The prepuce and circumcision: dual application as a graft

Circumcision is probably one of the first plastic surgery operations that has been used for centuries. The aim of this study was to apply the bilamellar tissue (skin and mucosa) obtained from circumcision to various defects and to evaluate the clinical results. During the last 2 years, 19 patients have been operated, and the skin and mucosal grafts were applied individually or simultaneously. The etiology was trauma for the whole series of patients (12 burns and 7 strap injuries). In 15 patients the defect was localized to the hand whereas in 4 patients it was located on the dorsum of the foot. In 10 patients, mucosa and skin graft were applied to the same defect as a single, compact layer. In 9 patients, skin and mucosa were applied separately to multiple defects. Using these methods, comparative evaluation of the consequences of prepuce mucosal and skin graft applications could be made. Four obvious differences were observed: (1) in mucosal grafts, early graft edema that resolves spontaneously after 48 hours; (2) better adaptation of the mucosal grafts to the recipient bed; (3) hyperpigmentation in both graft types, but the skin part was slightly darker than the mucosa; and (4) less secondary contraction was seen in mucosal grafts. The results were evaluated in light of the authors' knowledge of the prepuce as an alternative full-thickness donor site. The relative differences in the dual anatomic structure of mucosa and skin, and the role of circumcision as a medical, cultural, and religious application in some societies are discussed.     

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."     

Site-specific production of TGF-β in oral mucosal and cutaneous wounds

Wound healing in the oral mucosa is clinically distinguished by rapid healing and lack of scar formation compared with dermal wounds. Mechanisms of favorable mucosal healing are yet to be elucidated. Utilizing a murine model of equivalent-size mucosal and skin wounds, we verified the rapid reepithelializaton and reduction in scarring of oral wounds reported in humans. Collagen fibrillar structure in oral wounds rapidly approached the size of normal collagen fibrils, while the collagen ultrastructure in skin remained immature through the later phases of healing. To determine whether the transforming growth factor-β (TGF-β) contributes to the lack of scar formation in oral mucosa, we compared the expression and production in oral and skin wounds. The RNase protection assay demonstrated significantly lower levels of TGF-β1 expression in oral wounds compared with dermal wounds, and no changes were observed in the expression levels of TGF-β2 or TGF-β3. ELISA analysis confirmed that oral wounds contained lower levels of TGF-β1 levels compared with dermal wounds, along with a significant increase in the ratio of TGF-β3 to -β1. These findings showed reduced scarring in oral wounds at the ultrastructural level, and provide evidence that site-specific differences in TGF-β production contributes to the superior healing of oral wounds.     

Stricture repair using free graft

Summary Single stage urthroplasty with an onlay patch graft of penile skin or buccal mucosa is an effective treatment for patients with complex anterior urethral stricture disease. Using buccal mucosa, operative time is substantially reduced by using a two-team approach in which one team harvests the graft from the mouth while a perineal team simultaneously exposes and calibrates the stricture. Excellent results can be expected using grafts urethral substitution in men with refractory bulbar strictures. Focal areas of severe stenosis may be excised from the graft bed. For patients with long or dense strictures, grafts may easily be combined with other tissue transfer techniques.      

Pathologic scars: an overview of surgical strategies

In most cases pathologic scars are managed using surgical procedures. In recent decades a trend towards the generalized use of flaps has been observed. Skin expanders have been applied for a while and are still useful in postburn alopecia. Large surfaces are being treated more and more with skin substitutes. These are mainly dermal substitutes covered with partial thickness skin grafts. These procedures can be combined in order to cover very large skin surfaces. Prefabricated flaps are based on angiogenesis induction via vessel carriers implanted in the depth of the skin structure. The use of skin substitutes limits skin harvesting, which may be a source of scarring.     

构建含黑色素细胞组织工程皮肤的研究

目的 探讨运用组织工程方法构建含有黑色素细胞的组织工程皮肤。方法 以包皮组织作为细胞来源，采用消化法获得角朊细胞、成纤维细胞和黑色素细胞，在自行设计的组织工程皮肤培养系统构建组织工程皮肤。行Dopa染色、透射电镜和S-100免疫组织化学检测构建的皮肤中黑色素细胞的分布和状态。结果 构建的组织工程皮肤结构完整，细胞状态良好，Dopa染色、透射电镜和S-100免疫组织化学检测均显示含有大量黑色素细胞并处于良好状态。结论 构建了含黑色素细胞的组织工程皮肤，可用于下一步的动物实验和临床实验。     

Treatment of severe scrotal hypospadias with onlay-type urethroplasty using mouth mucosa

Failure in repairing severe hypospadias complicated with fistula and cutaneous retraction is often associated with lack of subcutaneous tissue and skin providing protection to the neourethra. We report the results of treatment in 6 patients with scrotal hypospadias with severe deviation and scarce dorsal prepuce. A neourethra was created by the onlay technique applying an oral mucosa graft and preserving in all cases the dorsal preputial skin for the island cutaneous flap. All patients had hypospadias without previous repairs excepting one of them, who had had one first time hypospadias repair in other hospital. Patients age ranged between 2 years and 3 months, and 4 years (mean: 2 years and 9 months). In all cases, hypospadias was scrotal type with severe deviation and scarce dorsal prepuce. All patients had prior hormone stimulation with dehydrotestosterone 3%. Surgical repair was performed in one-stage. Urethroplasty included preservation of the urethral plate, oral mucosa graft to provide ventral coverage, and island cutaneous flap with the dorsal preputial skin. In all cases, the chord was dissected behind the urethral plate. In 3 patients a dorsal Nesbit plication was necessary to obtain a complete straighten penis. Results in all 6 cases were satisfactory. Only one patient had a small leakage at the previous neomeatus. The other five patients are asymptomatic. Follow-up ranges from 6 months to 2 years. We conclude that urethroplasty in association with a well vascularized island flap of dorsal preputial skin decrease the incidence of fistulae. In patients with severe hypospadias with scarce dorsal prepuce urethroplasty should be completed with oral mucosa grafts preserving dorsal preputial skin for the ventral cutaneous plasty.     

Two stage urethroplasty

Summary Between 1977 and 1996 we treated 176 patients suffering from complicated urethral strictures with the mesh-graft urethroplasty. This operation technique has replaced the Bengt-Johanson-Operation which had been used frequently until that date. The Cecil-Operation has been totally abandoned, because in our opinion the usage of scrotal skin in urethral reconstruction is obsolete today. The mesh-graft technique is based on the free transfer of meshed prepuce (full-thickness skin or split-thickness skin) in a two stage procedure. In 37 patients the inner layer of the prepuce was used, in 63 patients we only used split-thickness skin grafts and in 76 patients we applied a combination of both, the inner layer of the prepuce in addition to a split-thickness skin graft. After complete healing of the graft (first stage) the formation of the neourethra follows as the second stage procedure. The mesh graft procedure can be used to treat all kinds of strictures independant of the etiology or localisation. Hair growth, diverticula development and stone formation that are observed frequently as complications with scrotal skin substitutes can be avoided. Due to these advantages encouraging long term results could be obtained with the mesh graft urethroplasty. In 162 patients (92 %) with a minimum follow-up of 7 years we achieved a successful result of the operations, a significant improvement could be obtained in 7 patients (4 %). Unfortunately in further 7 cases (4 %) the operation method ultimately failed. In particular in patients with complicated and severe strictures after numerous unsuccessfull prior reconstructive attempts, extensive long strictures and strictures in paraplegic patients, mesh graft urethroplasty has been shown to be a safe and reliable treatment option.      

胎猪皮肤前体组织异种移植研究

目的 系统筛选猪胚胎皮肤前体组织异种移植的最佳妊娠时间窗,了解其创面修复能力. 方法 取胎龄35、42、56、70 d的胎猪皮肤前体组织,制成微粒后移植于BABL/c裸鼠背部创面,以整形患者术后剩余皮肤或者成年猪皮覆盖.观察术后移植物生长发育特性,并于移植后6、12周取材,用组织学方法观察其形态结构及成瘤性. 结果 胎猪皮肤前体组织移植后具有如下特点:(1)能成活并继续生长发育,微粒可融合成片;胎龄35、42、56、70 d的前体组织移植后12周,新生组织面积分别为(18±8)、(47±6)、(31±12)、(20±8)mm2,其中胎龄42 d的组织与其余三者比较,差异有统计学意义(P＜0.05).(2)新生(猪)皮肤组织具有表皮层和真皮层,真皮乳头明显.(3)能生长成为具有毛发、皮脂腺及汗腺等皮肤附属器的"完整"皮肤,且表皮层有黑索细胞.(4)胎龄56、70 d的胎猪皮肤前体组织移植后未出现畸胎瘤. 结论 胎龄56 d的胎猪皮肤前体组织可用于异种移植修复皮肤创面.     

Development of a tissue-engineered human oral mucosa equivalent based on an acellular allogeneic dermal matrix: A preliminary report of clinical application to burn wounds

Tissue-engineered skin equivalents composed of epidermal and dermal components have been widely investigated for coverage of full-thickness skin defects. We developed a tissue-engineered oral mucosa equivalent based on an acellular allogeneic dermal matrix and investigated its characteristics. We also tried and assessed its preliminary clinical application. Human oral mucosal keratinocytes were separated from a piece of oral mucosa and cultured in a chemically-defined medium. The keratinocytes were seeded on to the acellular allogeneic dermal matrix and cultured. Histologically, the mucosa equivalent had a well-stratified epithelial layer. Immunohistochemical study showed that it was similar to normal oral mucosa. We applied this equivalent in one case with an extensive burn wound. The equivalent was transplanted three weeks after the harvest of the patient's oral mucosa and about 30% of the graft finally survived. We conclude that this new oral mucosa equivalent could become a therapeutic option for the treatment of extensive burns.     

Development of a tissue-engineered human oral mucosa equivalent based on an acellular allogeneic dermal matrix: a preliminary report of clinical application to burn wounds.

Tissue-engineered skin equivalents composed of epidermal and dermal components have been widely investigated for coverage of full-thickness skin defects. We developed a tissue-engineered oral mucosa equivalent based on an acellular allogeneic dermal matrix and investigated its characteristics. We also tried and assessed its preliminary clinical application. Human oral mucosal keratinocytes were separated from a piece of oral mucosa and cultured in a chemically-defined medium. The keratinocytes were seeded on to the acellular allogeneic dermal matrix and cultured. Histologically, the mucosa equivalent had a well-stratified epithelial layer. Immunohistochemical study showed that it was similar to normal oral mucosa. We applied this equivalent in one case with an extensive burn wound. The equivalent was transplanted three weeks after the harvest of the patient's oral mucosa and about 30% of the graft finally survived. We conclude that this new oral mucosa equivalent could become a therapeutic option for the treatment of extensive burns.     

Refinements in closure of radiation induced rectovaginal fistula

A two stage procedure for closure of a large rectovaginal fistula is presented. The gracilis muscle with full thickness skin patches is used for this purpose. In the first operation full thickness skin grafts, corresponding to the size of the mucosal defects, are applied to either side of the muscle for closure in the second stage. In the second operation the temporary extradermal exposed muscle pedicle, covered with healed skin grafts, is placed into the defect. All structures are reconstructed, rectal mucosa, rectovaginal space and vaginal mucosa.     

CORONAL CUFF: A PROBLEM SITE FOR BUCCAL MUCOSAL GRAFTS

PURPOSE: Urethral reconstruction of complex hypospadias or epispadias continues to present a significant challenge. Buccal mucosa as an onlay or tube graft is an excellent option when faced with paucity of penile skin. We identified the factors that lead to success or failure in these repairs. MATERIALS AND METHODS: During 6 years we placed 34 buccal mucosal grafts in 31 patients to repair complex hypospadias and epispadias. Penile skin was preferentially used for urethroplasty but a free buccal mucosal graft was used for reconstruction due to lack of adequate penile skin. The cases were complicated with an average of 5 previous unsuccessful repairs each in 16. Grafts ranged from 1.5 to 10 cm. and 10 patients required pieced grafts. We created 1 combination, 16 onlay and 17 full tube grafts. Buccal mucosa was used with a Thiersch-Duplay urethroplasty in 8 patients. RESULTS: Anastomotic stricture in 5 patients was proximal in 4. Fistula was a complication in 13 grafts that generally developed on the distal shaft, particularly at the coronal cuff. Of the 7 patients who underwent proximal Thiersch-Duplay urethroplasty with a distal buccal graft 6 had a coronal fistula. Fistula was more common with tube and pieced than with onlay grafts. CONCLUSIONS: Fistula is overwhelmingly the most common complication after buccal mucosal graft urethroplasty. Most fistulas develop at the coronal cuff, and we suspect that skin coverage and potential blood supply have not been good in that region. Anticipation of this problem during stage 1 of hypospadias repair would allow more advantageous distribution of the existing penile skin. Good distal skin coverage cannot be compromised in these complex cases.     

Invited commentary

Summary A two stage procedure for closure of a large rectovaginal fistula is presented. The gracilis muscle with full thickness skin patches is used for this purpose. In the first operation full thickness skin grafts, corresponding to the size of the mucosal defects, are applied to either side of the muscle for closure in the second stage. In the second operation the temporary extradermal exposed muscle pedicle, covered with healed skin grafts, is placed into the defect. All structures are reconstructed, rectal mucosa, rectovaginal space and vaginal mucosa.     

Replacement of colonic mucosa by free and pedicled grafts of ileal mucosa in the dog

Mucosal proctectomy and ileo-anal anastomosis is a relatively new operation in the treatment of patients with ulcerative colitis. The diseased rectal mucosa is removed and gastrointestinal continuity is restored by replacing it with full thickness ileum. The main disadvantage of the operation is frequency of bowel action and in an attempt to resolve this problem the feasibility of replacing colonic mucosa with grafts of ileal mucosa alone was explored. Both free and pedicled autografts of ileal mucosa were grafted into isolated loops of canine colon, denuded of mucosa and submucosa. All the free grafts failed to survive (eight dogs) and histological examinations confirmed graft rejection. All the pedicled grafts (seven dogs) were successful and retained the histological characteristics of normal ileum. Net movement and bidirectional transport of water and electrolytes were measured in six dogs with pedicled grafts and in four control dogs with intact full thickness ileal loops. Whereas the control loops absorbed water and electrolytes, the grafted loops secreted water, sodium, and potassium and absorbed significantly less chloride. The mucosa of the colon can thus be replaced successfully by grafts of ileal mucosa provided that an intact blood supply is preserved. The capacity and sensation of the neorectum after mucosal proctectomy may be improved if mucosal grafts were used instead of full thickness ileum. Before this procedure could be used in man, however, practical problems would have to be overcome and the secretion of water and electrolytes corrected.     

Effect of vagotomy on gastric wall autonomic responses, mucosal cholinesterase activity and gastric acid secretion in cats

Adrenergic and cholinergic innervation of the stomach was investigated using histochemical techniques, and gastric mucosal cholinesterase (ChE) activity was measured by a calorimetric method. The effects of vagal nerve stimulation on gastric mucosal ChE activity was examined, and the following results were obtained. No differences in innervation and mucosal ChE activity were found between the lesser and greater curvatures of the stomach. High ChE activity and a wide and dense network of cholinergic nerve fibers were observed in the fundic mucosa, but in the antral mucosa the fibers were limited and ChE activity was low. The number of cholinergic fibers was markedly reduced in the intermediate zone. Mucosal ChE activity increased temporarily after truncal vagotomy, but after 6 months it returned to the original value. Antral mucosal ChE activity became elevated temporarily after vagal stimulation, but decreased rapidly thereafter. Denervation of hepatic, celiac and antral branches of the vagus caused a significant decrease in acid secretion. This suggests that these nerves are also involved in gastric secretion, and that the vagal nerve fibers are distributed to the greater curvature of stomach via these branches.     

The use of tissue expander in the management of staged proximal hypospadias repair: report of case

Multiple failed hypospadias reconstructions may cause minimal residual skin, as a result of extensive scarring. However, extragenital full thickness skin grafts or mucosal grafts are often used for urethral substitutions; local tissue expansion can provide additional matched skin, which can be easily harvested and used for penile constructions. Though tissue expanders were used as the choice of treatment in children with multiple failed hypospadias repairs, the use of tissue expander in the management of staged proximal hypospadais repair has not been reported previously. A 3-year-old boy with proximal hypospadias is presented to discuss the use of tissue expansion in the management of staged proximal hypospadias repair.     

含银异种脱细胞真皮基质的实验研究

目的了解含银异种脱细胞真皮基质(Xeno-ADM)的多项生物学性状,观察其移植效果。方法制备单纯xeno-ADM,再用2 g／L硝酸银浸泡,制成含银xeno-ADM。检测两种xeno-ADM对笔者单位烧伤患者创面常见菌的抑菌效果,并进行组织学观察;测量含银xeno-ADM的Ag+含量。在27只家兔背部制作全层皮肤缺损创面,分为A、B、C组,每组9只。A组移植自体刃厚皮,B组移植单纯xeno-ADM+自体刃厚皮,C组移植含银xeno-ADM+自体刃厚皮。术后2、4、6周取移植部位皮肤标本作形态学观察,并计算创面收缩率;术后2周计算移植皮片(未)成活率,并检测各组家兔淋巴细胞增殖活性。结果(1)含银xeno-ADM对创面常见菌的抑菌效果明显优于单纯xeno-ADM (P<0．05)。两种xeno-ADM中的表皮已完全除去,胶原纤维粗细均匀、排列规则、无明显变性,真皮中无细胞及细胞碎片。含银xeno-ADM的Ag+含量为(2．7±0．7)mg／g。(2)术后6周,A组家兔移植皮片呈暗红色,挛缩明显,易破溃,胶原纤维排列紊乱;B、C组移植皮片颜色接近周围正常皮肤,光滑无瘢痕,质地良好,胶原纤维排列有序,表皮-真皮连接结构和基底细胞桥粒、半桥粒结构以及基底膜重建明显。术后2、4、6周,A组家兔创面收缩率均明显高于B、C组(P<0．05);B、C两组创面收缩率相似(P>0．05)。术后2周,C组皮片完全成活率为91．7％,显著高于A组(77．8％)及B组(80．6％);3组家兔淋巴细胞增殖活性相似(P>0．05)。结论含银xeno-ADM脱除了基质中有免疫原性的细胞成分,保留了组织的基本结构和完整的胶原纤维支架,且具有较好的局部抗菌效果,不失为一种良好的真皮替代物。     

真皮替代物移植后的血管化过程及组织学变化的实验研究

目的了解不同种类真皮替代物移植后的血管化过程及组织学变化。方法将21只SD大鼠根据其皮下埋植不同的真皮替代物分为猪脱细胞真皮基质(sADM)组、人脱细胞真皮基质(hADM)组及人工真皮(Integra)组。于埋植后2、3、4、7、10、14、21、30、60、90、120、150、180d行移植物大体观察,采用免疫组织化学法观察移植物的血管化过程及组织学变化。结果大体观察术后各组大鼠创口周围皮肤无明显红肿及炎性反应,切口愈合良好,移植物与创面接触紧密。90d后各组移植物不易从体表触及。180d时,部分移植物面积缩小、厚度变薄甚至难以辨认。组织学观察移植术后2d起可见成纤维细胞、中性粒细胞、淋巴细胞等侵入移植物内,3d时与受床组织连接处可见长入的新生毛细血管芽。30—60d,移植物内形成丰富的血管网。150d后近似正常真皮结构。180d后部分移植物有不同程度吸收退化。结论3种真皮替代物移植后均能很快建立与受床组织的血液循环,并长时间存留于创面,但有一定程度的吸收退化。     

Potential of skin fibroblasts for application to anterior cruciate ligament tissue engineering

Fibroblasts isolated from skin and from anterior cruciate ligament (ACL) secrete type I and type III collagens in vivo and in vitro. However, it is much easier and practical to obtain a small skin biopsy than an ACL sample to isolate fibroblasts for tissue engineering applications. Various tissue engineering strategies have been proposed for torn ACL replacement. We report here the results of the implantation of bioengineered ACLs (bACLs), reconstructed in vitro using a type I collagen scaffold, anchored with two porous bone plugs to allow bone-ligament-bone surgical engraftment. The bACLs were seeded with autologous living dermal fibroblasts, and grafted for 6 months in goat knee joints. Histological and ultrastructural observations ex vivo demonstrated a highly organized ligamentous structure, rich in type I collagen fibers and cells. Grafts' vascularization and innervation were observed in all bACLs that were entirely reconstructed in vitro. Organized Sharpey's fibers and fibrocartilage, including chondrocytes, were present at the osseous insertion sites of the grafts. They showed remodeling and matrix synthesis postimplantation. Our tissue engineering approach may eventually provide a new solution to replace torn ACL in humans.