Basal cell carcinoma mimicking a chronic unstable scar in an adolescent patient with Kindler syndrome

We present the case of Kindler syndrome in a 17-year-old man. After excision, histomorphological analysis, and wound closure of a chronic unstable scar in the right popliteal region, a basal cell carcinoma was diagnosed accidentally. A malignancy was not suspected, although the patient already had biopsies, multiple trials of debridement, and skin grafting earlier elsewhere. While an initial attempt to close the defect with a microsurgical flap was abandoned, due to microvascular irregularities, a wound closure was achieved with a free skin graft. The postoperative histomorphologic analysis revealed the surprising diagnosis of a basal cell carcinoma, fortunately with free margins. At follow-up 1 year later, the grafted area was stable, and there was no recurrent disease. A preoperative histomorphologic analysis of the complete excised chronic wound, especially in known skin disorders—regardless of young age—is mandatory. Furthermore, the presented case showed that an abnormal deposition of collagen, and enhanced coprostasis with migration of granulocytes, destroys the normal consistency of small vessels and presents a limitation for microsurgical procedures in these patients.     

Axillary hidradenitis suppurativa: wide excision and flap coverage is best

Summary The extent of axillary excision and method of closure in 17 patients (29 axillae) with symptomatic chronic axillary hidradenitis suppurativa was analyzed. Limited excision of only the diseased skin led to recurrence in 2 of 3 patients, and excision of the hair-bearing skin alone, in 2 of 5 patients. There was no recurrence in 11 patients after wide excision. Some patients had more than one procedure. Three of four patients who had skin grafts used for closure, developed axillary contractures. Primary closure was achieved successfully in 7 patients (14 axillae). Flap coverage was used to close 12 axillae in 9 patients (3 patients had both axillae treated). These flaps included Limberg 4; random fasciocutaneous 3; parascapular fasciocutaneous: 5. Our experience suggests that wound closure after wide excision in the axilla is best achieved by means of a flap. While smaller defects can be closed with random fasciocutaneous flaps, wide axillary excision often leads to a large defect. The fasciocutaneous parascapular flap should be considered where a large defect exists.     

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。     

Skin regeneration for giant pigmented nevus using autologous cultured dermal substitutes and epidermis separated from nevus skin

We have developed a modality of treatment of giant pigmented nevus of intradermal type. This method involves application of autologous cultured dermal substitute (CDS), followed by grafting of epidermis separated from the patient's nevus skin. To prepare the wound bed, autologous CDS was applied onto a full-thickness skin defect after complete excision of the nevus. The excised nevus skin was preserved for 1 week, after which the epidermis was separated from the nevus skin by enzymatic treatment with dispase. The epidermis thus obtained was grafted onto the resulting wound bed. This procedure was used to treat a giant pigmented nevus on a 7-year-old patient. The grafted region was soft with good tone 1 year after epidermis grafting. These results indicate that the present method can achieve complete excision of giant nevus, with esthetically acceptable results, although it requires careful monitoring for a long time.     

Reconstruction of full-thickness loss skin wounds using skin collagen allografts.

Sheets of allogeneic dermal collagen measuring 20 X 15 mm and prepared by trypsin treatment of full-thickness skin were grafted under skin flaps in rats. After 2 to 5 weeks the protective recipient skin was excised and replaced by split-thickness skin isografts which remained viable on their supportive collagen beds. On average such composite grafts maintained 84 per cent of their original size over 3 to 28 weeks and in contrast with split-thickness skin grafts achieved full-thickness reconstruction of the excised skin.     

Charles procedure for lymphedema: A warning

Five patients with lower extremity lymphedema treated by subcutaneous excision and split-thickness graft resurfacing (from the opposite extremity) have been followed up. Three of these patients underwent amputation of the leg because of exophytic changes within the grafted skin, chronic cellulitis and skin breakdown. Resurfacing with a split-thickness graft causes a deformity that is significantly worse than the original lymphedema.In the Charles procedure (subcutaneous and deep fascial excision followed by full-thickness grafts), deep muscle fascia should be excised with the subcutaneous tissue and the extremity resurfaced with more durable full-thickness grafts taken from the excised tissue. However, the risks of graft failure should be considered.Over the past 9 years, 25 patients with lymphedema have been successfully managed by staged subcutaneous excision beneath flaps. This procedure safely provides consistent reduction in size, improvement in function and very satisfactory esthetic results. In the author's opinion the Charles procedure is therefore preferred for treating lymphedema of the extremity.     

First experiences with the collagen-elastin matrix Matriderm as a dermal substitute in severe burn injuries of the hand

Restoring function after hand burns plays a major role in the restitution of a quality of life. Thereby the reconstructed pliability of the grafted areas is of utmost importance for good hand function. The collagen elastin matrix Matriderm was evaluated as a dermal substitute for the treatment of severe hand burns. In a series of 10 patients, mean age 43 years, TBSA 22.8%, an early debridement and immediate grafting with the matrix and unmeshed skin graft was carried out in a one-stage procedure. In the early postoperative follow up an overall take rate of 97% was observed. In contrast to conventional skin grafts, the color of the skin grafts over the matrix appeared pale in the first few days, but after 2 weeks no difference was observed. After three months, pliability of the grafted area was excellent, (mean VSS 3.2+/-1.2). Full range of motion was achieved in all hands, no blisters and no unstable or hypertrophic scars occurred. Matriderm has proved to be a dermal substitute suitable for the treatment of hand burns. We therefore consider Matriderm as a promising dermal substitute for the treatment of severe hand burns.     

The use of cultured autologous epidermis in the treatment of extensive burn wounds

Seventeen patients with deep second- and third-degree burn wounds have been grafted with cultured autologous epidermis. These epidermal cell sheets were cultivated according to the feeder layer technique as described by Rheinwald and Green. After dispase treatment and detachment from the culture vessel, the cell sheets, mounted on a polyamide mesh, were ready for grafting. Patients with wounds excised at an early stage, prepared with human cadaver allografts or synthetic dressings, showed a significantly better graft take than nonexcised, chronic granulating wounds which were grafted at a later stage (47% versus 15%; p less than 0.002). Sandwich treatment of expanded mesh autografts and cultured autograft overlay did not improve the graft take, although in some cases wound healing was accelerated. The graft take was inversely correlated with the age of the patient (p = 0.01), and showed a weak inverse correlation with the day of first (and subsequent) culture grafting (p = 0.07). Wound infection was the main cause of graft failure. Up to 4 years after grafting, the grafted areas showed continued stability and the regenerated skin became supple, smooth, and pliable. Hypertrophic scar formation was less than observed in comparable areas treated with meshed grafts. Wound contraction occurred approximately to the same extent as in split-thickness skin grafts. We emphasize that by a better control of wound infection the graft take, also in secondary-stage procedures, can significantly improve.     

Application of V.A.C.-therapy during plastic surgical treatment of a bifocal Marjolin ulcer

Marjolin ulcers are scar carcinomas most often found in old instable burn scars, the majority histopathologically characterized as squamous cell carcinomas. Surgical therapy includes radical excision and subsequent defect closure. We report about a 69 year old patient suffering from two scar carcinomas on the right cheek and right chest and abdomen due to an extensive infant burn injury. During a 2 stage procedure, both ulcers were initially excised and resulting soft tissue defects were closed temporarily by applying V.A.C. therapy. During a second procedure defect closure on the right cheek was achieved by using a free radial forearm flap following neck dissection. Additionally, the extensive defect including chest and abdominal wall as well as the flap donor site on the left forearm were covered with split thickness skin grafts and subsequently secured by applying V.A.C. therapy for 5 days. 13 days later, the patient was discharged from our clinic. All skin grafted areas as well as the free flap were stably healed. Our report demonstrates that the application of vacuum therapy is not only useful during temporary closure of large wound sites but also secures healing of large and critical areas grafted with split thickness skin grafts in tumour patients.     

Microcrystalline collagen hemostat (MCCH) and wound healing.

The effect of MCCH on wound healing was studied in animals and patients. A full thickness dorsal skin defect was made in mice and standard amounts of MCCH applied immediately to the wound in half the mice. There were no significant differences in wound closure rates between control and MCCH treated mice. A standard dorsal skin incision was made in rats. In half the rats, MCCH was put into the incision just before suturing with fine stainless steel sutures. There were no statistically significant differences in breaking strengths between control and MCCH treated rats when tested on the 8th, 20th and 40th days postoperatively. Histologic examination of the wounds showed mild inflammatory reaction surrounding the MCCH-fiber fragments, but no giant cells. Small amounts of MCCH were demonstrable at 40 days. Full thickness skin burns in pigs were excised one day after burning. MCCH was applied immediately in some pigs; excess MCCH was removed by saline irrigation. Split thickness skin autografts were applied. MCCH was applied to donor sites. The "takes" of the grafts were excellent and not affected by the use of MCCH and the donor sites healed uneventfully. MCCH was used in four patients with burns, three of whom underwent early excision of full thickness skin burns and immediate autografting. The fourth underwent skin grafting to the granulating areas 3 months after injury. The MCCH was applied to some donor sites and to some areas of excision. In one patient with severe burns, wound sepsis developed equally in areas with and without MCCH and the grafts were lost. In the other three patients, there were excellent takes of the grafts at all sites. All donor sites, treated and untreated, healed normally in all patients.     

延期皮肤移植术在烧伤后重度关节畸形整复中的应用

目的　探索治疗重度瘢痕挛缩性关节畸形简便有效的整复技术。方法　Ⅰ期手术整复关节畸形 ,创面延期 3～ 5天 ,Ⅱ期手术植大片中厚皮。观察皮片成活质量及远期整复效果。结果　延期植皮法皮片成活率达 1 0 0 % ,关节畸形经分期整复可达到完全复位 ,远期整复效果良好。结论　延期植皮技术是一种简单有效的重度关节畸形整复方法。     

Negative‐pressure wound dressings to secure split‐thickness skin grafts in the perineum

Several researches have shown that negative‐pressure wound dressings can secure split‐thickness skin grafts and improve graft survival. However, in anatomically difficult body regions such as the perineum it is questionable whether these dressings have similar beneficial effects. In this study, we evaluated the effects of negative‐pressure wound dressings on split‐thickness skin grafts in the perineum by comparing wound healing rate and complication rate with that of tie‐over dressings. A retrospective chart review was performed for the patients who underwent a split‐thickness skin graft to reconstruct perineal skin defects between January 2007 and December 2011. After grafting, the surgeon selected patients to receive either a negative‐pressure dressing or a tie‐over dressing. In both groups, the initial dressing was left unchanged for 5 days, then changed to conventional wet gauze dressing. Graft success was assessed 2 weeks after surgery by a single clinician. A total of 26 patients were included in this study. The mean age was 56·6 years and the mean wound size was 273·1 cm². Among them 14 received negative‐pressure dressings and 12 received tie‐over dressings. Negative‐pressure dressing group had higher graft taken rate (P = 0·036) and took shorter time to complete healing (P = 0·01) than tie‐over dressing group. The patients with negative‐pressure dressings had a higher rate of graft success and shorter time to complete healing, which has statistical significance. Negative‐pressure wound dressing can be a good option for effective management of skin grafts in the perineum.     

New application of purse string suture in skin cancer surgery

Closure of large wounds may require full‐thickness skin grafts, but their use is burdened by donor tissue availability and morbidity; the use of the purse string technique is an elegant way to overcome this problem. The study highlights the gain in terms of graft donor site morbidity and oncological radicality. The study included a group of 47 patients who underwent surgical excision for skin cancer and whose wounds were covered using a purse string suture and a skin graft. Radius of the defect left was measured after the lesion''s excision and after the purse string suture. Thereafter, the difference between the initial defect area and the area after purse string suture was calculated. Initial defects ranged from 3.85 to 61.5 cm². After skin graft, the purse string suture ranged between 2.2 and 40 cm² (mean area = 14 cm²). Gained area before the graft measured from 1.3 to 21.5 cm² (mean gained area = 7.1 cm²). Average reduction was 33%. The technique allows a reduction of the size of the area to be grafted and the skin graft donor area, thus increasing the possibility of the feasibility of full‐thickness grafts. In addition, it allows an optimal observation both of the area of tumour excision and margins during follow‐up controls.     

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.     

Wide local excision and split-thickness skin graft for circumferential Paget's disease of the anus

BACKGROUND: Our aim was to evaluate the results of wide local excision followed by split-thickness skin graft for circumferential perianal Paget's disease. METHODS: Between 1995 and 1999, 5 patients with perianal Paget's disease underwent wide local excision of the disease. The circumferential involvement was documented by preoperative mapping. Standard orthograde bowel cleansing and oral antibiotics were given the day prior to surgery. The wound was allowed to granulate and confirmation of negative margins was obtained on permanent sections taken from the excised specimens. On postoperative day 4, split-thickness skin grafts harvested from the lateral thigh were applied (surface using area ranging from 100 cm(2) to 240 cm(2)). The grafts were secured in place with a 3-0 Vicryl suture and covered with a pressure dressing. After 4 days of bedrest, the dressing was taken down under anesthesia (day 8). RESULTS: Graft survival was 100% in 3 patients, 80% in 1 patient, and 70% in another. Postoperatively, clinical follow-up was conducted at 3-month intervals. In 2 patients, anal stenosis developed after the operation and resolved by gentle self-dilation. At a mean follow-up of 42 months (range 21 to 78), adequate cosmetic and functional results were obtained. Recurrence of Paget's disease has occurred in 1 patient (at 21 months) and an invasive anal gland carcinoma was found in 1 patient (at 48 months). CONCLUSIONS: Wide local excision and circumferential split-thickness skin grafting achieves adequate cosmetic and functional results without the need for diverting colostomy. However, there is a considerable recurrence rate after surgery, which warrants very close follow-up to rule out recurrent disease or underlying adenocarcinoma.     

Early burn wound excision and skin grafting postburn trauma restores in vivo neutrophil delivery to inflammatory lesions

This study assessed the effect of early vs delayed postburn wound excision and skin grafting on the in vivo neutrophil delivery to a delayed-type hypersensitivity (DTH) reaction and a bacterial skin lesion (BSL). Male Lewis rats were presensitized to keyhole-limpet hemocyanin. Group 1 comprised sham controls. Groups 2 through 4 were given a 30% 3 degrees scald burn, but the burn wounds were excised, and skin was grafted on days 1, 3, and 7, respectively, after the burn. Group 5 comprised burn controls. Twelve days after burn trauma, all rats were injected at different intervals (during a 24-hour period) with a trio of intradermal injections of keyhole-limpet hemocyanin, Staphylococcus aureus 502A, and saline at different sites. In vivo neutrophil delivery to these dermal lesions was determined by injecting indium in 111 oxyquinoline-labeled neutrophils isolated from similarly treated groups of rats. Neutrophil delivery to DTH and BSL lesions was restored to normal by excision and skin grafting of the burn wound one day after burn trauma. Waiting three days after burn trauma to excise and skin graft the wound partially, but not completely, restored the in vivo neutrophil delivery to DTH and BSL lesions. Waiting one week to excise and skin graft a burn wound resulted in no improvement in neutrophil delivery to DTH and BSL dermal lesions. It was concluded that burn wound excision and skin grafting immediately after burn trauma restored in vivo neutrophil delivery to a BSL and DTH dermal lesion. This may, in part, explain the beneficial effect of early aggressive burn wound debridement in patients with burn injuries.     

Acellular allograft dermal matrix: immediate or delayed epidermal coverage?

In a prospective, randomized study seventeen patients received skin grafts to a freshly excised burn wound. One group was grafted with a deantigenized dermal matrix and immediately overgrafted with thin autograft. The second group was grafted with dermal matrix, which was then covered with bank allograft for protection, and autografted 1 week later. Each group also received a standard split thickness control graft. Assessment was carried out for up to 1 year. There were no statistically significant differences of graft take between any of the groups, or in the Vancouver scar score at follow-up. Thin donor sites used for dermal matrix coverage healed faster than standard control graft sites, P<0.001. Immediate grafting of acellular dermal matrix with thin autograft works well and leads to an acceptable late result, with faster donor site healing than standard split thickness grafts.     

The rate of re-epithelialization across meshed skin grafts is increased with exposure to silver

The objective in this study was to determine whether exposure to pure silver increases the rate of re-epithelialization across a partial thickness wound. A meshed skin graft, placed on an excised burn wound was used as a healing model. Methods: The rate of meshed skin graft epithelial closure on an exposed burn using a moist healing environment was shown. A moistened silver delivery system (Acticoat) was compared with a standard xeroform and eight ply gauze dressing continually moistened with a 0.01% neomycin and polymyxin solution (NP). Twenty burn patients with deep burns of over 15% of TBS were excised and grafted with 2:1 meshed grafts. One graft area was treated with the antibiotic solution and another with the silver delivery. The meshed graft was performed within 3 days of injury. Results: No infections were noted and quantitative swab cultures gave less than 10(2) bacteria in all cases at wound closure. At day 7, re-epithelialization was complete with silver and 55% closed with NP solution. Wound closure was complete in the NP solution group at day 10. Silver increased re-epithelialization rate by over 40%, a significant increase. Graft take was over 95% in both groups. Conclusion: Silver released in a moist wound surface environment significantly increases the rate of re-epithelialization compared to a standard antibiotic solution.     

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."     

Efficacy of hydrosurgical excision combined with skin grafting in the treatment of deep partial-thickness and full-thickness burns: A two-year retrospective study

IntroductionDeep partial-thickness and full-thickness burn wounds often undergo tangential excision or escharectomy to expose healthy tissue, combined with skin grafting to promote wound healing. However, conventional tangential excision with the humby knife leads to inevitable damage to the dermis while excising burn tissue due to the lack of precision. Indeed, the preservation of dermal tissue is a key factor in determining wound healing and scar quality. The precision and tissue selectivity of the Versajet Hydrosurgical System has been established for excising burn tissue while preserving dermal tissue. In this study, we retrospectively compared the efficacy of "Hydrosurgical excision combined with skin grafting" and "Conventional tangential excision combined with skin grafting" in treating deep partial-thickness and full-thickness burn wounds to demonstrate that hydrosurgery improved the treatment of deep partial-thickness and full-thickness burns.MethodsA total of 86 patients with deep partial-thickness and/or full-thickness burns with a total burn surface area (TBSA) ≤ 25% from July 2018 to July 2020 were included in this study and were divided into experimental (hydrosurgical excision combined with skin grafting, n = 43) and control (conventional tangential excision combined with skin grafting, n = 43) groups. Parameters were analyzed, including the intraoperative blood loss volume per unit area of grafted skin, surgery duration, wound healing time, skin graft survival, and the treatment costs per unit of burned area. Scar assessment was performed at 1 year with the modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA).ResultNo significant difference was found in male to female ratio, age, weight, TBSA, burn depth, skin grafting area (SKA), skin grafting methods, cases treated with carbon dioxide fractional laser or incidence of inhalation injury, and the incidence of hypovolemic shock between two groups(p > 0.05). Compared with the control group, patients treated with hydrosurgical excision combined with skin grafting experienced less intraoperative blood loss volume per unit area of grafted skin (p < 0.05). The mVSS-TBSA of patients that underwent hydrosurgical excision combined with skin grafting was significantly improved in comparison to the control group (p < 0.01). No significant difference was found in surgery duration, wound healing time, skin graft survival and treatment costs per unit of burned area between the two groups (p > 0.05).ConclusionHydrosurgical excision combined with skin grafting reduced intraoperative blood loss volume per unit area of grafted skin, improved scarring 1-year after injury, and did not increase the treatment costs per unit of burned area. This technique provides a novel alternative for managing deep partial-thickness and full-thickness burn wounds.