Autologous skin transplantation: comparison of minced skin to other techniques

BACKGROUND: Skin grafting may be necessary to close nonhealing skin wounds. This report describes a fast and minimally invasive method to produce minced skin suitable for transplantation to skin wounds. The technique was evaluated in an established porcine skin wound healing model and was compared to split-thickness skin grafts and suspensions of cultured and noncultured keratinocytes. MATERIALS AND METHODS: The study included 90 wounds on 3 pigs. Fluid-treated full-thickness skin wounds were grafted with minced skin, split-thickness skin grafts, noncultured keratinocytes, or cultured keratinocytes. Controls received either fluid or dry treatment. The wound healing process was analyzed in histologies collected at Days 8 to 43 postwounding. Wound contraction was quantified by photoplanimetry. RESULTS: Wounds transplanted with minced skin and keratinocyte suspension contained several colonies of keratinocytes in the newly formed granulation tissue. During the healing phase, the colonies progressed upward and reepithelialization was accelerated. Minced skin and split-thickness skin grafts reduced contraction as compared to keratinocyte suspensions and saline controls. Granulation tissue formation was also reduced in split-thickness skin-grafted wounds. CONCLUSIONS: Minced skin grafting accelerates reepithelialization of fluid-treated skin wounds. The technique is faster and less expensive than split-thickness skin grafting and keratinocyte suspension transplantation. Minced skin grafting may have implications for the treatment of chronic wounds.     

Treatment of full-thickness skin defect with concomitant grafting of 6-fold extended mesh auto-skin and allogeneic cultured dermal substitute

The aim of this clinical study was to evaluate an allogeneic cultured dermal substitute (CDS) as a biological dressing for highly extended mesh auto-skin grafting. The subjects were five patients with extensive deep burn wounds. Allogeneic CDS was prepared by seeding fibroblasts on a spongy matrix of hyaluronic acid and atelo-collagen. Six-fold extended auto-skin graft was applied to the debrided wound, on which allogeneic CDS was placed. A conventional ointment-gauze dressing was used to protect the CDS. The CDS was applied repeatedly at intervals of 5-7 days. In all cases, the wounds were closed by successful take of mesh auto-skin graft and prompt epithelization from the grafted skin. The skin on the grafted area had a cicatrix appearance, but was soft and thin, maintaining good quality. The application of 6-fold extended auto-skin graft in conjunction with allogeneic CDS is an effective method for treatment of extensive severe burn wounds.     

The efficacy of collagen dermis membrane and fibrin on cultured epidermal graft using an athymic mouse model

A human skin substitute consisting of human cultured keratinocytes, collagen dermis, and fibrin was evaluated in athymic mice. Eighty athymic mice were divided randomly into four groups. A 1.5x1.5-cm full-thickness wound defect was created on the back of each athymic mouse under anesthesia. These wounds were covered by sheets of cultured epidermal graft (group A), cultured epidermal graft with collagen dermis and fibrin (group B), cultured epidermal graft with collagen dermis (group C), or cultured epidermal graft with fibrin (group D). The grafts were secured and kept moist by specially designed saline gauze chambers. The take rates of the cultured graft with more than 50% of the wound covered were 65%, 15%, 50%, and 45% respectively. Group B had a significantly lower graft take rate, however the difference was not significant among groups A, C, and D. Light microscopy of biopsies of the grafted sites at 12 days showed complete epithelialization. The incidence of discharge from wound beds in groups A, B, C, and D was 0%, 15%, 15%, and 10% respectively. The results suggest that cultured cells are best grafted directly onto the wound bed or in combination with either a thin layer of collagen or fibrin but not both because the collagen dermal membrane and the fibrin together may impose too great a diffusion barrier for the cultured cell graft to become vascularized.     

Biology of infections of split thickness skin grafts

The purpose of this study was to identify determinants of split thickness skin graft infection. The bacterial count of the experimental wounds was proportional to the incidence of infection in split thickness skin grafts. When the wound was heavily contaminated with 10⁷ organisms, infection developed under most grafts. Graft take frequently occurred in wounds subjected to a lower level of inoculum. The importance of bacterial counts as a determinant of potential skin graft infection was also suggested by a clinical study. We now routinely use quantitative bacterial counts to identify the granulating wounds that are ready for grafting. The type of organism played no significant role in the development of infection.The recipient site on which the graft was placed had an important bearing on infection of split thickness skin grafts. The incidence of skin graft infection was higher in fascial wounds than in dermal wounds contaminated with the same level of inoculum. Meshing of the split thickness skin graft offered no significant protection against infection. The infection rates of meshed and nonmeshed grafts did not differ significantly in experimental and clinical wounds.     

The application of new biosynthetic artificial skin for long-term temporary wound coverage

Temporary dressings protect wounds from desiccation and infection. In our previous study, we used meshed acellular porcine dermis (APD) to enhance wound healing and decrease wound contraction; however, the wounds showed meshed scar [Wang HJ, Chen TM, Cheng TY. Use of a porcine dermis template to enhance widely expanded mesh autologous split-thickness skin graft growth: preliminary report. J Trauma 1997;42(2):177–82]. In this study, we produced an artificial skin composed of a cross-linked silicon sheet on the surface of APD which we have called silicone acellular porcine dermis (SAPD). This new artificial skin can protect the wound long enough to promote wound healing either by second intention or covered long enough until cultured epithelium autograft (CEA) or autologous skin graft can be harvested for permanent coverage.

We delivered 4 cm × 5 cm full-thickness wound on the back of 350 g Sprague–Dawley rats. Thirty-six rats were divided into two groups. Eighteen rats had SAPD and the other 18 were covered with Biobrane. The wounds were first examined 2 weeks after grafting and followed weekly for an additional 4 weeks to evaluate the wound and study pathological changes by using H.E. and Masson's stains. Wound size was calculated by ruler and analyzed by Student's t-test.

At the 2-week inspection, both SAPD and Biobrane showed tight adherence to the wound with no change of wound size. Both the SAPD and Biobrane dermal templates were pink. In the Biobrane-covered group, the wounds contracted soon after the tie-over dressing was removed. Its dermal layer is a layer of thin porcine dermal substance, which was promptly digested by tissue hyaluronidase and provides no real dermal template. In the SAPD-covered group however, the wound size was maintained significantly from third to sixth week after grafting (p < 0.001). SAPD was designed with thick epidermal silicone and a well-organized porcine dermis so that it incorporates into the recipient wound. Clinically the silicone layer of SAPD dislodged from APD about 6–7 weeks after grafting and was followed by dermal matrix exposure and infection. In pathological examination, much like a human skin graft, new vessels were found in APD about 1 week after grafting with minimal inflammatory cells infiltrated in the graft and wound. Six weeks after grafting, the collagen of APD incorporated into the wound, showing palisade arrangement and no sign of rejection. In the Biobrane group however, the wounds showed severe inflammation, the porcine dermal matrix was digested and disappeared 3 weeks after coverage.

In conclusion, SAPD is a thick biosynthetic artificial skin, which protects the rat wound significantly longer than Biobrane and prevents contraction. We expect that using of SAPD for temporary wound coverage will provide enough time to grow autologous-cultured epithelium or to reharvest skin grafts.     

培养的自体角朊细胞膜片与异体真皮重组复合皮移植的实验研究

目的探讨用自体培养的角朊细胞膜片（ＣＫＳ）及异体真皮重组复合皮移植后的成活机理和组织学变化。方法以３０只ＳＤ大鼠为实验动物,分为自体ＣＫＳ组及异体复合皮组。术后９０天内定期检查并取活检标本作组织学检测,观察移植物存活情况,伤口愈合,表皮真皮连接区的重建和异体真皮的归宿等。结果自体角朊细胞膜片成活尚好,但其质地及组织学结构欠佳,且太薄易磨损和破溃;胶原纤维增生并排列错乱,创面明显收缩。异体复合皮组不仅移植物成活好,且质地、组织结构、创面收缩及抗磨损等方面均优于ＣＫＳ组,移植后９０天仍能看到异体真皮成分,未见明显的免疫排斥反应。结论体外培养的自体角朊细胞膜片不适用于全层皮肤缺损的创面,而异体真皮复合皮有潜在的发展前景。     

Negative-pressure dressings in the treatment of hidradenitis suppurativa

Negative-pressure dressings have been used in the treatment of a variety of open wounds, and as a bolster for skin grafts. The benefits of these dressings include increased oxygen tension in the wound, decreased bacterial counts, increased granulation formation, and the prevention of shear force on wounds. Also, by virtue of the diminished need for daily dressing changes, there are the additional advantages of enhancing patient comfort, decreasing nursing work, and diminished cost of wound care. Hidradenitis suppurativa (HS) is a chronic infection of the apocrine sweat glands. Treatment options range from oral isotretinoin to radical excision. Wound closure may be achieved by secondary intention, skin grafting, or flap closure. Complications may still arise and include disease progression and squamous cell carcinoma. Radical excision yields the best results in terms of disease eradication. The authors describe using the negative-pressure dressing in two cases of bilateral axillary HS to secure skin grafts firmly to the wound bed after radical excision of all involved tissues. Patient comfort and acceptance was high, and skin graft take was excellent. The dressings themselves are simple to apply and are highly effective.     

培养的自体角朊细胞膜片与异体真皮重组复合皮移植的实验研究

目的 探讨用自体培养的角朊细胞膜片（CKS）及异体真皮重组复合皮移植后的成活机理和组织学变化。方法 以30只SD大鼠为实验动物,分为自体CKS组及异体复合皮组。术后90天内定期检查并取活检标本作组织学检测,观察移植物存活情况,伤口愈合,表皮－真皮连接区的重建和异体真皮的归宿等。结果 自体角朊细胞膜片成活尚好,但其质地及组织学结构欠佳,且太薄易磨损和破溃;胶原纤维增生并排列错乱,创面明显收缩。异体复合皮组不仅移植物成活好,且质地、组织结构、创面收缩及抗磨损等方面均优于CKS组,移植后90天仍能看到异体真皮成分,未见明显的免疫排斥反应。结论 体外培养的自体角朊细胞膜片不适用于全层皮肤缺损的创面,而异体真皮复合皮有潜在的发展前景。     

Buried chip skin grafting for treatment of perianal burns

A technique of buried chip skin grafting for perianal burn injury is described. Small chip skin grafts are buried in the granulating wound around the anus and this procedure achieves epithelialization of the perianal and perineal wound within about 5 or 6 cm laterally from the middle with extremely small amounts of skin graft. Graft survival is not disturbed by stools or gently wiping of the wound to remove stools, as grafts are buried in the holes. If infection occurs soon after the operation, graft survival does not appear to be affected because the grafted holes show good drainage. This procedure is considered to be very useful for treating perianal or perineal granulating wounds in extensively and deeply burned patients who have limited autograft donor sites.     

A prospective randomized controlled trial comparing negative pressure dressing and conventional dressing methods on split-thickness skin grafts in burned patients

Introduction

Split-thickness skin grafting (SSG) is a technique used extensively in the care of burn patients and is fraught with suboptimal graft take when there is a less-than-ideal graft bed and/or grafting conditions. The technique of Negative Pressure Dressing (NPD), initially used for better wound healing has been tried on skin-grafts and has shown to increase the graft take rates. However, comparative studies between the conventional dressing and vacuum assisted closure on skin grafts in burn patients are unavailable. The present study was undertaken to find out if NPD improves graft take as compared to conventional dressing in burns patients.

Materials and methods

Consecutive burn patients undergoing split-skin grafting were randomized to receive either a conventional dressing consisting of Vaseline gauze and cotton pads or to have a NPD of 80 mm Hg for four days over the freshly laid SSG. The results in terms of amount of graft take, duration of dressings for the grafted area and the cost of treatment of wound were compared between the two groups.

Results

A total of 40 split-skin grafts were put on 30 patients. The grafted wounds included acute and chronic burns wounds and surgically created raw areas during burn reconstruction. Twenty-one of them received NPD and 19 served as controls. Patient profiles and average size of the grafts were comparable between the two groups. The vacuum closure assembly was well tolerated by all patients. Final graft take at nine days in the study group ranged from 90 to 100 per cent with an average of 96.7 per cent (SD: 3.55). The control group showed a graft take ranging between 70 and 100 percent with an average graft take of 87.5 percent (SD: 8.73). Mean duration of continued dressings on the grafted area was 8 days in cases (SD: 1.48) and 11 days in controls (SD: 2.2) after surgery. Each of these differences was found to be statistically significant (p < 0.001).

Conclusion

Negative pressure dressing improves graft take in burns patients and can particularly be considered when wound bed and grafting conditions seem less-than-ideal. The negative pressure can also be effectively assembled using locally available materials thus significantly reducing the cost of treatment.     

Vertical (two-layer) skin grafting: new reserves for autologic skin

The main, permanent source of burn coverage continues to be autologic skin. In patients with major burns, the amount of available autologic skin may be insufficient. Consequently, severe wounds are covered after debridement with other biological or synthetic skin substitutes. Another source of skin reserves for wound coverage is the use of cultured keratinocyte sheet graft alone or with any dermal substitute. Some of these materials provide only temporal coverage and are often costly and time-consuming in preparation. These factors can be critical in burned patients. To expand the effective means of wound coverage, the authors sought a new source of autologic skin. The dermal grafts that were the marginal product of skin harvesting were meshed and grafted on the debrided third-degree burn, granulated wound, or muscle. The authors observed good dermal grafts "take" with rapid or slow epithelialization. They saw no the delay in donor site healing where the skin grafts overlapped. The histological difference in usual skin grafts and dermal grafts was studied after their harvesting and "taking."     

PVP-iodine in hydrosomes and hydrogel--a novel concept in wound therapy leads to enhanced epithelialization and reduced loss of skin grafts

BACKGROUND: Moist wound treatment improves healing at a possibly increased risk of bacterial infection and many local antiseptics impair healing. A moist treatment modality with efficient antimicrobial activity would be desirable. METHODS: In this monocentric, randomized, observer blinded, phase III study, a new hydrosome polyvinyl-pyrrolidone (PVP)-iodine preparation in hydrogel containing iodine in a 3% concentration (Repithel) was investigated for its effect on epithelialization in patients receiving meshed skin grafts. Grafts of 167 patients (donor site defects, burn wounds, or chronic defects) were dressed either with Repithel (n=83) covered with a gauze (Jelonet), or Jelonet-gauze only (n=84) until healing. RESULTS: Grafts receiving Repithel healed significantly earlier (9.4 days versus 12.4 days; p<0.0001) and faster than controls as measured by neo-epithelialization of mesh holes between days 7 and 11 (91.2+/-22.8% versus 82.3%+/-28.6, p<0.0001). A subgroup analysis showed that the effects on grafted burn wounds (p=0.0042) and chronic defects (p<0.0001) was more significant than on donor sites. Also a higher take rate of grafts (p=0.0053) and a reduced loss of grafts was observed with Repithel treatment (8 grafts versus 20 grafts) (p=0.0063, respectively). Smokers had improved graft take (p=0.0069) and higher rate of epithelialization (p=0.0040) compared to smokers of the control group. CONCLUSIONS: The results demonstrate significant clinical advantages of Repithel. This new local wound healing drug combines antisepsis and wound moisture efficiently resulting in significantly enhanced epithelialization, decreased transplant losses, and significantly improved healing especially in smokers.     

大鼠自体异体表皮细胞悬液混合移植的实验研究

目的　探讨自、异体表皮细胞悬液混合移植技术在创面修复中的应用。　方法　 30只大鼠随机配成 15对后 ,分成细胞悬液移植组 (A组 ,10对 )和细胞膜片移植组 (B组 ,5对 )。取每只大鼠全厚皮 ,分离表皮细胞 ,并根据配对情况按 1∶1的细胞比例混合 ,体外常规培养。 4d后收获A组混合细胞悬液 ,14d后收获B组混合细胞膜片。将此细胞悬液和膜片分别转移至A、B组相应供体大鼠的去全厚皮创面。随后A组每对大鼠的创面交叉覆盖配对方的异体全厚皮 ;B组创面覆盖胶原膜及“优妥”敷料。比较移植后 2～ 3周两组的创面修复情况。　结果　术后 2～ 3周 ,A组创面大多愈合 ,表面光滑 ,与皮下连接紧密。术后第 5天 ,B组创面部分细胞膜片脱落 ,部分成活 ,膜片成活的创面后期再次出现小创面 ,经久不愈。　结论　自、异体表皮细胞悬液混合移植是一种可行的、体内构建皮肤、修复创面的方法。     

Vacuum closure as a skin-graft dressing: a comparison against conventional dressing

Background

Grafting condition is one of the important determinants of skin-graft take. The technique of Vacuum-Closure has been claimed to improve the same and thereby graft take. However, there are few comparative studies against the conventional dressing technique evaluating its effectiveness in skin grafting. The present study was undertaken to compare Vacuum-closure with conventional dressing over freshly laid split-skin grafts.

Methods

Consecutive patients undergoing split-skin grafting were randomized into cases and controls. The grafts in controls were covered by a conventional dressing consisting of vaseline gauze and cotton pads. Those in cases were covered by a vacuum-closure assembly and connected to a wall-suction of 80 mm Hg continuously for four days. The percentage of graft take was assessed at nine days and at two weeks and duration of the dressing were compared between the two groups. The difference in cost of the dressing was noted down.

Results

Sixty four patients underwent split skin grafting of 71 wounds. Forty three of them were males and twenty nine were females. The grafted wounds included fresh surgically created wounds, traumatic wounds, acute and chronic burn wounds, post-inflammatory wounds and diabetic wounds. Thirty five of the grafts were cases and 36 were controls. Final graft take at two weeks in the study group ranged from 70-100 per cent with an average of 95.29 per cent graft take (SD: 5.9) while the control group showed a graft take ranging between 0-100 percent with an average graft take of 85.89 percent (SD: 25.1) Duration of dressing of the grafts was 11.63 days in cases as against 15.11 days in controls. The differences were statistically significant. The additional cost of the vacuum-closure assembly for an average sized ulcer was 6.27 pounds.

Conclusion

Negative pressure dressing increases the amount of graft take and should be used particularly when the wound bed and grafting conditions seem less-than-ideal for a complete graft take. Negative-pressure dressing can be economically and effectively assembled using locally available materials.

Level of Evidence:

Level I, therapeutic study.     

Deckung ausgedehnter Wundflächen durch Kombination von autogenen Netztransplantaten und fetalen Hautxenotransplantaten

Zusammenfassung Durch Überdeckung von Netztransplantaten mit fetaler Kalbshaut, die mit Nucleinsäuren vorbehandelt war, wurde eine Beschleunigung des Wundheilverlaufes bei gleichzeitiger Verhütung von Komplikationen erzielt. Bei vergleichenden experimentellen Untersuchungen an 12 Zwergschweinen waren standardisierte Defekte nach Abdeckung mit Netztransplantaten und zusätzlicher Überdeckung mit fetaler Kalbshaut durchschnittlich 3 Tage früher geschlossen, als die mit feuchten Verbänden versorgten Netztransplantate. Unter dem Schutz des biologischen Deckmaterials war das Anwachsen der Netztransplantate sichergestellt, während es sonst zu teilweisem Verlust kam. Bei der klinischen Anwendung bestätigten sich die im Tierversuch erstellten Ergebnisse. Das Deckmaterial bewirkte eine rasche Eindämmung der Eiweiß-, Elektrolyt- und Flüssigkeitsverluste, unterdrückte das Bakterienwachstum, verhinderte überschießende Granulationen und hypertrophe Narben, womit, im Vergleich zum konventionellen Verfahren, sowohl ein besseres kosmetisches, als auch funktionelles Resultat erzielt werden konnte.

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Cover of extensive wound areas by combined autogenous mesh grafts and foetal xenografts

Summary In spite of acknowledged advantages for accomplishing early closure of large wounds using mesh grafts, the value of this method is limited by various disadvantages, such as continued loss of biological fluids, the lack of control of infection, and the eventual cosmetic disfigurement—which includes hypertrophic scarring. This paper discusses the use of sheets of foetal calf skin pretreated with nucleic acid to act as an immuno-suppressive agent.Studies have been carried out over the past 20 years by various workers on the use of foetal calf skin grafts as a dressing over healing areas. In humans it has been noted that there is a surprising lack of host reaction to these grafts. The process of epithelialisation has continued extremely satisfactorily underneath them, with a marked reduction in infection of burn wounds etc.—and in the ultimate degree of contraction of the resultant scars. The use of nucleic acids appears to increase the survival time of these protective xenografts from 21.5 days to 42.5 days (Fig. 1).Experimentally, three raw areas created on the backs of each of twelve Yorkshire pigs were covered first by mesh grafts (Fig. 2) and then by, (a) foetal calf skin pretreated with nucleic acids, (b) collagen, (c) moist saline dressings (Fig. 3). The mesh grafted defects covered with the foetal calf skin showed better healing and less contraction (Fig. 4). There was no destruction of the mesh graft and the level of the granulations was even and flat. This temporary covering remained firmly adherent until the entire area beneath was covered with epithelium, at an average time of 8 days. With the collagen sheets, the defects were epithelialised 1–2 days earlier, but contraction of the defect was appreciable. When wet dressings were used as covering material, partial loss of the mesh grafts was observed and a very pronounced wound contraction became obvious. Total epithelialisation took 10–12 days.In an attempt to evaluate clinically the use of foetal calf skin, pretreated as described, as a possible healing adjuvant on mesh grafts, we applied this material to eleven patients with large burn wounds or skin defects following avulsion injuries. The results confirmed the animal experiments. Infection was reduced and wound healing was accelerated. The technique and clinical progress in one patient with third degree burns is illustrated (Figs. 5–10).The combination of mesh grafts with these xenografts as a temporary coverage has proved to be remarkably useful in reducing and preventing infection and decreasing fluid loss. Healing is noticeably better beneath them, and its application stimulates markedly the growth of healthy, highly vascular granulation tissue, and thus encourages maximum take of the mesh grafts. It is apparent that the application of these xenografts serves not only as a stimulatory substance but also accelerates epithelialisation. Total epithelialisation of the interstices between the ribbons of the mesh graft was achieved between the 5th and 7th postoperative days in contrast to the usual time of between 9 and 12 days. The final appearance was improved cosmetically, and compared favourably to the use of sheet grafts. Scar formation and post-operative contraction were noticeably decreased.

     

Allogeneic skin substitutes applied to burns patients

Early re-surfacing of burn wounds remains the ideal but is limited by the availability of skin graft donor sites. Cultured grafts overcome these problems and autologous keratinocytes can be grown in culture and placed on a dermal substitute, but this results in delay and requires two operations. We developed an organotypic skin substitute, which achieves cover in one procedure, and have previously found allogeneic cell survival up to 2.5 years after grafting onto clean elective wounds (tattoo removal). Here, we report a short series using the same model applied to burns patients with less than 20% total body surface area affected. The skin substitutes consisted of allogeneic dermal fibroblasts embedded in a collagen gel overlain with allogeneic epidermal keratinocytes, and were grafted to patients with tangentially excised burns. A side-by-side comparison with meshed split-thickness autografts was performed. No grafts became infected. The allogeneic skin substitute showed little effective take at 1 week, and by 2 weeks only small islands of keratinocytes survived. These sites were subsequently covered with meshed split-thickness autograft, which took well. It is concluded that further development of this model is needed to overcome the hostile wound bed seen in burns patients.     

复合皮混合移植治疗深Ⅱ度烧伤患者创面疗效观察

目的观察深Ⅱ度烧伤患者创面削痂术后应用复合皮混合移植治疗的效果。方法对23例烧伤患者的30个深Ⅱ度烧伤肢体在伤后3d内分次行削痂术,削至浅筋膜后移植大张异体脱细胞真皮基质,然后切取大张自体刃厚皮(0.10～0.25mm)覆盖于其上。术后10—12d计算移植皮片的存活率,记录创面愈合时间。观察随访3—6个月时患者的肢体外观及功能恢复情况。取1例患者随访3个月时的愈合创面皮肤标本,行病理学观察。结果本组患者复合皮片成活率为93%,7%的皮片因术中固定较差,移植后自体刃厚皮与异体脱细胞真皮基质分离致皮片坏死,或因感染致皮片溶解。随访3—6个月,移植部位皮肤外观、弹性及功能恢复良好。病理学观察显示,成活皮片表皮、真皮结构正常。结论烧伤后早期削痂立即移植复合皮是治疗深Ⅱ度创面的有效方法。     

The use of Omiderm as an interface for skin grafting

Burn wounds which require skin grafts are often heavily contaminated. Conventional methods of skin grafting demand bulky dressings and immobilization for 3-5 days. During this period, we cannot treat the wound topically, but can only hope that the skin graft will win the battle against infection and survive on the wound. The concept of an interface that has emerged in the past few years allows us to treat the wound topically through a transparent, permeable membrane that covers the skin graft without disturbing it. Omiderm, a hydrophilic polyurethane film that was developed as a burn dressing, has been used as an interface on 10 patients. Skin grafts on problematical areas and heavily contaminated wounds were covered with 1:1.5 non-expanded meshed Omiderm. An external layer of dressing with a topical antimicrobial agent was changed 8-24 h postoperatively and then at regular intervals. About 75 per cent 'take' was achieved, which was better than expected with other dressings under similar conditions.     

Grafting of deeply burned problem zones in the lower extremity with a dermal substitute

Functional results after deep excision and split thickness skin grafts are often limited as a consequence of unstable grafted areas and contractures. In two patients with a full-thickness thermal injury to the lower extremities and one patient with a chronic unstable skin area over the knee, the Integra^TM bilayered membrane dermal substitute was applied. After uneventful dressing changes graft take was complete without infection or other complications. Complete wound closure was achieved in all three patients within 3–4 weeks after the initial operation. The functional range of motion of the involved joints and the skin quality and contour was superior to conventional grafted skin after excision down to fascia and rather more comparable to skin grafts over a tangentially excised eschar. After wound healing, the neodermis was histologically similar to normal dermis. Considering the high incidence of unstable skin and contractures after regular grafting of deeply excised burns, this concept may present a significant improvement not only for the primary but also for secondary reconstructive procedures, with respect to the long-term quality of life for burn patients. Received: 1 December 1997 / Accepted: 13 June 1998     

A new approach in the management of chronic nonhealing leg ulcers.

Chronic leg ulcers are a major cause of mortality and morbidity. The efficacy of hyperbaric oxygen treatment is being evaluated in the management of nonhealing leg ulcers to improve skin graft survival. Twenty-seven patients with 36 chronic leg ulcers were examined. Each wound received 12 preoperative hyperbaric oxygen treatments, split-thickness skin grafting, followed by 12 postoperative hyperbaric oxygen treatments. Wound transcutaneous oxygen tension measurements (TCOM) were taken. The graft take was evaluated. At 18 months follow-up, 18 skin grafts (50%) showed complete take, 15 (41.7%) demonstrated partial take, and 3 (8.3%) failed. Hyperbaric oxygen treatment is an effective adjunct in the management of chronic leg ulcers, and its use resulted in increased graft take and survival.