Use of split‐thickness plantar skin grafts in the management of leg and foot skin defects

The basic principle of donor site selection is to take skin from areas that will heal with minimal scarring while balancing the needs of the recipient site. For skin loss from the lower legs and feet, the most common harvest site for split‐thickness skin grafts is the anterior or posterior thigh; grafts from the plantar areas have been mostly used to cover the volar aspect of digits and palms. Between September 2015 and September 2017, 42 patients with areas of skin loss on the legs or feet were treated with plantar skin grafts because of their cosmetic benefits and the convenience of the surgical procedure and postoperative wound care. Our technique of harvesting a single layer of split‐thickness skin graft (0.014 in. thick) from a non‐weight‐bearing area of the foot of the injured leg is simple and provided good functional and cosmetic outcomes at both the donor and recipient sites. All patients were very satisfied with the recovery progress and final results. Therefore, in the management of skin defects in the lower legs or feet that comprise less than 1.5% of the total body surface area, our surgical method is a reliable alternative to anterior or posterior thigh skin grafting.     

The use of the Meek technique in conjunction with cultured epithelial autograft in the management of major paediatric burns

Background

The management of major paediatric burns remains challenging, in part due to limited donor sites. Skin graft expansion facilitates rapid closure of the burn wound, reducing the risk of sepsis. We reviewed our unit's experience with a combined modified Meek technique and cultured epithelial autograft (CEA).

Methods

A retrospective chart review over a seven year period from April 2004 to April 2011 was conducted of patients whose burns were treated with Meek and CEA.

Results

The Meek technique was combined with meshed split skin grafts and CEA to either donor, graft site or both in 7 cases. One case had Meek skin grafts alone with cultured cells applied to both donor and graft sites. There were two scald burns and five flame burns, with total body surface area ranging from 30% to 70%. Mean length of stay was 51 days (range 41–74 days). The average number of surgical procedures undergone to obtain good coverage was 3.3. There were small (1–3%) areas of breakdown in six cases which received regrafting. Two of these patients had confirmed wound infections. All patients had varying degrees of hypertrophic scarring (HTS) but remained well at follow up.

Conclusions

The Meek technique facilitates high expansion ratios, allowing for a greater area of skin coverage. Epithelialisation in the burn wound appeared to be enhanced by the application of CEA. The Meek technique in combination with CEA would appear a useful additional option in achieving wound closure in the severely burned paediatric patient.     

The mesh skin graft--true expansion rate

Using the mesh graft II dermatome (Zimmer) for split skin graft expansion, the 3 to 1 and 1.5 to 1 expansion rates were evaluated for true clinical expansion. In one hundred and one 1.5 to 1 expanded grafts the actual expansion was 1.2 and in sixty 3 to 1 expanded grafts, it was 1.5.     

人组织工程全层皮肤在烧伤创面中厚供皮区的应用

目的观察人组织工程全层皮肤(ActivSkin)在中厚供皮区临床应用效果.方法 9例患者,年龄17～43岁.其中5例1%～6%总体表面积烧伤,深Ⅱ度～Ⅲ度;4例烧伤后瘢痕.每例患者2个部位创面,均使用自体中厚皮片修复.切取皮片后供区遗留创面随机分为试验组和对照组,行自体对照观察.试验组创面采用ActivSkin修复,对照组创面采用凡士林油纱覆盖.术后观察创面疼痛、愈合时间及治愈率;术后7～30 d每日观察创面愈合情况,1、3、6个月定期随访.结果试验组创面术后疼痛明显减轻,愈合时间为9.67±2.92 d,比对照组16.56±2.96 d提前,差异有统计学意义(P＜0.05);治愈率均为100%.术后随访试验组创面供皮区愈合后未见水疱、残余创面发生,瘢痕形成减轻;对照组创面4例于术后3个月内有水泡形成,残余创面发生. 结论ActivSkin可减轻中厚供皮区创面疼痛,加速愈合,并能预防供皮区愈合后水疱、残余创面发生,降低瘢痕形成.     

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.     

自体刃厚头皮片移植厚中厚皮片供区以抑制瘢痕增生

目的:探讨应用自体刃厚头皮片移植厚中厚皮片供区以抑制瘢痕增生的可行性及应用效果。方法:烧伤后全身大范围的增生性瘢痕患者24例,行功能部位的增生性瘢痕切除,应用非功能部位的大张厚中厚皮片修复,厚中厚皮片供区应用刃厚头皮片移植修复。结果:24例患者非功能部位厚中厚皮片供区经刃厚头皮片移植后,未见有明显的瘢痕增生。经随访半年至2年11例,2年以上3例,均未见有明显的瘢痕增生。头皮片供区无瘢痕形成,头发生长良好。结论:应用自体刃厚头皮片移植厚中厚皮片供区抑制瘢痕增生是一种可行的方法,值得临床推广。     

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.     

Mesh graft urethroplasty using split thickness skin graft or foreskin

Long urethral strictures remain one of the hazards of modern urology. Reconstructive operations with scrotal skin suffer a high rate of recurrent stricture. To avoid complications, meshed split thickness skin graft or foreskin was used to construct a neourethra. In stage 1 split thickness skin graft is harvested and transplanted along the opened urethra. In stage 2 the neourethra is formed 8 to 12 weeks later. Since 1977 mesh graft urethroplasty has been performed in 96 patients using meshed foreskin (76) or split thickness skin grafts (23). In all but 1 patient excellent anatomical and functional results were achieved regardless of which type of graft was used. This technique was most useful in exceedingly long or problematic strictures, for example in spinal cord injury patients.     

无细胞真皮基质与自体皮复合移植愈合过程的观察

目的 :为改善植皮区外观和功能 ,并同时减轻供皮区瘢痕增生。方法 :应用自制的无细胞真皮基质与薄的刃厚自体皮复合移植应用于 2例切削痂后的烧伤创面。结果 :未发现对复合移植物的排异反应。创面愈合后 ,大体观察发现移植网状自体皮的网状形式已变得不明显 ,自体小皮片的轮廓基本消失 ,均反应了愈合过程的特殊性。光镜和电镜观察发现复合移植区基底膜清晰、连续且完整等。与对照部位相比 ,复合移植区瘢痕增生减轻 ,未见明显挛缩 ,皮肤弹性较好。结论 :至少到目前为止的观察期 (3～ 4个月 )内 ,较薄的刃厚自体皮与无细胞真皮基质复合移植后外观和功能等同或优于单纯刃厚自体皮移植     

In vivo expansion and regeneration of full‐thickness functional skin with an autologous homologous skin construct: Clinical proof of concept for chronic wound healing

A new cell‐tissue technology uses a patient's skin to create an in vivo expanding and self‐organising full‐thickness skin autograft derived from potent cutaneous appendages. This autologous homologous skin construct (AHSC) is manufactured from a small full‐thickness skin harvest obtained from an uninjured area of the patient. All the harvested tissue is incorporated into the AHSC including the endogenous regenerative cellular populations responsible for skin maintenance and repair, which are activated during the manufacturing process. Without any exogenous supplementation or culturing, the AHSC is swiftly returned to the patient's wound bed, where it expands and closes the defect from the inside out with full‐thickness fully functional skin. AHSC was applied to a greater than two‐year old large (200 cm²) chronic wound refractory to multiple failed split‐thickness skin grafts. Complete epithelial coverage was achieved in 8 weeks, and complete wound coverage with full‐thickness functional skin occurred in 12 weeks. At 6‐month follow‐up, the wound remained covered with full‐thickness skin, grossly equivalent to surrounding native skin qualitatively and quantitatively equivalent across multiple functions and characteristics, including sensation, hair follicle morphology, bio‐impedance and composition, pigment regeneration, and gland production.     

An evaluation of Aquaphor Gauze dressing in burned children

Aquaphor Gauze was evaluated as a dressing for skin graft donor sites, for partial thickness burn injuries and for split thickness skin grafts. Control dressings consisted of: fine mesh gauze for skin graft donor sites. silver sulphadiazine (Silvadene) on coarse mesh gauze for the partial thickness burns, and nitrofurazone cream (Furacin) on fine mesh gauze for the skin grafts. The Aquaphor Gauze was found to be inferior to the fine mesh gauze for donor site dressings. No statistically significant difference was identified between Aquaphor Gauze and controls for the treatment of partial thickness burns. As a dressing for skin grafts the Aquaphor Gauze was significantly superior to the control dressing as measured by graft take and reduced patient pain. We would recommend that Aquaphor Gauze be used as a dressing for skin grafts where the risk of infection is not excessive.     

Ultrastructural and surface-area changes of acute and traditionally expanded full thickness skin grafts.

The purpose of this study was to determine the effect of expansion on the survival of full thickness skin grafts. In eight pigs 300 ml rectangular tissue expanders were placed into subcutaneous pockets. In four pigs (group I), the expanders were inflated rapidly with a mean 200 ml saline. In the other four pigs (group II), a mean total of 300 ml saline was injected in weekly increments over eight weeks. At the completion of expansion, full thickness skin grafts were taken from the expanded area and sutured back to the donor defects. In both groups surviving graft areas were similar to controls (p greater than 0.06). This study showed that acute and traditional expansion does not lead to increased loss of full thickness skin grafts of the expanded skin.     

厚中厚皮片游离移植修复下肢慢性溃疡创面

目的:探讨厚中厚皮片游离移植治疗下肢慢性溃疡创面的临床效果。方法:2016年1月-2018年12月,收治20例下肢慢性溃疡创面患者,切除肉芽创面基底纤维板层后,进行厚中厚皮片游离移植修复手术。结果:17例患者皮片完全成活,2例患者皮片出现少量水疱,1例患者皮片出现局部感染、坏死。术后随访6~12个月,下肢外观及功能恢复良好。结论:去除肉芽创面基底纤维板层,应用厚中厚皮片游离移植修复下肢慢性溃疡创面,可获得良好临床效果。     

Die homologe Spalthautnetztransplantation bei ausgedehnten Verbrennungen

Zusammenfassung Es wird über Anwendungsm?glichkeiten homologer Spalthautnetztransplantate in der Interimsdeckung schwerer Verbrennungen berichter. Hauptvorteile sind neben der Materialersparnis die gute Drainage des Wundgrundes, die Einsparung von Autotransplantaten nach tangentialer Nekrosenexzision durch Protektion des Wundgrundes und multizentrischer Epithelisation aus erhaltenen Anhangsgebilden sowie die gegenüber ganzen, homologen Spalthautlappen offensichtlich verz?gerte Absto?ungsreaktion.

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Summary The main advantages of applying split thickness mesh grafts for interim treatment of severe burns consists in the small amounts of skin needed and in the excellent wound drainage. In addition a homologous mesh graft is rejected later than a conventional homologous split thickness skin graft.

     

An Alternative Treatment for the Split Skin-Graft Donor Site

There are a variety of methods employed in the postoperative management of the partial thickness donor site created during harvest of a split thickness skin graft. Each technique may be associated with potential complications of fluid loss, excessive pain, prolonged period for healing and delayed mobility, hypertrophic scarring, undesirable pigment aesthetics, and thin skin poorly resistant to everyday trauma. Thompson, and Converse and Robb-Smith have previously shown improved donor site outcome with the application of thin split skin grafts. Based on these studies, we present a technique that involves 1.5:1 meshing of a split skin graft and dividing it into equal halves so that one half is used to cover the defect and the other half is immediately returned to the donor site. Patients who are elderly, debilitated, or who have thin, poor-quality skin can expect less discomfort, reduction of fluid loss, improved durability and elasticity, and lower incidence of hypertrophic scarring with the proposed donor site regrafting.     

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.     

Epidermal grafting for wound healing: a review on the harvesting systems,the ultrastructure of the graft and the mechanism of wound healing

Epidermal grafting for wound healing involves the transfer of the epidermis from a healthy location to cover a wound. The structural difference of the epidermal graft in comparison to the split‐thickness skin graft and full‐thickness skin graft contributes to the mechanism of effect. While skin grafting is an epidermal transfer, little is known about the precise mechanism of wound healing by epidermal graft. This paper aims to explore the evolution of the epidermal graft harvesting system over the last five decades, the structural advantages of epidermal graft for wound healing and the current hypotheses on the mechanism of wound healing by epidermal graft. Three mechanisms are proposed: keratinocyte activation, growth factor secretion and reepithelialisation from the wound edge. We evaluate and explain how these processes work and integrate to promote wound healing based on the current in vivo and in vitro evidence. We also review the ongoing clinical trials evaluating the efficacy of epidermal graft for wound healing. The epidermal graft is a promising alternative to the more invasive conventional surgical techniques as it is simple, less expensive and reduces the surgical burden for patients in need of wound coverage.     

Simultaneous dermal matrix and autologous split‐thickness skin graft transplantation in a porcine wound model: A three‐dimensional histological analysis of revascularization

Despite the popularity of a simultaneous application of dermal matrices and split‐thickness skin grafts, scarce evidence exists about the process of revascularization involved. In this study, we aimed at analyzing the progression of revascularization by high‐resolution episcopic microscopy (HREM) in a porcine excisional wound model. Following the surgical procedure creating 5 × 5 cm² full‐thickness defects on the back, one area was covered with an autologous split‐thickness skin graft alone (control group), the other with a collagen–elastin dermal matrix plus split‐thickness skin graft (dermal matrix group). Two skin biopsies per each group and location were performed on day 5, 10, 15, and 28 postoperatively and separately processed for H&E as well as HREM. The dermal layer was thicker in the dermal matrix group vs. control on day 5 and 28. No differences were found for revascularization by conventional histology. In HREM, the dermal matrix did not appear to decelerate the revascularization process. The presence of the dermal matrix could be distinguished until day 15. By day 28, the structure of the dermal matrix could no longer be delineated and was replaced by autologous tissue. As assessed by conventional histology and confirmed by HREM, the revascularization process was comparable in both groups, notably with regard to the vertical ingrowth of sprouting vessels. The presented technique of HREM is a valuable addition for analyzing small vessel sprouting in dermal matrices in the future.     

A thrombin ointment that achieves rapid haemostasis of split thickness donor wounds, particularly on the scalp

A procedure is described to achieve rapid haemostasis of split thickness donor wounds by using an ointment containing thrombin (10,000 units mixed in 10 g of petroleum jelly-based gentamicin ointment). The ointment, prepared just before the removal of the skin graft, is immediately spread over the wound after the graft has been taken. With this technique, a steady haemostasis is promptly and simply achieved without the recurrence of bleeding compared to the technique using only a thrombin solution (bleeding time: a mean of 11.5 s for the thrombin ointment and 25.5 s for the thrombin solution, P less than 0.01). Thus, particularly when many skin grafts are needed, further skin grafts from adjacent areas can be readily taken without interference by bleeding. This procedure has proved to be extremely useful in achieving rapid haemostasis of split thickness skin donor wounds, especially when taking skin grafts from the scalp.     

Cultured epidermal autografts: a life-saving and skin-saving technique in children.

The recent more widespread availability of cultured keratinocytes has increased their clinical applicability in pediatric surgical problems. In life threatening burns (3 patients) and in elective procedures (3 patients) we have used sheets of cultured epithelial autografts. Body surface area affected ranged from fifteen to 85%. Five patients were successfully treated in one grafting session and one required four sessions. Take of the cultured keratinocytes ranged from 75% to 95%. Follow-up as long as 30 months has shown the skin to be comparable to if not superior to conventional split thickness grafts. The use of cultured keratinocytes allows wound coverage without expansion of the affected body surface area seen with conventional split-thickness skin grafting. Although there is an initial delay in the preparation of the grafts, the overall results have been excellent and suggest the more frequent use of this method.