Superficial skin texture: a study on full-thickness skin grafting in facial reconstruction

Usually in harvesting a full-thickness skin graft, we match color, skin thickness, and the presence of hair in the potential donor site with the recipient site to obtain as good an esthetic result as possible. Superficial skin texture is, in part, responsible for the esthetic result in facial reconstruction. Full-thickness skin grafts harvested from the supraclavicular region in 20 patients operated on for facial skin tumors and immediate reconstruction, were included in this study. The superficial skin texture was reproduced using a silicone cast technique; a polyvinylsiloxane derivative was used and it was analyzed by scanning electron microscopy (SEM) in order to detect and measure morphological features of the skin surface. The mechanism affecting superficial skin texture was studied to elucidate the importance of the superficial skin texture of the graft donor site and consequently the intraoperative orientation of the graft into the recipient area to improve the esthetic outcome. Our study shows that the forces of the recipient site are able to modify full-thickness skin graft dermis and as a result change the overlying superficial skin pattern. The graft always tends to change to the features of the recipient area after 24 months because of the environment of the new site. These findings suggest that color and thickness of the donor site still remain more important than intraoperative graft orientation in the recipient area in order to achieve good esthetic results in skin grafting.     

Malignant melanoma in a skin graft: burn scar neoplasm or a transferred melanoma?

Malignant melanomas (MM) arising in burn scars are rare with 16 cases previously reported. Malignant melanomas arising on skin grafts are even more rare with only two cases reported. We present the case of MM arising on a burned area that had been previously grafted with a split thickness skin graft. A 19-year-old patient sustained 20% burns in a road traffic accident. The burned areas were debrided and skin grafted. Six months later, the patient developed MM on the left calf (an area that was burned and grafted). The tumour was excised with wide margins. Six months following the excision of the MM, the patient started to develop multiple dysplastic naevi in the skin grafted burned areas. In the present case, the main question to be answered is whether the MM arose from the donor or the recipient site of the split thickness skin graft. After thorough discussion of the two options and reviewing the literature, the authors believe that the MM and the atypical naevi were transferred to the recipient site with the skin graft. Therefore, it is suggested that in the process of harvesting skin grafts, any pre-existing naevi should be avoided or removed, and if this is not feasible, should be recorded in detail in the operation notes. Also, patients at discharge should be advised that any change in the appearance of the grafts or any new lesions in the engrafted areas should be reported to their physicians.     

A Comparison of Full and Split Thickness Skin Grafts in Radial Forearm Donor Sites

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.     

Evaluation of a porcine origin acellular dermal matrix and small intestinal submucosa as dermal replacements in preventing secondary skin graft contraction

The degree to which a split thickness skin graft (STSG) contracts after application to its recipient bed is related in part to the proportion of the dermis harvested from the donor site. Harvesting thicker skin grafts may produce better cosmetic results in the recipient bed but result in increased donor site morbidity. The combination of an autologous ultra thin split thickness graft with an underlying non-autologous dermal component may reduce secondary skin graft contraction without further increasing donor site morbidity. This study was aimed at assessing the suitability of two porcine derived biomaterials (Permacol and small intestinal submucosa, SIS) for use in combination with skin grafts in a Sprague-Dawley rat model. Full thickness wounds (1 cm(2)) were created in Sprague-Dawley rats and grafted with skin in combination with Permacol or SIS either as a one-stage operation or following a 2-week-period of vascularisation of these dermal matrices before a second stage operation to cover with skin. Skin graft viability and wound area were assessed at weekly intervals until 4 weeks after graft application. Both Permacol and SIS were able to support an overlying skin graft but had no beneficial effect on skin graft contraction in this model compared to skin grafts alone.     

Melanoma arising in a skin graft

Cutaneous melanoma remains an ongoing public health threat, and the cornerstone of management continues to be early diagnosis and treatment. Unfortunately, primary melanomas may have atypical presentations, making early diagnosis difficult and causing significant treatment delays. In this report, an unusual case is presented in which a patient experienced the synchronous development of a melanoma in situ within a skin graft donor site and an invasive melanoma within the recipient skin graft site. This exceptional presentation of cutaneous melanoma is discussed to highlight key principles of skin grafting in relation to the management of malignant melanoma.     

Clinical application of split skin graft from scar tissue for plastic reconstruction in post-extensive burn patients

We evaluated the use of autologous split-thickness skin taken from scars on the backs of patients with extensive burns, without sufficient normal donor skin. Between 1998 and 2008, a total of 15 patients underwent 47 operations using split-thickness skin grafts from scar tissue. Split-thickness skin was harvested from scars on the patient's back. In each operation, two thirds of donor skin was used at the recipient site and the remaining part was used to cover the donor site. All skin grafts survived. The skin function and appearance at the reconstruction site was improved in all cases, and reconstruction had therapeutic effects similar to those achieved by graft procedures using normal autologous split skin. Moreover, 6 months later, the skin graft procedure could be repeated at the donor site. Therefore, we concluded that split-thickness skin from scars on patients' backs is a valuable source of skin graft material that can be used repeatedly for plastic reconstruction in extensively burned patients.     

Recurrence of a basal cell carcinoma in a skin graft in spite of total excision. A case report

The authors report an original case of a recurrence of basal cell carcinoma in a skin graft recipient site. The skin graft was used to resurface the defect following complete excision of basal cell carcinoma in the mandibular angle area. Three answers can be given to the question of the origin of that new carcinoma: recurrence of the primary carcinoma, metastasis to a lymph node or a transfer of a basal cell carcinoma located into the skin graft which grew further. This last hypothesis remains the most probable because the histology of the two carcinomas was different and that the patient presented many others locations of basal cell carcinomas. Skin grafted areas must be checked for recurrence of basal cell carcinoma in such patients because invisible basal cell carcinoma can be transferred within the graft where they can grow for their own.     

A Novel Composite Skin Graft Technique with Fat Derivatives

Skin grafting, although a relatively classic and well-known technique, still has multiple disadvantages such as secondary contracture of the skin graft, sunken depression, poor elasticity, and color mismatch. Adding adipose tissues significantly improved the graft appearance compared to traditional skin grafting methods. Herein, we report two cases of modified skin graft procedures, both showing positive outcomes. In case 1, a mechanically processed fat-derived product was injected into the lower half of the skin graft area. In case 2, left upper eyelid blepharoplasty was performed, and the orbital fat strip was transferred and placed under the recipient area on the right side. Hair growth was observed only in case 1, whereas the extent of sunken depression was significantly reduced in both cases. Compared to traditional skin grafting methods, adding fat components to the skin graft recipient area improved the appearance and blood supply, together with enhancing the regenerative rate.     

全手或全足皮肤脱套伤的显微外科修复

目的　评价应用显微外科技术修复全手、全足皮肤脱套伤的临床效果。　方法　 1984年 3月～ 2 0 0 1年 10月采用皮瓣、肌皮瓣、口止母趾甲皮瓣和游离大网膜上植皮修复全手、全足皮肤脱套伤共 6例 ,患者年龄 2 2～ 38岁。全手皮肤脱套伤 2例 ,其中 1例采用大网膜游离移植加植皮 ;1例采用 口止母趾甲皮瓣加腹部 S形皮瓣移植及中厚植皮 ,择期进行分指。全足皮肤脱套伤 4例 ,其中 2例采用背阔肌皮瓣游离移植 ,1例采用小腿外侧逆行岛状皮瓣移植 ,1例采用阔筋膜张肌皮瓣游离移植。皮瓣、肌皮瓣范围 :7cm× 9cm～ 2 2 cm× 15 cm。急诊一期手术 1例 ,延迟一期手术 5例 ,延迟时间 2～ 14天 ,平均 6 .6天。　结果　移植的皮瓣、肌皮瓣、口止母趾甲皮瓣及大网膜全部成活 ,术后随访 1～ 2年 ,手、足的外形与功能较好。　结论　应用显微外科技术修复全手、全足皮肤脱套伤可取得较好的效果。受区的彻底清创 ,供区的合理选择 ,高质量的血管吻合 ,积极的术后康复是手术成功的关键。     

Pemphigus Foliaceus Masquerading as Postoperative Wound Infection: Report of a Case and Review of the Koebner and Related Phenomenon following Surgical Procedures

BACKGROUND: The Koebner phenomenon, also known as the isomorphic response, is the development of preexisting skin disease following trauma to uninvolved skin. Various cutaneous disorders have been described to arise at surgical wounds and scars. Moreover, dermatologic procedures, such as cold-steel and laser surgery, can evoke koebnerization. OBJECTIVE: To describe a case of pemphigus foliaceus arising in postoperative wounds and to present a review of dermatologic disorders triggered by surgical procedures. METHODS: We report a case of pemphigus foliaceus initially presenting at sites of Mohs' micrographic surgery, shave biopsy, and cryotherapy and, subsequently, at a nonsurgical site. We reviewed the English literature in MEDLINE from November 1955 to April 2004 for reports of Koebner and related phenomenon following surgical procedures. RESULTS: To our knowledge, this is the first reported case of pemphigus foliaceus erupting at surgical and cryotherapy wounds. The clinical appearance can mimic wound infection. In addition to inducing preexisting disease, cutaneous procedures can also trigger the onset of new disease, which can either be limited only to the surgical site or subsequently become generalized. CONCLUSION: Postoperative Koebner or related responses should be included in the differential diagnosis of poorly healing surgical wounds. Skin biopsies for histopathology and immunologic studies may be necessary for definitive diagnosis and optimal management.     

Prolonged skin allograft survival through enhancement effects on donor tissue

A skin allograft retransplantation model was utilized to study the mechanism of immunological enhancement in a murine system. Enhancement was accomplished by treating allografted recipients with host antidonor serum (B6AF1 anti-B10.D2 alloantiserum). Grafts from enhanced or untreated hosts were retransplanted after seven days onto a second recipient. Enhanced retransplanted grafts had significantly prolonged survival as compared with unenhanced grafts. The survival of enhanced retransplanted grafts was as prolonged as that of primary skin grafts on antiserum-treated hosts. Splenocytes harvested from recipients of enhanced retransplanted allografts showed delayed and diminished development of T cell responses to graft alloantigens. Sensitization of the second recipient abrogated prolonged survival of enhanced retransplanted grafts. Also, enhancement prevented sensitization of allografted recipients. One interpretation of these studies suggests that a sensitization block is a sufficient mechanism of skin allograft enhancement. The site of action of antisera is within the graft itself. Decreased T cell responses in the host are indirect effects of diminished antigenicity of enhanced grafts. Further studies of immunological enhancement should be directed to the graft, not toward the graft recipient.     

Nerve endings in palm skin grafts

We examined regeneration of Meissner corpuscles in palm skin grafts. In only one of the specimens (split-thickness skin graft from the sole of the foot), numerous regenerated Meissner corpuscles were found in the dermal papilla. This suggests that the nerve pattern of the graft depends on reinnervation from the recipient site and the regeneration of encapsulated nerve endings contained in the graft. It is recommended that skin grafts containing the encapsulated nerve endings be used in digits to obtain a satisfactory recovery of the sensory function.     

Optimal use of negative pressure wound therapy for skin grafts

Skin grafting is a technique used for transplanting human skin (i.e. epidermal and some dermal layers) from a harvest site to a recipient site. However, advancements in bioengineered matrices have also introduced alternatives to skin grafts. The method used to secure the graft, whether skin or biomatrix, is critical in reducing graft failure. During the past several years, negative pressure wound therapy using reticulated open-cell foam (NPWT/ROCF; V.A.C.? Therapy, KCI USA, Inc., San Antonio, TX) has become a well-established method for bolstering grafts to recipient beds and is being used more frequently over biomatrices to help improve graft outcomes. This review will combine expert opinion with scientific evidence for the use of NPWT/ROCF over grafts.     

皮肤外扩张法在供皮区的应用

目的 解决大面积烧伤后瘢痕畸形进行手术时的皮源不足的难题。方法 采用皮肤组织外扩张法，以增加供皮区面积。结果 经临床4 实践证明取得了预期效果，且扩张具有延迟效应，对超过常规长宽比例的皮瓣可进行即时移转，皮瓣及全厚皮片供应区可直接缝合，供区和受区同步愈合。结论 我们认为这是对修复大面积皮肤组织缺损时，提供“额外”皮肤组织的切实可行的方法。     

带蒂比目鱼肌瓣修复前足软组织缺损

目的 :探讨腓动脉为蒂逆行外侧半比目鱼肌瓣修复前足软组织缺损的临床疗效。方法 :自2005年1月至2013年1月,采用腓动脉为蒂逆行外侧半比目鱼肌瓣修复前足软组织缺损患者8例,其中男6例,女2例;年龄16~48岁,平均26.8岁。逆行外侧半比目鱼肌瓣转移至前足软组织缺损区,在肌瓣表面行Ⅰ期中厚网状游离植皮,供区直接缝合。术后观察肌瓣修复前足后成活情况。结果:肌瓣全部成活,术后没有发生血管危象,其中1例受区术后发生轻微的表浅感染,1例发生肌瓣远端小的植皮坏死,经2周换药处理自然愈合。术后随访2.5~5.5年,平均3.5年。受区外形较好。踝关节功能按Cedell标准评定,良6例,可2例。结论:当局部带蒂皮瓣或肌瓣应用受限时,外侧半比目鱼肌瓣修复后肌瓣成活较满意,很适宜修复前足软组织缺损。     

Use of single saphenous interposition vein graft for primary arterial circuit and secondary recipient site in head and neck reconstruction: a case report

BACKGROUND: Autologous vein grafts are a valuable tool in microsurgical free tissue transfer. Interposition vein grafts offer the surgeon greater freedom when placing the free flap and choosing the recipient vessels, providing valuable options in case recipient vessels are not available for those patients with large wounds. Free flaps transferred to head and neck regions carry a higher risk of failure, which may be expected to increase more with the use of vein grafts. METHODS: We present our case with the double use of a single vein graft for both primary arterial conduit in end-to-end fashion and secondary end-to-side recipient site in the microsurgical reconstruction of a complicated head and neck defect. RESULTS: All these anastomoses and flaps survived perfectly, and the patient was discharged 14 days after the transfer of the second flap. CONCLUSION: Although the anastomosis of 2 flaps to a single vein graft was successful in our case, it represents a higher risk option than different recipient vessels. We provide this alternative procedure in selected patients, as there is no other receipt vessel or recipient blood flow strong enough to supply more than 1 flap.     

The skin overlying the sentinel lymph node: a full thickness skin graft donor site after local excision for cutaneous melanoma

Wound defects resulting from wide local excision for cutaneous melanoma, can require the use of skin graft for closure. Harvesting the skin graft can result in an additional morbidity. The increasing use of sentinel lymph node biopsy in cutaneous melanoma allows us the development of an alternative technique for obtaining donor skin. This method utilizes the skin overlying the sentinel lymph node as the skin graft donor site. Sixteen patients with cutaneous melanoma over than 1 mm of Breslow index, underwent wide local excision with sentinel lymph node biopsy and full thickness skin graft harvested from the node biopsy site. After a median follow-up of 18 months, there were no graft failure, one case of lymph swelling was relieved in the donor site. There were no melanoma recurrence and no metastasis. One case of in transit metastasis was treated by local excision and suture. In cases were primary closure is not feasible or cosmetically unfavourable, the use of the sentinel lymph node site as a skin graft donor, provides an alternative technique sparing the patient an additional skin graft donor site defect.     

Hypertrophic skin grafts in burned patients: a prospective analysis of variables

A prospective study of 70 consecutive burned patients, 26 pediatric patients and 44 adults, who had 173 separate anatomic sites grafted, was carried out to determine the incidence of hypertrophic skin grafts after thermal injury. The age, race, postburn day grafted, anatomic site grafted, and nature of the recipient graft bed was recorded. The patients were followed for a minimum of 1 year, at which time the skin grafts were classified as Excellent (E)--skin graft flat and not thickened; Good (G)--less than 5% of skin graft thickened or elevated; Fair (F)--greater than 5% of skin graft thickened or elevated; and Poor (P)--skin graft elevated greater than 2 mm or contracture present. Overall, 55% of the grafted sites were excellent, 18% were good, 13% were fair, and 14% were poor. Pediatric patients had a higher incidence of fair or poor results (50%) than adults (17%) (p less than 0.001), and blacks had poorer (39% F or P) results than whites (12% F or P) (p less than 0.001). The presence of dermal elements in the recipient graft bed was associated with less long-term skin graft scarring than when the grafts were placed on recipient beds without dermal elements (p less than 0.01). Skin grafts that were performed within 14 days of the injury had a lower incidence of F or P results (24%), than grafts performed after 14 days postburn (37%) (p less than 0.03). Based on the results of this prospective study, it is possible to identify and quantitate the relative risk of a burned patient developing a hypertrophic skin graft.     

The coriotome--a new hand-held device for trimming of skin grafts.

BACKGROUND: Skin grafts require a meticulous removal of subcutaneous fat from their underside to ensure their survival at the recipient site. Often a dermal layer is trimmed as well to improve the take of a skin graft or to adapt its thickness to the depth of a defect. OBJECTIVE: The authors present a new hand-held surgical device, the coriotome, that permits trimming a skin graft more evenly and in a considerably shorter period of time than by applying the conventional method using surgical scissors or a scalpel. RESULTS: A total of 154 skin grafts (98 from preauricular, 45 from supraclavicular, and 11 from inguinal donor sites) were trimmed with the coriotome to a desired thickness. In 2 cases minor lacerations (<3 mm) of skin grafts occurred as a result of an inappropriate use. CONCLUSION: The coriotome permits a fast and safe trimming of skin grafts.     

Mohs Micrographic Surgery-Induced Pemphigus

BACKGROUND: Pemphigus is an autoimmune blistering disease that presents with flaccid intraepidermal blisters, erosions of the skin and mucous membranes, acantholysis, and in vivo bound and circulating autoantibodies against keratinocyte antigen. Currently a handful of reports incriminate surgical trauma as an initiating factor in this disease. OBJECTIVE: To document pemphigus evolving in a wound after Mohs micrographic surgery. METHODS: Case report. RESULTS: We present a case of pemphigus that started in a Mohs surgical wound after the excision of a squamous cell carcinoma (SCC) from a 49-year-old woman. Biopsy of the preoperative lesion did not reveal pemphigus. Biopsy of the postoperative lesion revealed pemphigus with no residual SCC. CONCLUSION: We suggest that Mohs surgery, like any other skin surgery, may nonspecifically activate pemphigus. This change must be differentiated from postoperative wound infection and other causes of poor wound healing.