Skin Allograft in the Treatment of Toxic Epidermal Necrolysis (TEN)

BACKGROUND: TEN is a severe form of exfoliative dermatitis. Its course is acute and its outcome fatal in 40% of cases. Wound cover to prevent fluid/protein loss and infections and to control pain, is the first step, as for burns. Skin allograft can be successfully used for this purpose. OBJECTIVE: We report two cases of TEN with de-epithelialization of 50 and 70% of the total body surface area. The patients were given support therapy and treated with human glycerol-preserved skin allografts for wound cover. METHODS: Patients were grafted with glycerol-preserved donor skin, obtained from a skin bank. RESULTS: Re-epithelization of treated areas was complete in 8 days; pain relief was obtained soon after the graft. CONCLUSIONS: Glycerol-preserved skin allograft is an effective treatment in extensive skin loss, for its barrier and analgesic effect. Quality standards of this product ensure safety and simplicity of use at limited cost.     

Fulminant group A streptococcal necrotizing fasciitis of the head and neck region

A resurgence of severe group A streptococcal soft tissue infections has been observed in Europe and the United States during the last decade. These infections are characterized by extensive local destruction and systemic toxicity. In this particular entity, necrotizing fasciitis is the most common clinical presentation, usually localized in the lower abdomen or in the limbs. As streptococcal necrotizing fasciitis is associated with a high mortality rate, early diagnosis and aggressive surgical treatment are crucial in the management of these affections. We report a case of group A streptococcal necrotizing fasciitis of the face which is a rare localization. There was no history of trauma or infection in the head and neck region. The condition had a fulminant progression leading to toxic shock syndrome with a fatal outcome.     

Surgical treatment of Fournier’s gangrene: use of cultured allogeneic keratinocytes

We discuss the value of the use of skin culturing as an addition to the classic treatment of Fournier’s gangrene. A 32-year-old morbidly obese man was admitted with signs of a severe septic shock syndrome due to Fournier’s gangrene. He recovered completely after an aggressive surgical débridement, combined with the use of broad spectrum antibiotics and invasive ventilator support for respiratory failure. The surgical reconstruction of the extensive skin defects following removal of the infected skin and soft tissues was successfully achieved with a combined application of meshed autologous skin grafts and the use of cultured allogeneic keratinocytes. Early cover of large skin defects is a major therapeutic goal, regardless of the nature of the primary etiology. The combined use of meshed autologous skin grafts and cultured keratinocytes represents one of the newer techniques. The contribution of this technique on the quality of healing and coverage of extensive skin loss zones is being investigated, since it seems to be a valuable option in reconstructing some of the sequelae of Fournier’s gangrene. Received: 29 April 1999 / Accepted: 3 January 2000     

Negative pressure wound therapy: an adjuvant to surgical reconstruction of large or difficult skin and soft tissue defects

Wide and deep wound defects are a challenge to surgeons, particularly when aggressive or more radical operations are unavailable. This article introduces refined techniques, indications and the clinical experience of the application of negative pressure wound therapy (NPWT) as an easy ancillary wound dressing method for the reconstruction of large or difficult skin and soft tissue defects. The authors used NPWT on 88 patients as an adjuvant therapy before reconstructive surgery since 2006. NPWT was applied for two different treatment strategies: as an adjuvant therapy to facilitate the formation of a healthy wound bed and to reduce the size and depth of a defect. NPWT was used as an alternative dressing method for skin grafting for infants or mobile skin surfaces such as the neck, penis, dorsum of the hand, knee joint, abdomen, etc. There were no typical wound complications. NPWT application, if used appropriately, produces successful surgical reconstructions for large, deep skin and soft tissue defects without extensive or radical flap surgery or loss of skin graft.     

The "rubber band technique": a simple method for closing large skin defects

Traditional methods of obtaining definitive soft-tissue cover in open wounds after high-energy trauma necessitate repeated surgical procedures and sophisticated soft-tissue reconstructions. A simple one-stage technique to treat skin loss in severe open fractures is described. The "rubber band technique" enables postoperative exposure and drainage of the fracture site. The wound closes gradually by facilitated mobilization of skin in response to continuous tension from the rubber band. This technique may prevent the need for additional procedures. Continuous drainage is achieved. When deep infection is suspected, removal of the elastic rubber band permits sufficient exposure of the deep tissues. The "rubber band technique" has proved to be a safe, simple, and efficient method for treating extensive soft-tissue loss in open fractures and after incisions for open reduction or fasciotomy.     

皮肤混合移植的现状和未来

1 皮肤混合移植的演变过程 皮肤移植是外科修复皮肤缺失的主要方法之一.大面积深度烧伤患者可供移植的自体皮有限,探索相应的皮肤移植技术成为烧伤医学的重要研究课题之一[1].     

Acute complex traumas of the lower limbs: a modern reconstructive approach with negative pressure therapy

Acute traumas of the lower limbs cause complex functional damage for the association of skin loss with exposed tendons, bones, and/or vessels, requiring a multidisciplinary approach. Once bone fixation and vascular repair have been carried out, the surgical treatment for skin damage is usually based on early coverage with conventional or microsurgical flaps. Negative pressure therapy can play a primary role in the management of the elderly or intensive care patients, where wounds are secondary to life-threatening problems. A total of 35 patients with 37 acute traumatic wounds of the lower limbs were treated with vacuum-assisted closure (VAC) therapy for an average of 22 days (range 3-46 days). The sponge was applied the day after bone fixation, vascular repair, and surgical debridement of nonviable tissues, so as to obtain a better control of bleeding. After VAC treatment, all patients quickly developed healthy granulation tissue and a significant reduction in both extent and depth of wounds. Split-thickness skin grafts were used to cover granulation tissue in most of the cases (66% -- 24 cases), and then local flaps (13% -- five cases) or direct sutures (8% -- three cases). The wounds healed spontaneously without surgical management in four patients. One patient died during the treatment period for concomitant diseases. No relevant complications directly related to VAC therapy were observed other than one case of severe pain in an amputated stump. The average follow-up duration was 265 days (range 33-874 days). No further tegumentary reconstruction was required. VAC therapy may represent a valid alternative to immediate reconstruction in selected cases of acute complex traumas of the lower limb and allows for a stable functional result, using a minimally invasive approach.     

Chemical Debridement of Burns

The development of effective, non-toxic (local and systemic) methods for the rapid chemical (enzymatic and non-enzymatic) debridement of third degree burns would dramatically reduce the morbidity and mortality of severely burned patients. Sepsis is still the major cause of death of patients with extensive deep burns. The removal of the devitalized tissue, without damage to unburned skin or skin only partially injured by burning, and in ways which would permit immediate (or very prompt) skin grafting, would lessen substantially the problems of sepsis, speed convalescence and the return of these individuals to society as effective human beings, and would decrease deaths. The usefulness and limitations of surgical excision for patients with extensive third degree burns are discussed. Chemical debridement lends itself to complementary use with surgical excision and has the potential advantage over surgical excision in not requiring anesthesia or a formal surgical operation. The authors' work with the chemical debridement of burns, in particular the use of Bromelain, indicates that this approach will likely achieve clinical usefulness. The experimental studies indicate that rapid controlled debridement, with minimal local and systemic toxicity, is possible, and that effective chemotherapeutic agents may be combined with the Bromelain without either interfering with the actions of the other. The authors believe that rapid (hours) debridement accomplished by the combined use of chemical debriding and chemotherapeutic agents will obviate the possibility of any increase in infection, caused by the use of chemical agents for debridement, as reported for Paraenzyme(21) and Travase.(39,48) It is possible that the short term use of systemic antibiotics begun just before and continued during, and for a short time after, the rapid chemical debridement may prove useful for the prevention of infection, as appears to be the case for abdominal operations of the clean-contaminated and contaminated types.     

Denatured acellular dermal matrix seeded with bone marrow mesenchymal stem cells for wound healing in mice

It is the basic task of burn therapy to cover the wound with self-healthy skin timely and effectively. However, for patients with extensive burns, autologous skin is usually insufficient, and allogenic or heterogeneous skin leads to strong immune response. It is vital to choose an appropriate treatment for deep extensive burns. Nowadays, the dermal substitute combined with bone marrow mesenchymal stem cells (BM-MSCs) is a prospective strategy for burn wound healing. Denatured acellular dermal matrix (DADM), as one of dermal substitutes, which prepared by burn skin discarded in escharotomy, not only maintains a certain degree of 3D structure of collagen, but also has good biocompatibility. In this study, the preparation method of DADM was improved and DADM was seeded with BM-MSCs. Then BM-MSCs-seeded DADM (DADM/MSCs) was implanted into mice cutaneous wound, and the effect of DADM/MSCs dermal substitute was assessed on skin regeneration. As a result, BM-MSCs survived well and DADM/MSCs scaffolds significantly promoted wound healing in terms of angiogenesis, re-epithelialization and skin appendage regeneration. DADM/MSCs scaffold may represent an alternative promising therapy for wound healing in deep extensive burns.     

Scoliosis in Steinert syndrome: a case report.

BACKGROUND CONTEXT: Steinert syndrome is described as an autosomal dominant condition characterized by progressive muscular wasting, myotonia, musculoskeletal manifestations and rare spinal defects. Little is reported about spinal deformity associated with this syndrome. PURPOSE: We present a patient with Steinert syndrome complicated by scoliosis. In the literature on muscular dystrophy, other than Duchenne, little mention is given to the problem of scoliosis in general and its treatment in particular. STUDY DESIGN: A case report of a patient with Steinert syndrome associated with thoracic scoliosis and hypokyphosis is presented. METHODS: A 17-year-old boy presented with King type II right thoracic scoliosis (T5-T11, Cobb angle of 40 degrees) and hypokyphosis--10 degrees. He was treated with posterior stabilization and instrumentation at level T3-L2 with a postoperative correction of the scoliotic curve to 20 degrees. Histopathologic examination of the muscles confirmed the diagnosis of Steinert myotonic dystrophy. RESULTS: At 30-month follow-up, the patient was clinically pain free and well balanced. Plain radiographs showed solid spine fusion with no loss of deformity correction. CONCLUSIONS: Scoliosis in Steinert syndrome shares the characteristic of an arthrogrypotic neuromuscular curve and demands the extensive soft tissue release for optimal surgical correction. Intraoperative observations included profound tissue bleeding, abnormally tough soft tissues and a difficult recovery from anaesthesia.     

Einzeitige Defektdeckung von denudiertem Knochen und freiliegenden Sehnen mittels MATRIDERM? und Spalthaut

Background

Full-thickness skin defects over functional structures (tendons, vessels) or deperiosted bones of the extremities usually require extensive soft tissue reconstruction to cover the defect. A new option for coverage of the defect is the application of MATRIDERM?, a bovine matrix consisting of collagen and elastin, as a neodermis underneath skin transplants. Can this combined one-stage surgical intervention successfully cover deperiosted bone or tendon?

Patients and methods

We performed this one-stage procedure in ten patients instead of soft tissue reconstruction. The success of wound coverage with the one-stage method and in combination with skin transplantation for defects generally associated with considerable loss of transplants (deperiosted bones and tendons without paratenons) was determined.

Results

In nine of ten patients, complete defect coverage could be achieved. A one-stage wound closure in extensive defects with exposed tendons in four of five locations could be achieved. In deperiosted bone defects the one-stage coverage was only successful in two of six patients. However, complete wound closure could be achieved with a second skin transplantation in a patient with exposed tendon and bone in three of the four locations.

Conclusion

As a one- or two-stage procedure, MATRIDERM? application with skin transplantation resulted in an effective defect closure without the need for a complex plastic reconstructive procedure. With regard to its functionality it cannot be considered as a substitute for skin flaps. In selected cases MATRIDERM? is an interesting and successful method in plastic reconstructive surgery.     

A Rare Case of Pulmonary Restrictive Syndrome after Liquid Silicone Injection: The Role of the Plastic Surgeon

Despite being especially used in its solid form, silicone is still injected as a liquid filler for breast contouring in many countries. Here, we present a rare case of a woman with silicone pneumonitis and extended breast scarring after breast silicone injection. Because of evidence of a restrictive syndrome due to the thoracic extensive scarring tissue and the high demand of oxygen therapy, as jointly agreed with the pulmonologists, we decided to perform a surgical asportation of the scarring tissue and covering with microsurgical flap. We chose the deep inferior epigastric perforator flap mainly because of the large amount of skin that is possible to use, the good skin texture matching, and the possibility of double team working without changing patient’s position.     

Reparation of sequelae of penile-scrotal and perineal gangrene. Apropos of 4 cases

The authors report different techniques for surgical reconstruction of the sequelae of penile, scrotal and perineal gangrene. The repair of skin defects and the reconstruction of the scrotum requested several interventions. Where the scrotal skin loss was limited to a 1/2 of scrotum, the testis could be covered by mobilising the surrounding rim. When the disease was confined to the penis or inguinal region, skin cover has been provided by free grafts. More elaborate techniques of skin cover were necessary when the disease was extended to the whole scrotum: a fasciocutaneous flap from the thigh was used for reconstruction of the scrotum. The scrotal myocutaneous flap was used to cover skin and anterior urethral loss of tissue.     

足底内侧皮瓣在足跟部恶性黑色素瘤的应用

目的探讨足跟部恶性黑色素瘤的手术切除和修复重建的方法。方法5例老年足跟部恶性黑色素瘤患者，手术行局部扩大切除，切缘距病损2cm，深度达跟骨骨膜，足跟部软组织缺损Ф5～9cm，根据缺损大小，用带足底内侧血管神经束的皮瓣移位修复，皮瓣面积8cm×6cm-10cm×8cm。结果5例皮瓣全部成活。随访2年6个月～5年，患者均健在，肿瘤未见局部复发，皮瓣感觉功能良好，患足功能与对侧相比无明显差异。结论足跟部恶性黑色素瘤应行局部扩大切除术，切除范围应距肿瘤边缘不小于2cm为宜，在切缘阴性的基础上进行修复重建，应用足底内侧皮瓣移位修复，临床疗效满意。     

Reconstruction of extensive tissue defects of the scalp by microsurgical composite tissue transplantation.

Two cases of severe and extensive electrical burns of the scalp and skull are presented. Large segments of composite groin tissue were successfully transplanted to cover the scalp defects. Microvascular surgical techniques were employed. Both patients had short postoperative hospitalizations. It is possible that a cranioplasty may now be performed as a second stage under the healed full-thickness skin. The advantages of providing a thick protective skin cover in a single operation are outlined.     

Multiple subcutaneous haematomas of the legs causing skin necrosis in an elderly patient affected by corticosteroid‐induced skin atrophy: Case report and review of literature

Corticosteroid‐induced skin atrophy (CISA) consists of a thinning of the skin and subcutaneous tissues, representing the natural consequence of a prolonged glucocorticosteroids use, both systemic as well as topical. It is characterised by the loss of elasticity and skin thickness, associated with an increased skin fragility leading to ecchymoses, haematomas, and steroid purpura. The management of CISA is a challenge for physicians, as the pathology is reversible in a minimal percentage of cases and only after a short topical steroid or low‐dose course therapy. Often wounds with large loss of substance represent the more common complication, after a surgical drainage which is often necessary. Skin necrosis with compartment syndrome of a leg is another potential risk for these patients. Here, we report a case of an elderly patient affected by multiple subcutaneous haematomas of the legs causing skin necrosis, arisen after the use of anticoagulants for a deep venous thrombosis. The patient was successfully treated with surgical drainage, negative pressure wound therapy (NPWT), and porcine xenograft with no complications. Finally, we discuss the evidence of the current literature on topic.     

Local composite neurovascular island flap for skin cover in pulp loss of the thumb.

A local composite neurovascular island flap to provide stable skin cover with good soft tissue padding and sensibility for extensive pulp loss of the thumb was used in five patients. The island flap included the dorsoradial branches of the radial digital neurovascular bundle of the thumb.     

Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene

Fournier’s gangrene is an infection of the genitals and perineum that is treated with extensive soft tissue debridement, often leading to loss of scrotal skin. Multiple options for reconstruction of the scrotum are available. Four cases of recreation of the scrotum with meshed split thickness skin grafts (STSG) are presented. The discussion includes a comparison of STSG with other treatment options. We conclude that STSG are a safe, technically easy treatment option with satisfactory cosmetic and functional results.     

闭合性骨折后发生全身剥脱性皮损而病原学阴性的猩红热患者一例

目的提高对特殊临床表现猩红热的认识。 方法通过1例罕见的肱骨闭合性骨折后发生全身剥脱性皮损、病原学阴性的猩红热患者的临床诊疗情况,强调与葡萄球菌烫伤样皮肤综合征（SSSS）、川崎病、麻疹鉴别诊断的必要性。 结果通过临床症状、体征、辅检,患者得到准确诊断。经科学隔离、规范治疗而达到临床治愈。 结论鉴于猩红热的主要病原为A组β型溶血性链球菌（GABHS）,具有传染性,因而快速诊断、消毒隔离极为重要。