Thin Split-thickness Skin Graft Research Articles

Deep burn surgery of the whole dorsum of the hand: Composite skin grafting over acellular dermal matrix versus thick split-thickness skin grafting.

Preservation and restoration of hand function after burn injuries are challenging yet imperative. This study aimed to assess the curative effect of a composite skin graft over an acellular dermal matrix (ADM) and a thick split-thickness skin graft (STSG) for treating deep burns on the hand. Patients who met the inclusion criteria at the First Affiliated Hospital of Wenzhou Medical University between September 2011 and January 2020 were retrospectively identified from the operative register. We investigated patient characteristics, time from operation to the start of active motion exercise, take rates of skin graft 7 days post-surgery, donor site recovery, complications and days to complete healing. Patients were followed up for 12 months to evaluate scar quality using the Vancouver Scar Scale (VSS) and hand function through total active motion (TAM) and the Jebsen-Taylor Hand Function Test (JTHFT). A total of 38 patients (52 hands) who received thin STSG on top of the ADM or thick STSG were included. The location of the donor sites was significantly different between Group A (thick STSG) and Group B (thin STSG + ADM) (p = 0.03). There were no statistical differences in age, gender, underlying disease, cause of burn, burn area, dominant hand, patients with two hands operated on and time from burn to surgery between the two groups (p > 0.05). The time from operation to the start of active motion exercise, take rates of skin graft 7 days post-surgery and days to complete healing were not significantly different between Group A and Group B (p > 0.05). The rate of donor sites requiring skin grafting was lower in Group B than in Group A (22.2% vs. 100%, p < 0.001). There were no statistically significant differences in complications between the groups (p = 0.12). Moreover, 12 months postoperatively, the pliability subscore in the VSS was significantly lower in Group A than in Group B (p = 0.01). However, there were no statistically significant differences in vascularity (p = 0.42), pigmentation (p = 0.31) and height subscores (p = 0.13). The TAM and JTHFT results revealed no statistically significant differences between the two groups (p = 0.22 and 0.06, respectively). The ADM combined with thin STSG is a valuable approach for treating deep and extensive hand burns with low donor site morbidity. It has a good appearance and function in patients with hand burns, especially in patients with limited donor sites.

Prospective study on the influence of dobutamine on blood perfusion in free flap repair of diabetic foot wounds

Objective: To investigate the influence of clinical administration of dobutamine on blood perfusion in free flap repair of diabetic foot wounds. Methods: A prospective self-controlled study was conducted. From January to November 2022, 20 patients with diabetic foot who met the inclusion criteria were hospitalized in the Department of Burns and Plastic Surgery of Affiliated Hospital of Zunyi Medical University, including 9 males and 11 females, aged from 44 to 75 years, with the foot wounds area ranging from 5 cm×4 cm to 20 cm×10 cm, which were repaired by free anterolateral thigh flaps. Heart rate (HR) and mean arterial pressure (MAP) were recorded before anesthesia induction, 10 minutes after vascular recanalization, when the target blood pressure (i.e., MAP being 6-10 mmHg (1 mmHg=0.133 kPa) higher than that before anesthesia induction) was reached after infusion of dobutamine, and 10 minutes after tracheal catheter removal. Additionally, indocyanine green, a contrast agent, was injected intravenously at 10 minutes after vascular recanalization and when the target blood pressure was reached after infusion of dobutamine to assess flap blood perfusion using infrared imager, and the area ratio of flaps with hyperperfusion and hypoperfusion was calculated. Other recorded variables included flap harvesting area, surgical duration, total fluid infusion amount, infusion dose and total usage of dobutamine, intraoperative adverse events, postoperative flap complications, and follow-up outcomes. Data were statistically analyzed with paired sample t test, analysis of variance for repeated measurement, Bonferroni method, and generalized estimating equation. Results: Compared with those before anesthesia induction, HR and MAP of patients were significantly decreased at 10 minutes after vascular recanalization (P<0.05), while HR and MAP of patients were significantly increased when the target blood pressure was reached after infusion of dobutamine (P<0.05). Compared with those at 10 minutes after vascular recanalization, HR and MAP of patients were significantly increased when the target blood pressure was reached after infusion of dobutamine and at 10 minutes after tracheal catheter removal (P<0.05). Compared with those when the target blood pressure was reached after infusion of dobutamine, HR and MAP of patients were significantly decreased at 10 minutes after tracheal catheter removal (P<0.05). The area ratio of flaps with hyperperfusion of patients was 0.63±0.11 when the target blood pressure was reached after infusion of dobutamine, which was significantly higher than 0.31±0.09 at 10 minutes after vascular recanalization (t=-9.92, P<0.05). The area ratio of flaps with hypoperfusion of patients was 0.12±0.05 when the target blood pressure was reached after infusion of dobutamine, which was significantly lower than 0.45±0.10 at 10 minutes after vascular recanalization (t=17.05, P<0.05). The flap harvesting area of patients was (174±35) cm², the surgical duration was (372±52) min, the total fluid infusion amount was (2 485±361) mL, the infusion dose of dobutamine was 3-13 μg·kg⁻¹·min⁻¹, and the total usage of dobutamine was 5.7 (2.1, 9.7) mg. Two patients showed a significant increase in MAP during the infusion of dobutamine compared with that at 10 minutes after vascular recanalization, but before reaching 6 mmHg higher than that before anesthesia induction, their HR had reached the maximum (over 130 beats/min). The HR gradually returned to around 90 beats/min after the infusion of dobutamine was stopped. On post operation day 2, one patient had partial necrosis at the distal part of the flap, which was repaired by transplantation of thin split-thickness skin graft from the opposite thigh. During the follow-up of 3 to 6 months after operation, all the flaps survived well, with soft texture and well-formed shape, and no adverse cardiovascular events of patients were reported. Conclusions: The administration of dobutamine in free flap repair of diabetic foot wounds can significantly improve the MAP of patients, expand the area of hyperperfusion, reduce the area of hypoperfusion, and enhance the flap viability, with promising short-term follow-up results, which is suitable for promotion in clinical applications.

A new way of repairing special wounds

PurposeWound repair has always been the basic method of burn surgery, but not all wounds in clinical work can regain both function and appearance. For relatively small wounds with irreversible functional damage accompanied by necrotic bone, joint and tendon exposure, and the wounds in non-functional sites with necrotic bone, tendon exposure and poor surrounding tissue conditions, the value and significance of tissue flap transplantation for wound repair are debatable. This paper discusses a new repair method as a supplementary choice for tissue flap transplantation: autologous granulation tissue and autologous thin split-thickness skin graft, which not only repairs the wound in a simple way but also avoids the cost of tissue flap transplantation. MethodsA total of 11 patients were collected from June 2019 to July 2022, with a total of 20 exposed wounds of bone, joint and tendon necrosis. During the operation, the necrotic exposed bone tissue and the completely necrotic tendon tissue were removed, and the necrotic soft tissue around the wound was completely excised until the wound appeared bleeding. We cut granulation tissue from other parts of the patient's body with a thickness of about 0.5–0.8 mm, cover the deep wound after thorough debridement with granulation tissue, and transplant autologous thin split-thickness skin to the deep wound covered with granulation tissue. The surgical area was compressed and immobilized. ResultsIn 11 patients, 20 wounds were surgically treated, and the wounds healed 15–25 days after the operation, and no bone tissue, joints, or tendons were exposed. No case underwent secondary surgery after surgery. Some wounds were treated with bedside allograft with the consent of the patient due to a small amount of residual granulation wound healing after transplantation. ConclusionUsing autologous granulation tissue and autologous thin split-thickness skin transplantation to repair some special wounds can not only repair the wounds simply and effectively but also avoid the cost of tissue flap transplantation.

Comparison of Glyaderm with different dermal substitute matrices in a porcine wound model

BackgroundThe closure of extensive burn wounds with widely expanded autologous split-thickness skin grafts (STSG) is associated with undesirable scar formation and contraction, due to the lack of dermis. Various materials for dermal replacement have been developed, either of xenogeneic, allogeneic or synthetic origin and are placed in the wound underneath a thin STSG in order to improve scar quality. In this study, a porcine wound model was used to compare several commercially available acellular dermal substitutes with an acellular dermal substitute prepared from glycerol preserved human skin: GlyadermⓇ. MethodsAntigenic components of the allografts were removed by incubation in the 0.06 M NaOH solution. In the first experiments, the dermal substitutes were applied to full thickness wounds and covered simultaneously with STSG. Controls were covered with STSG only. The wound healing response was analyzed for 8 weeks, both macroscopically and histologically. The Mann-Whitney U test was used for statistical analysis. In the second series of experiments, GlyadermⓇ was applied in a two-stage procedure in comparison to Integra. The STSG was placed on the dermal substitutes one week later. ResultsIn the first series, the inflammatory response and myofibroblast influx in GlyadermⓇ were limited, indicating possible beneficial outcomes on final wound healing results. The survival of the STSG on the acellular dermis was lower compared to the control wounds. Second series: the take of the STSG was the same as in the controls, but additionally wound contraction was reduced. The application of GlyadermⓇ was non-inferior to Integra. ConclusionGlyadermⓇ can be successfully used for the reduction of wound contraction when applied in a two-stage procedure.

Clinical effects of flaps with cervical cutaneous branch of transverse cervical artery in repairing neck radiation ulcers

Objective: To explore the clinical effects of flaps with cervical cutaneous branch of transverse cervical artery in repairing neck radiation ulcer. Methods: The retrospective observational research was conducted. From January 2016 to December 2019, 8 cases with neck radiation ulcer were admitted to Guangzhou Red Cross Hospital of Jinan University and repaired with flaps based on cervical cutaneous branch of transverse cervical artery. There were 6 males and 2 females, aged 52-75 years. The ulcers occurred 14.5 years after radiotherapy on average, with ulcer areas of 5.0 cm×3.0 cm-7.0 cm×6.0 cm on admission. The wound areas were ranged from 6.0 cm×5.0 cm to 13.0 cm×6.5 cm after ulcers and fibrotic tissue around were resected. Seven cases underwent resection of flaps and wound repair operation on the first stage, and the other 1 case underwent pre-expansion of flap donor area on the first stage and resection of flap and wound repair operation on the second stage, with flap sizes of 8.0 cm×7.0 cm-15.0 cm×8.5 cm. The wounds in the donor areas of flaps in 7 patients were sutured directly, and the wound in the donor area of flap in the other 1 patient was repaired with thin split-thickness skin graft from thigh after being sutured partially. The preoperative ulcer tissue was collected for pathological examination, and the postoperative survival of the flaps and healing of the flap donor areas were observed. The flaps, the recurrence of the neck ulcers and neck function, and the scar hyperplasia in the donor areas of flaps were observed during follow-up. Results: Preoperative pathological examination of ulcer tissue showed that full-thickness necrosis occurred in ulcer skin, obvious fibrotic tissue hyperplasia, collagenization, and small-scale calcification in the base and surrounding tissue of the ulcers, and a large amount of chronic inflammatory cells and a small amount of acute inflammatory cells infiltration were observed in intercellular substance, which excluded the recurrence of tumor. All the flaps in 8 cases survived, the wounds were repaired effectively, and the postoperative donor areas of flaps healed well. During postoperative follow-up of 6-24 months, the flaps had good appearances without recurrence of ulcer, the movement function of neck was significantly improved, and no obvious scar hyperplasia was observed in the donor areas of flaps. Conclusions: Radiation ulcer in the neck is a serious long-term complication of neck after radiotherapy, which is difficult to heal with conservative treatment. The flap with cervical cutaneous branch of transverse cervical artery is close to the neck, with rich blood supply, constant anatomy, and is easy to cut. Neck radiation ulcers treated with the flaps showed good wound healing and improved functions, with no obvious scar hyperplasia.

Comprehensive treatment of 25 cases of acute necrotizing fasciitis

From May 2013 to March 2020, 25 patients with acute necrotizing fasciitis were admitted to Beijing Chaoyang Emergency Rescue Center, including 18 males and 7 females, aged 7 to 78 years. The lesions were mainly located in the lower extremities, with the original lesion areas ranging from 20 cm×15 cm to 83 cm×42 cm. After admission, comprehensive systemic treatment was performed, the lesion area was cut open and drained as soon as possible, and the necrotic tissue was removed. Vacuum sealing drainage was performed when the necrotic tissue in the wound was reduced. The wounds were directly sutured or repaired with thin split-thickness skin grafts taken from head and/or thigh or local skin flaps after the wounds were improved. The skin grafts and flaps survived well after surgery, and the wound was completely closed. None of the 25 patients had amputation. A total of 21 patients were followed up for more than half a year, showing no recurrence of acute necrotizing fasciitis and no difference in the function of their injured limb after the wound healing than before the onset.

Outcome of successful graft take of Integra and split thickness skin graft after the release of post-burn neck contracture.

Objective: To determine the frequency of the successful graft take of Integra™ and split thickness skin graft after the release of post-burn neck contracture. Study Design: Descriptive Case Series. Setting: Department of Plastic Surgery, Jinnah Burn and Reconstructive Surgery Centre, Lahore. Period: 1st October, 2017 to 30th September, 2018. Material &amp; Methods: A total of 70 cases, those who full filled the inclusion criteria were included in the study through non-probability consecutive sampling. Informed consent was obtained from all the patient. Integra was applied in all the patients after the release of contracture and excision of scar tissue and was inspected every 3-5 days. After 3 weeks, the outer layer of silicone sheet was removed and replaced by thin split-thickness skin graft. The graft was secured with skin staples, absorbent gauze and the crepe bandage. All the patients were followed up regularly and the final outcome was assessed at 6 weeks. Results: The mean age of the patients was observed as 34.51 ± 14.19 years with age range of 11to 59 years. Among these 70 patients 61.4% were male and 38.6% were females. The mean body mass index was observed to be 22.59 + 3.68 kg/m2. Out of these 70 patients, the outcome in terms of successful graft take with Integra treatment was achieved in 60 (85.7%) patients. On stratification, statistically insignificant difference was observed for the effect modifiers like age, gender and BMI. Conclusion: In our study we found that Integra and STSG can be considered as one of emerging and promising modality in burn management and reconstructive surgery with the significantly high success rate in terms of complete re vascularization and skin graft take.

Clinical effects of individualized free anterolateral thigh flap in repairing complex refractory wound

Objective: To explore the clinical effects of individualized free anterolateral thigh flap in repairing complex refractory wound. Methods: From July 2015 to May 2019, 19 patients with complex refractory wounds were hospitalized in Yulin NO.1 People's Hospital of Guangxi Zhuang Autonomous Region, including 12 males and 7 female, aged 13-67 years. There were 5 patients with multiple tissue defects, 7 patients with large area of wounds, and 7 patients with wounds in special areas. The sizes of wounds after complete debridement were 8 cm×5 cm-23 cm×7 cm. According to the repair demand, the wounds in 5 patients were repaired with anterolateral thigh flaps and flow-through, the wounds in 7 patients were repaired with anterolateral thigh flaps chimed with lateral thigh muscle flaps, with vascular anastomosis in 2 patients, the wounds in 6 patients were repaired with unilateral anterolateral thigh lobulated flaps, and the wound in 1 patient was repaired with bilateral anterolateral thigh flap in series connection. The sizes of flaps were 10 cm×7 cm-25 cm×9 cm. The donor sites were sutured directly or repaired with thin split-thickness skin graft of head. The survival of the flaps, the appearance of the donor sites, and wounds repair after the operation and during follow-up were observed. Results: The lobulated flap in 1 patient had local necrosis after the operation and finally healed by debridement, dressing change, and transplanting medium split-thickness skin graft in groin. The flaps in 18 patients survived with good blood supply, and the lobulated flap tissue was swollen in 1 of 18 patients. The donor sites which were directly sutured in 18 patients only had linear scar, and the donor site which was repaired with thin split-thickness skin graft of head in 1 patient had flaky scar. Follow-up of 1-12 months showed that all the wounds healed well, the flap thinning operations were performed in 5 patients in 3 months post operation because the flaps were slightly bloated. The CT angiography after the operation showed that the anastomosed blood vessels were unobstructed in 7 patients with reconstructed local blood supply. Conclusions: The special forms of anterolateral thigh flap, such as lobulation, series connection, and chimerism can be designed according to the anatomical characteristics of the descending branch of the lateral femoral artery to meet individualized repair demand for complex refractory wounds, and achieve the double purposes of making full use of the donor site tissue and good repair of the recipient site.

Clinical strategies for preservation of the exposed implant in chronic wounds and wound repair

Objective: To explore the clinical strategies for preservation of the exposed implant in chronic wounds and wound repair. Methods: From January 2016 to January 2019, totally 8 patients (4 males and 4 females, aged 10 to 73 years) sustaining postoperative chronic wounds with exposed implants were admitted to the Fourth Medical Center of PLA General Hospital. There were 2 cases of abdominal patch exposure after abdominal trauma surgery, 2 cases of titanium plate exposure post craniocerebral surgery, 3 cases of internal fixator exposure post orthopedic surgery, and 1 case of cerebrospinal fluid drainage tube exposure after craniocerebral surgery. The wound exudate was collected for bacterial culture on admission. On the basis of glycemic control and correction of anemia and hypoproteinemia, thorough wound debridement was performed as soon as possible and the wound area after debridement ranged from 2.0 cm×0.5 cm to 6.0 cm×5.0 cm. The wounds of 4 patients were immediately closed after debridement, including 1 case by primary closure, 1 case by primary closure after local filling of platelet rich plasma gel, and 2 cases by local flap transplantation, with flap size of 10.0 cm×8.0 cm and 12.0 cm×8.0 cm, respectively. The donor sites of flaps were sutured directly and all the incisions were treated with continuous vacuum sealing drainage (VSD) after surgery. The other 4 patients were treated with continuous VSD after debridement to improve the wound bed. The wound of 1 case healed gradually, 1 case received direct wound suturing, and the wounds of 2 cases were repaired with thin split-thickness skin grafts from the thigh or the head. The results of bacterial culture of wound exudate on admission, wound healing post surgery, and follow-up were observed and recorded. Results: The bacterial culture of wound exudate on admission was positive in 6 patients, and 10 strains of bacteria were isolated with Staphylococcus epidermidis as the main pathogen. All the skin grafts or flaps of patients survived post surgery, with the incisions and wounds healed and all the implants preserved. After 1 to 3 years of follow-up, no recurrence of wound was found in any patient. Conclusions: The postoperative chronic wounds with exposed implants can be closed in primary stage by direct suturing or flap transplantation if it is clean enough on the basis of thorough debridement. The wounds with large defects or serious infection can be treated with continuous VSD firstly and then closed with direct suturing or skin grafting for delayed wound closure, thereby to reach the treatment goal of preserving the implants and repairing the wounds simultaneously.

Laser versus dermabrasion and split thickness skin graft for management of post burn leucoderma

Background: The aim of the study is to compare between dermabrasion and split thickness skin grafting and fractional CO2 laser in management of post burn leucoderma. Deep burn can have serious aesthetic consequences as it often result in scar tissue and pigmentary changes in the skin. It is understood that skin pigmentation involves melanin. Leucoderma results from melanin loss at the basal layer of the epidermis. Fibrosis ultimately inhibits melanocyte migration and subsequent production of melanin in the injured area. Management of post burn leucoderma was either non-surgical or surgical treatment. Non-surgical therapies are make-up, tattooing and fractional CO2 laser. The surgical treatments include dermabrasion with thin split thickness skin grafting, non-cultured keratinocyte-melanocyte suspensions, mini grafting, cultured epithelium, blister epidermal grafting, chip skin grafting and epidermal cell suspension spray.Methods: A prospective study of 30 patients with post burn leucoderma between May 2018 and May 2019, at Ahmed Maher Teaching Hospital. Dermabrasion and split thickness skin grafting in 15 patients (group 1). Fractional CO2 laser in another 15 patients (group 2).Results: Group one: 13% of patients showed excellent colour match, 33% good colour match and 53% poor colour match. Group two: 27% of patients showed excellent colour match, 47% good colour match and 26% poor colour match (p value=0.311).Conclusions: Fractional CO2 laser is better than dermabrasion and STSG for management of post burn leucoderma.

Split Thickness Grafts Grow From Bottom Up in Large Skin Injuries.

Autologous split thickness skin graft is necessary for the survival of patients with large burns and skin defects. It is not clear how a thin split thickness skin graft becomes remarkably thicker within a few weeks following transplantation. Here, we hypothesized that growth of split thickness graft should be from bottom up probably through conversion of immune cells into collagen producing skin cells. We tested this hypothesis in a preclinical porcine model by grafting split thickness meshed skin (0.508 mm thickness, meshed at 3:1 ratio) on full thickness wounds in pigs. New tissue formation was evaluated on days 10 and 20 postoperation through histological analysis and co-staining for immune cell markers (CD45) and type I collagen. The findings revealed that a split thickness graft grew from bottom up and reached to almost the same level as uninjured skin within 60 days postoperation. The result of immune-staining identified a large number of cells, which co-expressed immune cell marker (CD45) and collagen on day 10 postoperation. Interestingly, as the number of these cells reduced on day 20, most of these cells became positive for collagen production. In another set of experiments, we tested whether immune cells can convert to collagen producing cells in vitro. The results showed that mouse adherent immune cells started to express type 1 procollagen and α-smooth muscle actin when cultured in the presence of fibroblast conditioned media. In conclusion, the early thickening of split thickness graft is likely happening through a major contribution of infiltrated immune cells that convert into mainly collagen producing fibroblasts in large skin injuries.

Wound repair and functional reconstruction of high-voltage electrical burns in wrists

Objective: To explore the methods and effects of wound repair and functional reconstruction of high-voltage electrical burns in wrists. Methods: From January 2009 to June 2016, 71 patients with high-voltage electrical burns in wrists were hospitalized, with 118 wrist wounds including 21 of type Ⅰ, 69 of type Ⅱ, 9 of type Ⅲ, and 19 of type Ⅳ. According to the wrist injuries, different surgical operations were performed. Forearm amputation was conducted in 20 wrists with necrosis in the distal end. On the basis of fasciotomy for decompression, early debridement was performed on the other 98 wrist wounds. After debridement, wounds with area ranging from 10 cm×7 cm to 30 cm×18 cm were repaired with tissue flaps with abundant blood supply. Thirty-two wounds were repaired with pedicled groin flaps, 11 wounds with pedicled paraumbilical flaps, 3 wounds with pedicled anterolateral thigh island flaps, 9 wounds with combined abdominal axial pattern flaps, 37 wounds with free skin flaps or myocutaneous flaps, and 6 wounds with flow-through descending branch of lateral femoral circumflex artery flaps, with tissue flap area ranging from 12 cm×8 cm to 34 cm×20 cm. Ulnar artery or radial artery vascular reconstruction was performed in 20 wrist wounds. Forty-one donor sites were sutured directly, while 14 were closed by thin split-thickness skin grafts from same-side thighs, and 43 were closed by thin split-thickness skin grafts from opposite-side thighs. Fifty-three wrist wounds were performed with tendon and nerve repair surgery, of which 20 were performed with simple tendon and nerve release surgery. Flexor digitorum profundus tendons and (or) flexor pollicis longus tendons were reconstructed with autologous or allogeneic tendon transplantation in 33 wrist wounds, and the median nerve was repaired with sural nerve graft in 21 wrist wounds. In 6 to 24 months after the last operation, tendon function of 53 wrist wounds which had tendon repair was evaluated with finger total active motion (TAM) method, while median nerve function of 21 wrist wounds which had median nerve repair was evaluated with integrate estimation method. Results: (1) After forearm amputation, the incisions of 20 wrists with necrosis in the distal end were healed. (2) Among the 98 tissue flaps, 90 had good blood flow, while 8 had distal necrosis, of which 6 were healed after necrotic tissue removal and skin grafting, and two were sutured directly after debridement. Infection occurred under 7 flaps, of which 3 were healed by dressing change, and 4 were healed after second debridement. Twenty wrist wounds which had radial artery or ulnar artery repair had good blood supply of hand and amputation was avoided. During follow-up of 1 to 3 years, the incisions and flaps of patients who had tissue flap repair surgery healed well. (3) The excellent and good rate of TAM in each finger of the corresponding affected limbs of 53 wrist wounds which had tendon and nerve repair surgery was 51%. (4) Twenty wrists which had simple tendon and nerve release surgery were followed up for 1 to 2 years. The strength of muscle dominated by the median nerve was restored to grade Ⅴ in 1 wrist, grade Ⅳ in 3 wrists, and grade Ⅲ in 2 wrists. The strength of muscle dominated by the ulnar nerve was restored to grade Ⅳ in 3 wrists, with no recovery in other wrists. Sensory function examination showed grade S0 in 4 wrists, grade S1 in 2 wrists, grade S2 in 3 wrists, grade S3 in 8 wrists, and grade S4 in 3 wrists. Twenty-one wrists which had median nerve repair were followed up for 1 to 2 years. There was no recovery in muscle strength dominated by the median nerve. Sensory function examination showed grade S0 in 3 wrists, grade S1 in 5 wrists, grade S2 in 8 wrists, and grade S3 in 5 wrists. Conclusions: It is a good method to sequentially conduct early fasciotomy for decompression, early debridement, vascular reconstruction, transplant of tissue flap with abundant blood supply, tendon and nerve repair in repairing electrical burn wounds of wrists, avoiding amputation, and reconstructing hand function according to the condition of electrical burns of wrists.

Early application of tissue expansion in repair of traumatic soft tissue defects in the head and face

Objective To explore a novel strategy to repair traumatic soft tissue defects in the head and face by tissue expansion in the early stage. Methods Eighteen patients with traumatic soft tissue defects were treated with thorough debridement leaving the wound unclosed or simply closed with thin split-thickness scalp skin grafting, and adjacent expander implantation in the early stage and expanded flap transposition in the second stage. Results There were 11 male patients and 7 female patients ranging in age from 3.5 to 40 years [mean, (19.4±12.2) years], with average 15 months follow-up (range, 3-67 months). The average expansion time was 74.3 days (range, 53-96 days). The total of 18 patients with 22 expanders were treated with satisfactory results. All the flaps survived and the skin color, texture and contour well matched to those of the peripheral tissue. Only one complication of infection happened in the 18 cases (5.56%) and total 22 expanders (4.55%), which was similar to the rate reported in the literature. There were no any other complications related to the expander. Conclusions Debridement and tissue expansion in the early stage have been proved a more effective strategy to repair traumatic soft tissue defects in the head and face, which can not only achieve satisfactory color, unbulky and well matched texture similar to normal, but also can avoid unnecessary donor site injuries and does not increase the infection rate of tissue expansion. Key words: Soft tissue defects; Tissue expansion; Head and face; Trauma

Prospective Randomized Comparison of Scar Appearances between Cograft of Acellular Dermal Matrix with Autologous Split-Thickness Skin and Autologous Split-Thickness Skin Graft Alone for Full-Thickness Skin Defects of the Extremities.

Sir: We read with interest the recent article by Yi and Kim (Plast Reconstr Surg. 2015;135:609e–616e). The authors compared the effect of simultaneous application of acellular dermal matrix with autologous split-thickness skin graft and that of split-thickness skin graft alone on traumatic full-thickness skin defects on the extremities, and concluded that the cograft of acellular dermal matrix with split-thickness skin graft produced better outcomes than split-thickness skin graft alone in terms of scar appearance, without increasing complications. The combination of acellular dermal matrix with epidermal coverage, usually an autologous split- thickness skin graft, has increasingly replaced the full-thickness skin graft to reconstruct full-thickness skin defects. However, the timing of split-thickness skin grafting remains controversial. For a split-thickness skin graft to attach promptly after transplantation, a well-vascularized wound bed is required. The thickness of a skin graft that can easily become vascularized is approximately 0.7 to 1.0 mm. Therefore, most acellular dermal matrices thicker than 1.0 mm are covered by a split-thickness skin graft 3 to 4 weeks later to allow sufficient vascularization and to avoid graft necrosis or loss.1 However, this two-step approach is lengthy, gives no guarantee of success, and is an additional stress factor for the patient. More recent approaches include use of thinner dermal layers, with the aim of transplanting acellular dermal matrix simultaneously with split-thickness skin graft.2 Several of the authors’ procedures might contribute to the success of their single-step technique: (1) the wound bed was completely débrided and prepared with well-vascularized granulation tissue before grafting, (2) negative-pressure therapy was applied throughout to stimulate angiogenesis and prevent complications, and (3) the application of meshed acellular dermal matrix and thin split-thickness skin graft improved the take rate and allowed better blood supply to the cograft. However, we still have great interest in the thickness of the acellular dermal matrix in this article. Does the meshed morphology of acellular dermal matrix compensate for the thickness of it? In addition, the split-thickness skin graft combined with acellular dermal matrix was meshed and expanded, whereas the split-thickness skin graft applied alone was neither meshed nor expanded and was 0.1 mm thicker than the cografted one. The difference interests and confuses us. Beyond this, the pigmentation merits specific attention. Melanocytes and fibroblasts are believed to contribute to the repigmentation process.3 Because acellular dermal matrix does not contain cellular components, it is acceptable in this article that the pigmentation subscore was not improved in the cograft group. In our experience, noncultured autologous cell suspensions, such as ReCell (Avita Medical, Northridge, Calif.), could commendably improve skin color, as it contains viable melanocytes and fibroblasts apart from abundant keratinocytes.4 As these authors move forward, it could be tentatively used to aid the cograft of acellular dermal matrix and split-thickness skin graft or even cografted directly with acellular dermal matrix to heal full- thickness skin defects. We agree with the authors that the one-step graft of acellular dermal matrix and split-thickness skin graft is more than welcome and encourage them and others to investigate this approach so that this very important technique can be more completely understood and taken advantage of. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Panxi Yu, M.D.Zuoliang Qi, M.D., Ph.D.Plastic Surgery HospitalChinese Academy of Medical Sciences and Peking UnionMedical CollegeBeijing, People’s Republic of China

皮膚再建の再生医療

Skin has been a subject of generative medicine for long time. Technique of culture of human epithelium had been established in 1975 and the use of cultured epithelium is now major treatment option in management of extensive burn patients. However, the grafted cultured epithelium keeps rather fragility for several months after grafting, which is a current unsolved problem. We tested the effects of DFAT (dedifferentiated fat cells) on regeneration of basement membrane after cultured epithelial grafting in porcine experimental model. The result showed that the DFAT enhanced the laminin-5 supply and anchoring fibril formation, which may be beneficial to promote maturity of grafted cultured epithelium. Artificial dermis (AD) is a dermal regeneration template consisting of a spongy, porous collagen dermal replacement layer and a temporary epidermal substitute made of silicone. The advantage using AD to treat skin defects is that tissue quality resembling that with a full-thickness skin graft can be obtained with a thin split-thickness skin graft, which minimizes donor site morbidity. However, this treatment method requires two separate procedures, because the AD must be vascularized before skin grafting. Currently, reducing the time required for dermis-like tissue generation before the secondary skin grafting is desired. We tested the effects of DFAT on vascularization of the AD in rat experimental model. The result showed that the DFAT enhanced the angiogenesis, especially under bFGF treatment. We confirmed that one-step grafting procedure of the artificial dermis and the skin is possible by this method in porcine experimental model.

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.

Prospective study on burns treated with Integra®, a cellulose sponge and split thickness skin graft: Comparative clinical and histological study—Randomized controlled trial

BackgroundThe aim of this study was to compare three different methods to cover excised burn wounds in a randomized controlled trial. MethodsFascially excised burn wounds, measuring 10cm×5cm, were covered with Integra®, split thickness skin graft (STSG), and a viscose cellulose sponge Cellonex™ in each of ten adult patients. Integra® and Cellonex™ treated areas were covered with thin STSG on day 14. Biopsies were taken 3, 7, 14, and 21 days, 3 months, and 12 months after surgery, and samples were subjected to a range of immunohistochemical stains, in addition to hematoxylin and eosin (HE). Scar assessment was performed 3 and 12 months post-operatively with the Vancouver Scar Scale (VSS). ResultsInflammation was not substantial in any of the study areas, but Cellonex™ had the most neutrophils, histiocytes, and lymphocytes with significant differences on days 7 and 14. Complete vascularization of Integra® seemed to occur later compared to the other materials. STSG had the most myofibroblasts on day 14 (p=0.012). In VSS the quality of the scar improved in all materials from 3 to 12 months. ConclusionsThe final results for all treatments after 12 months demonstrate equal clinical appearance, as well as histological and immunohistochemical findings.

A case of giant naevus followed up for 22 years after treatment with artificial dermis

We present an ultra-long followed-up case in which an artificial dermis was used for the treatment of a giant naevus. A 5-year-old boy had a giant naevus on his lower back and both buttocks. The light black pigmentation extended to the lower abdomen and both upper thighs. The lesions on the lower back and both buttocks were treated using the artificial dermis Pelnac in three operative series every 2 years. After removal of the lesion, Pelnac was placed onto the skin defect. Three weeks postoperatively, the silicone film was peeled off and a thin split-thickness skin graft (STSG) taken from the upper-middle back was placed on the regenerated dermis-like connective tissue. Thin STSGs were harvested from the same upper back area repeatedly. The lesions on both posteromedial upper thighs and the lower abdomen were treated in three operative series using tissue expanders. Finally, tissue expanders were inserted subcutaneously in both buttocks where Pelnac had been used 5 years or 7 years before. The lesions around the anus were reconstructed using the expanded skin and local skin flaps. Twenty-two years after the first operation, both grafted and donor sites keep good condition not only cosmetically but also functionally.

Aesthetic Improvement of Burn Scar by Tangential Excision and Thin Split Thickness Skin Graft

It has been known that the post-burn scar may cause symptoms including pigmentation, pruritus, pain, and contracture, and result in psychosocial depression of individuals due to the loss of physical functions and dysmorphia depending on the location and severity of the burn scar, leading to substantial disruption in social life. In the particular case of hand and extremities where burn occurs frequently, although there have been a great deal of literature concerning the recovery of functional loss due to the burn contracture, the interest in the aesthetic recovery of the burning scar on the hand tends to be gradually increasing lately, reflecting the words “the hand is the secondary face”. The aesthetic treatments of the post-burn scar on the hand include tattoo, punch grafting, epidermal graft after dermabrasion, chip skin graft and thin sheet skin graft [1-6]. However, the tattoo generated different skin color, and the simple skin graft may result in regrettable outcomes such as prominent scar around the boundary of the burn site, collapse of skin graft site, donor site scar, and pigmentary degeneration over time. Accordingly, we aim to confirm the outcomes of the thin splitthickness skin graft with a thickness of less than 8/1,000 inches that was carried out following the tangential excision of burn scar using an electrical dermatome for the aesthetic improvement of the post-burn scar of the hand.

Novel Surgical Approach for Axillary Hidradenitis Suppurativa Using a Bilayer Dermal Regeneration Template

Hidradenitis suppurativa (HS) is a chronic debilitating disease of apocrine gland-bearing skin characterized by recurrent abscesses with subsequent rupture, scarring, and draining sinus tracts, most frequently affecting the axillary, inguinal, and anogenital regions. Conservative and temporizing treatment methods have been used to treat mild to moderate disease, but wide local excision of affected tissue is necessary for advanced disease. This creates a large soft tissue defect for which there is no consensus for reconstruction. Recovery is hampered by disease recurrence, tissue necrosis, and reoperation. The authors have described in this case study an alternative surgical approach to treat severe HS. All surgical procedures were performed by dedicated burn surgeons at a regional burn center using a two-stage surgical approach. The first stage is a wide local excision of all affected axillary tissue with immediate placement of a bilayer dermal regeneration template to cover the defect. This is secured with a negative pressure wound therapy dressing. The second stage uses a thin split thickness skin graft to close the wound. Results of four patients are presented. There were no recurrences of HS. Two patients required reoperations to address granulation tissue overgrowth and small areas of autograft loss. One patient experienced skin substitute loss as a result of infection. Inadequate excision of HS is the leading cause of disease recurrence. Using a bilayer dermal regeneration template with subsequent skin graft, surgeons can be aggressive in their excision of HS, achieving satisfactory functional and cosmetic results and minimizing axillary recurrence.