Tie-Over Dressings in Full-Thickness Skin Grafts

BACKGROUND A full-thickness skin graft is often performed by tie-over dressing to compress and immobilize it.
OBJECTIVE The aim of this study was to compare the results of a full-thickness skin graft with tie-over dressing performed with the classic technique and with simple dressing.
METHODS AND MATERIALS This was a prospective study in which 25 patients had tulle gras jelly tie-over dressing and 25 patients had a simple tulle gras dressing after full-thickness skin graft for nipple areola reconstruction.
RESULTS Graft success on the fifth day was evaluated at 100% for patients with a simple dressing and at 99% for those with tie-over dressing.
CONCLUSIONS In this study, simple dressing appeared to be at least as effective as the tie-over dressing. Simple dressing, however, was faster and left fewer residual marks than the tie-over dressing.     

The Beveled Edge Technique for Harvesting of Full-Thickness Skin Grafts

Background. Mohs surgery often uses the creation of a "beveled edge" of 45 degrees during the staged excision of skin cancers. Reconstruction of these defects frequently requires the use of full-thickness skin grafts. Because most wounds are best repaired with 90-degree edges, the beveled incision technique often used in Mohs micrographic surgery creates a wound that may need to be modified prior to reconstruction.
Objective. We present a method of harvesting the graft with a similar 45-degree angle beveled incision.
Methods. After marking, preparing, locally anesthetizing, and draping the donor site, the graft is harvested using a 45-degree angled incision. Any remaining fat is trimmed away from the base of the graft. The graft is then placed directly on the surgical defect without any "freshening" of the wound edges and is sutured into place.
Results. The graft takes well on the surgically created defect, leaving a cosmetically acceptable result.
Conclusion. We have found that harvesting the graft with a beveled incision of 45 degrees, similar to taking Mohs stages, hastens the repair process. This obviates the need to remove normal tissue to create a 90-degree angle and allows for better approximation of the dermal surface area of the graft to the base of the defect.     

The Australian Mohs Database: Short-Term Recipient-Site Complications in Full-Thickness Skin Grafts

BACKGROUND: There are only a few reports on the outcome with full-thickness skin grafts (FTSG) in defect reconstruction after Mohs micrographic surgery (MMS). OBJECTIVES: The objective was to evaluate the complications with FTSG in patients treated with MMS for cutaneous tumors. METHODS: This study is based on a prospective data collection of all patients in Australia treated with MMS and monitored by the Skin and Cancer Foundation, between 1993 and 2002. Primary outcome measures were FTSG recipient-site complications (partial/complete graft failure, graft infection, acute bleeding/hematoma, graft hypertrophy, and graft contracture). RESULTS: The study group included 2,673 patients (50.2% men) with a mean age of 64+/-14 years. Most tumors were basal call carcinoma (90.9%) and were located on the nose (63.8%), periocular area (14.8%), or auricular area (8.1%). A total of 11.7% of cases had recipient-site complications (graft hypertrophy, 42.3%; partial graft failure, 27.2%; graft contraction, 15.3%). Only 45.2% of complicated cases required treatment. CONCLUSION: Short-term recipient-site complications occurred in less than 12% of reconstructions with FTSG. Graft hypertrophy and partial graft failure accounted for most cases of complications. The authors have indicated no significant interest with commercial supporters.     

Irradiated Polyglactin 910 (Vicryl Rapide) for Placement of Full-Thickness Skin Grafts

BACKGROUND: The "unsuture" technique originally reported with the use of fast-absorbing gut for the placement of full-thickness skin grafts has provided years of successful full-thickness graft placement without the need for suture removal. OBJECTIVE: The objective was to explore another option for successful graft placement and survival using irradiated polyglactin 910 (Vicryl Rapide, Ethicon Inc, Somerville, NJ, USA), with its longer tensile strength of 7 to 10 days. METHODS: Irradiated polyglactin 910 was used to suture the edges and place basting sutures in full-thickness skin grafts. RESULTS: In our experience, we have found that the use of irradiated polyglactin 910 for the placement of full-thickness skin grafts provides an alternative to the "unsuture" technique with fast-absorbing gut. It provides excellent graft survival, easy workability, low inflammation, and good long-term cosmesis, without the need for suture removal. CONCLUSION: Irradiated polyglactin 910 provides another option for the placement of full-thickness skin grafts without the need for suture removal.     

A New Device for Securing Meshed Split-Thickness Skin Grafts

This report describes the design, operation, and biomechanical performance of the Auto Suture® Multifire Graftac-S® disposable surgical staplers and absorbable tacks. The performance of this reloadable stapler has been compared to that of the Auto Suture® Multifire Premium® disposable skin stapler. The Premium® stapler forms stainless steel staples to close the wound. The Graftac-S® ejects absorbable tacks into the graft from a cartridge, which can be reloaded during a single operation. In two clinical trials of 10 patients each, the Graftac-S® delivered absorbable tacks which were biocompatible and successfully secured the graft to the wound. The most obvious advantage of this device is that it obviates the need to remove the staples from the wound later. By the tenth postoperative day, about 90% of the tacks had extruded spontaneously, thereby reducing the amount of postoperative care required; discomfort to the patient during removal of the stainless steel staples is eliminated.     

Involvement of Keratinocyte Activation Phase in Cutaneous Graft Healing: Comparison of Full-Thickness and Split-Thickness Skin Grafts

BACKGROUND: Little is known about keratinocytic activation in the graft take and healing process. OBJECTIVE: To investigate the clinical and molecular differences between pure epidermal sheet graft (PESG), split-thickness skin graft (STSG), and full-thickness skin graft (FTSG). METHODS: Three different thickness skin grafts (PESG, STSG, and FTSG) were performed onto three kinds of porcine wounds: shallow, deep, and full. Graft take, contraction, and Ki-67 and beta1 integrin expression in epidermis were studied. RESULTS: All grafts took well. As expected, full wounds covered by PESG and STSG contracted more than those covered by FTSG, whereas shallow wounds covered by FTSG contracted more than those covered by STSG. No difference in contracture was observed among deep wounds covered by PESG, STSG, and FTSG. Up-regulation of Ki-67 and beta1 integrin expression was greater in PESG and STSG, compared with little expression in FTSG. CONCLUSION: The keratinocytic activation phase may occur both in the STSG and PESG healing process, as well as serum imbibition, inosculatory, and revascularization phases.     

Preoperative and Postoperative Topical Tretinoin on High-Tension Excisional Wounds and Full-Thickness Skin Grafts in a Porcine Model: A Pilot Study

BACKGROUND: Tretinoin induces neovascularization and the formation of collagen when applied topically. OBJECTIVE: The goal was to determine whether preoperative and postoperative treatment with tretinoin enhances the healing of high-tension, full-thickness excisional wounds and the survival of full-thickness skin grafts. METHODS: A blinded, randomized, placebo-controlled pilot study involved high-tension excisional wounds and full-thickness skin grafts treated perioperatively with tretinoin in a porcine model. RESULTS: Perioperative treatment of high-tension excisional surgery sites with tretinoin appeared to have no consistent beneficial or adverse effects on wound healing or scar spreading. In the full-thickness skin graft model, a trend toward impaired wound healing was noted. CONCLUSION: The collagen-inducing effects of topical tretinoin do not appear to enhance the healing of high-tension excisional surgery wounds in a porcine model. Tretinoin does not appear to improve the survival of full-thickness skin grafts and, in fact, a detrimental effect was apparent in our model.     

Clinical Trial of New Polyurethane Vascular Grafts for Hemodialysis: Compared with Expanded Polytetrafluoroethylene Grafts

Abstract: We developed a new polyurethane vascular access graft coated with gelatin and reinforced with knitted polyester fibers (PE-PEUG). Advantages over expanded-polytetrafluoroethylene graft (E-PTFEG) were previously reported in experimental studies. Between May 1990 and August 1992, 39 PE-PEUGs including 34 loop and 5 straight and 18 E-PTFEGs including 18 loop were implanted to create arteriovenous (AV) fistulas in a total of 52 adult patients on maintenance hemodialysis (HD). They were followed up until October 1994. Hemostasis on the suture line was achieved within 3 min in all patients implanted with PE-PEUGs. Bleeding from the needle holes of PE-PEUG stopped within 10 min with gentle finger pressure. Minimal local edema developed in only a few patients implanted with PE-PEUG while most patients implanted with E-PTFEG developed moderate lo cal edema. One seroma formation was found in an E-PTFE case. Aneurysmal dilatations were observed twice in a PE-PEUG patient 9 and 17 months after the implantation and once in a E-PTFEG patient 2 years after the implantation. The cumulative patency rate at 1 year in the PE-PEUG and E-PTFEG groups were 53.2 and 70.8%, respectively. Our clinical study showed that the PE-PEUG had several advantages over E-PTFEG: prompt hemostasis, no persistent edema and no formation of seroma, no change in elasticity, and sufficient mechanical strength. However, the cumulative patency rate was inferior to that with E-PTFEG implanted in our series. Further modifications are therefore necessary to improve the patency rate.     

Coronary Artery Bypass with "Snake" Grafts: Fifteen-year Follow-up

Abstract Background: Since 1970 we have used the "snake" graft in more than 8000 cases of coronary artery bypass grafting (CABG). We followed, for over 15 years, 214 patients who underwent CABG in 1981 with only a "snake" graft by one surgeon (William H. Sewell, M.D.). Methods : Eighty-four percent (180/214) were male and 16% (34/214) were female with an average age of 58 and 66 years, respectively. The average left ventricular ejection fraction (LVEF) was > 55% in 63% (135/214) of the patients and < 55% in 37% (79/214); 15% (33/214) had diabetes and 77% (164/214) were smokers. The mean preoperative New York Heart Association (NYHA) functional class was 3.1 ± 0.6 (range I-IV). Diagnostic arteriography demonstrated two vessel disease in 5% (9/214), three vessel disease in 89% (191/214), and left main disease in 6% (14/214). The average number of distal grafts per patient was 3.4. Coronary arteriography was performed 8-weeks post-operatively. Annual follow-up with a questionnaire determined incidence of redo procedures and survival. Results : The perioperative 30-day mortality was 1% (2/214). At 8 weeks there was a graft patency rate end-to-side of 85%, side-to-side 97%, and the proximal segment of 95%. Four percent (9/214) had redo surgery while 6% (13/214) underwent angioplasty during the 15 years. Sixty-seven percent (144/214) were alive at 15 years with a significantly improved mean NYHA functional class of 1.2 ± 0.9 (p < 0.001). Twenty-four percent of those 166 live patients (35/144) had an average LVEF of 50% by echocardiography. There were 34 (16%) noncardiac deaths, 32 (15%) cardiac deaths, and 2 (1%) unknown causes. Conclusions : The results of this study suggest that survival using the "snake" graft conduit is competitive with that observed using the internal mammary artery. (J Card Surg 1998; 13; 18–23)     

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 inguial 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.     

A Technique for Preclotting Vascular Grafts

Porous vascular grafts can be safely and securely sealed prior to use by a thirty-minute soak in cryoprecipitate followed by a ten-minute immersion in topical thrombin. This technique does not use the patient's blood and works in a patient fully anticoagulated with heparin. It has provided absolute graft competence in a series of 12 patients with valve conduits and 6 with patch enlargement of the ascending aorta.     

New Regenerative Vascular Grafts for Hemodialysis Access: Evaluation of a Preclinical Animal Model

The purpose of this study was to evaluate a suitable animal model for the in vivo evaluation of patency and vascular tissue regeneration in small intestinal submucosa (SIS) vascular grafts for hemodialysis access. First, a 4-mm U-shaped SIS vascular graft was implanted between the internal carotid artery (CA) and the external jugular vein (JV) in five sheep and six swine. The U-shape grafts remained functional for 53 ± 4 days in sheep and 32 ± 2 days in swine. The sheep model presented exaggerated inflammation, so the swine model was selected for the in vivo study. Based on these initial results, a 4-mm C-shape SIS vascular graft with SIS circumferential reinforcement was developed to mechanically improve the vascular graft and manage complications identified during surgery in both sheep and swine. The C-shape vascular graft was implanted in a swine model (n = 3) between the CA and JV. GORE-TEX® vascular grafts were used as controls in the contralateral side of the neck. C-shape grafts remained patent for 47 ± 4 days, whereas the GORE-TEX® grafts were patent for 30 ± 15 days. The C-shape vascular graft was easier to handle during surgery, and its circumferential reinforcement improved in vivo patency, avoiding kinks in the graft after implantation. Histological results showed neovascularization and some regeneration with the alignment of endothelial cells in the vascular wall of the grafts. The model developed may be helpful in other research involving in vivo studies of vascular grafts for hemodialysis access.     

Grafts in Dermatologic Surgery: Review and Update on Full- and Split-Thickness Skin Grafts, Free Cartilage Grafts, and Composite Grafts

Background. Skin grafting has evolved in the past centuries to encompass numerous well-established reconstruction techniques that are uniquely able to restore structure, function, and cosmesis to a variety of surgical wounds.
Objective. To provide a detailed overview of the general principles of skin grafting geared for the dermatologist and the dermatologic surgeon.
Methods. Comprehensive review of the literature.
Results. A summary of the different applications and techniques of full- and split-thickness skin grafts, free cartilage grafts, and composite grafts is presented. Indications, advantages, disadvantages, techniques, and complications are discussed in depth.
Conclusion. Skin grafting is a dynamic and versatile method of cutaneous reconstruction that can be accomplished successfully with a thorough understanding of the principles and techniques of grafting.