and prevent infection. These therapies may include antimicrobial dressings, skin substitutes, growth factors, or specialized wound care products. Once the acute treatment has been completed, multidisciplinary rehabilitation treatment takes place, which begins in the acute hospital and continues in the outpatient and inpatient rehabilitation areas. Surgical treatment of the secondary complications of burns and scars is also an important component of burn care. Comprehensive knowledge of the various components and players involved in the care of severely burned patients is, therefore, required in order to achieve the best possible outcome for the patient.

Reconstruction after inappropriate lower limb open degloving injury management resulting in the necrotic wound: a case report

Background: Trauma with shear mechanisms, which are typically the result of after trauma regarding traffic incidents, is the primary cause of degloving injuries. The condition is typified by the avulsion of skin and subcutaneous tissue, resulting in a deficiency in coverage and, in extreme situations, the loss of the limb involved. Case Presentation: A 58-year-old male was struck by a car and sustained a direct blow to his right lower leg from a rubber tire. The patient was hospitalized and did primary wound closure. A week later, the patient sought a second opinion in a different hospital due to necrotic tissue formation in his lower limb due to previous primary closure disregarding tissue vitality through split-thickness skin excision (STSE). Conclusion: This case reported management of necrotic tissue and reconstruction defect closure by skin graft through surgical cleaning and debridement. After establishing a viable grafting bed, split-thickness skin grafts were applied as covering.

Orthoplastics Management of Open Lower Limb Fractures at a Major Trauma Centre: Audit of Adherence to BOAST4 Guidelines

IntroductionThe British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guide the optimal management of open lower limb fractures. Adherence of the newly established Orthoplastic service at the Major Trauma Centre covering the Southeast of England was audited in relation to these standards. Materials and methodsAudit standards were produced. Data were collected using hospital records and the Trauma Audit and Research Network database. All open lower limb fractures managed between August 2020-August 2022 were included. Data collected included patient and injury demographics, and information related to initial and definitive management. ResultsOverall, 133 patients were identified, 70 men and 63 women, with an average age of 58 years. Women had a higher average age (69 years) and ASA grade (71% ASA 3 or higher). Low-energy injuries occurred in 69% of women compared to 78% of high-energy injuries in men (p<0.001). Among them, 108 (81%) were debrided within 24 h. The average time to first debridement was 18.78 h, and 95 (75%) were definitively closed within 72 h, 76 with primary closure, 7 with split-thickness skin graft, 7 with local flap and 36 with free flap. Overall, the post-operative infection rate was 13% with 94% of these fractures definitively closed within 72 h. ConclusionMost open lower limb fractures occurred in older women with higher ASA grade, from low-energy mechanisms. Most injuries were definitively managed as per the BOAST guidelines, but further efforts are required to improve the adherence to initial debridement targets, including training, appropriate resource allocation and implementation of procedures and proformas to guide injury management and improve documentation.

Shear Wave Elastography of the Skin following Radial Forearm Free Flap Surgery in Transgender Patients: Observational Study.

Background: Ultrasound shear wave elastography (SWE) noninvasively measures the stiffness of tissue by producing and measuring tissue deformation. Scar formation, a crucial aspect of wound healing, can lead to functional and aesthetic complications when pathological. While SWE has shown promise in dermatological evaluations, its role in surgical scar assessment remains underestimated. Our study aims to investigate SWE in evaluating surgical scars at the donor site after forearm free flap surgery in transgender patients. Methods: After radial forearm free flap harvesting, the donor site was grafted with a split-thickness skin graft with or without interposition of Matriderm. Eleven patients were evaluated more than one year after surgery, using SWE alongside scar characteristics, sensory outcomes, and patient satisfaction surveys. Results: Our study revealed no significant difference in stiffness (p > 0.15), pigmentation (p = 0.32), or erythema (p = 0.06) between operated and non-operated sides. The interposition of Matriderm did not influence the stiffness. Patients significantly (p < 0.0001) reported a loss of discrimination. Patients' subjective scar evaluation appeared in line with our quantitative and objective results. Conclusions: This study contributes to the evolving understanding of SWE's role in scar assessment, highlighting its feasibility in evaluating surgical scars. However, continued research efforts are necessary to establish SWE as a reliable and objective method for surgical scar evaluation and management.

Initial experience with ovine forestomach matrix graft for glossectomy defect reconstruction: A case series

Soft tissue reconstruction of oral cavity defects, such as glossectomy defects secondary to malignancy, pose a challenge for head and neck, oral, and maxillofacial surgeons. Reconstruction options for mucosal defects include primary closure, healing by secondary intention, full mucosal and split-thickness skin grafts, pedicled flaps, and microvascular free flaps. Biological grafts have become an integral part of the modern reconstructive ladder and are widely used for the regeneration of various soft tissue defects, including oral defects. This case series describes our initial experience using ovine forestomach matrix grafts in tongue and oral cavity reconstruction. Oral reconstruction using ovine forestomach matrix grafts was undertaken on three patients post wide excision and resulted in good functional and cosmetic outcomes. The rate of tissue formation provided by the graft and the grafts’ relative resistance to the hostile environment of the oral cavity support further clinical research to validate the use of these devices in oral reconstruction.

Characterising the use of full and split thickness skin grafts amongst dermatologists: An international survey.

Abstract Background The use of full-thickness and split-thickness skin grafts (FTSG/STSG) among dermatologists has not been well characterized. Objectives To characterize the utilization of graft techniques, fixation methods and training needs pertaining to graft use among an international cohort of dermatologists. Methods An online questionnaire was developed iteratively, and subsequently distributed between July and August 2022 to dermatologists from the UK, European countries and New Zealand (NZ). Results In total, 150 responses were obtained from the UK, Ireland, NZ, Australia, Brazil, USA and eight European countries. Among the respondents, 23.3% (35 of 150) undertook both FTSG and STSG; 46.7% (70 of 150) performed only FTSG; and 30.0% (45 of 150) did not undertake skin grafts in their practice. Of the 67 Mohs surgeons, only 42% (28 of 67) undertook both FTSG and STSG. Overall, common donor sites for FTSG included the preauricular area (86 of 105; 81.9%) and clavicle (75 of 105; 71.4%), while the thigh was the most common donor site for STSG (30 of 35; 86%). Grafts were fixed mostly with sponge tie-over dressings and basting/quilting sutures. For STSG, most were harvested using an electric dermatome (18 of 35; 51%), freehand skin-graft knife (17 of 35; 49%) and flexible razor blade (5 of 35; 14%). Of the total, 48.0% (72 of 150) considered skin grafting an essential skill in dermatology training, and most respondents cited a lack of training opportunity and insufficient surgical cases as significant barriers. Conclusions Our survey reveals diverse practices among an international cohort of dermatologists in the use of FTSG/STSG and highlights the need for further training.

A child developing alopecia areata at the scalp donor site after split-thickness skin grafting

A child developing alopecia areata at the scalp donor site after split-thickness skin grafting

The effectiveness of punch grafts in promoting the healing of surgical injuries and hard-to-heal wounds.

Punch grafting is a technique that can improve and accelerate the healing of hard-to-heal wounds and reduce the associated pain. It is a simple and inexpensive procedure that can be performed in the examination room. It is a technique that uses small split-thickness skin grafts (STSG) to promote the growth of epithelial tissue. It has been described as being used mainly to treat ulcers of venous, arterial, hypertensive and diabetic aetiology. Punch grafting has also been used successfully in postoperative dermatological surgical wounds. This article describes and details the performance of the punch-graft technique, with special emphasis on aftercare and the role of nurses in the procedure. A clinical case is presented of a patient who underwent surgery for cutaneous squamous cell carcinoma and whose primary closure was rejected. It was decided to place the STSGs obtained from the anterior aspect of the patient's thigh after preparation of the recipient area to ensure an optimal wound bed. The patient's pain subsided within a few days, and the wound healed within weeks with weekly dressing changes.

Clinical Analysis and Treatment Strategies About Cartilage Scaffold Exposure After Auricular Reconstruction With the Expanded Two-Flap Method.

Objectives: Soft tissue expansion is one of the main methods for autologous cartilage auricular reconstruction. The aim of this study was to analyze the risk factors for cartilage exposure after this method and to describe a surgical method for this complication. Methods: From January 2018 to December 2020, 853 patients (908 sides) underwent auricular reconstruction with an expanded two-flap method at our center. Thirty-two patients experienced cartilage exposure postoperatively. These patients were set as the case group, and 1:1 matched sampling was performed among patients who did not have cartilage exposure. The matched sample of 32 cases was set as the control group. All 64 patients were evaluated according to the Orbit, Mandible, Ear, Nerve, and Soft tissue (OMENS) classification system to analyze the correlation between cartilage exposure and hemifacial microsomia (HFM) and OMENS subtypes. The complication was repaired with superficial temporal fascial flap combined with skin graft. Results: HFM might be a risk factor for scaffold cartilage exposure, and there was a significant correlation between cartilage exposure and orbital malformation, facial nerve dysplasia, and soft tissue developmental malformation. The use of a superficial temporal fascial flap combined with a split-thickness skin graft to repair the complication achieved satisfactory outcomes. Conclusions: There is a correlation between cartilage scaffold exposure and the severity of HFM. Temporoparietal fascial flap transfer combined with skin grafting proved to be an effective method for cartilage exposure.

Local Control of Pyoderma Gangrenosum Using Human Amniotic Membrane and Transcriptome Analysis.

Pyoderma gangrenosum (PG) is a rare, chronic, ulcerative disease characterized by non-healing wounds that worsen with debridement, a phenomenon called pathergy. No consensus regarding pathogenesis, diagnosis, or treatment exists for PG. A previous pilot study using dehydrated human amniotic/chorionic membrane (dHACM), following excisional debridement, augmented PG wound healing and allowed for subsequent wound closure through split-thickness skin grafting (STSG). In this clinical trial (NCT05120726), four patients with an established PG diagnosis were enrolled to undergo treatment with dHACM and characterize the pre- and post-treatment transcriptome profiles. RNA sequencing was used to isolate the total RNA from specimens. Genes of particular interest were quantified through real-time quantitative reverse transcription polymerase chain reaction. We observed varied changes to the local expression of inflammatory response, positive regulators of cellular proliferation, and extracellular matrix disassembly cytokines. All PG wounds produced granulation tissue following treatment and were closed using split-thickness skin grafts.

Development of huge keloid at donor site and recurrent keloid at graft site after excision of pubic keloid followed by split-thickness skin graft: A case report.

Keloids are the result of abnormal tissue scarring that occur after skin injuries leading to pain, psychological distress, and impaired quality of life. Despite the high recurrence rate after surgical treatment, excision is often inevitable for symptom control. A 32-year-old female presented with a huge keloid on the pubic area accompanied by severe pain, pruritus, and infectious discharge. She also had multiple keloids on her chest and shoulders, indicating a strong predisposition to keloid formation. While high potential for recurrence was anticipated, surgical excision was inevitable for symptom control. Complete keloid excision followed by split-thickness skin graft was performed. Pathological report revealed keloid accompanied by ruptured epidermal inclusion cyst. Although postoperative care was highly recommended for prevention of keloid recurrence, the patient refused any additional management due to her financial difficulties. At postoperative 8 months, mild degree of keloid or hypertrophic scar at marginal area of the graft was observed, suggesting the potential sign of keloid recurrence. The patient voluntarily discontinued the outpatient follow-up for 2 years, and then returned with huge keloid not only at the graft site but also at the donor site. Keloid with inflamed epidermal inclusion cyst can cause severe pain where surgical excision is unavoidable, regardless of the high potential for recurrence. Additional postoperative care is necessary to prevent recurrence. Furthermore, attempts to minimize new keloid formation at the donor site after split-thickness skin graft, such as thin skin harvest or selecting the scalp as the donor site, should be considered.