The new reconstructive ladder: modifications to the traditional model

An evidence-based review of split-thickness skin graft donor site dressings

This evidence-based review aimed to identify and evaluate current existing evidence relating to the efficacy of dressing materials for spit-thickness skin graft donor site wounds in relation to promoting rapid healing and reducing patient pain. A comprehensive systematic search of the literature between 2006 and 2016 identified 35 publications that were included in the review. Based on the results of the review, it was found that moist wound-healing products have a clear advantage over non-moist products in the reduction of pain and increased healing rates. This review concluded that moist wound-healing products are more effective than non-moist wound-healing products in reducing pain and promoting healing in split-thickness skin graft donor site wounds. A recommendation based on this review is that further research examine the role of secondary dressing usage in donor site wound management, and the consideration of using more than one primary dressing product during the donor site wound-healing process should be undertaken.

The convergence of regenerative medicine and rehabilitation: federal perspectives

Regenerative rehabilitation is the synergistic integration of principles and approaches from the regenerative medicine and rehabilitation fields, with the goal of optimizing form and function as well as patient independence. Regenerative medicine approaches for repairing or replacing damaged tissue or whole organs vary from utilizing cells (e.g., stem cells), to biologics (e.g., growth factors), to approaches using biomaterials and scaffolds, to any combination of these. While regenerative medicine offers tremendous clinical promise, regenerative rehabilitation offers the opportunity to positively influence regenerative medicine by inclusion of principles from rehabilitation sciences. Regenerative medicine by itself may not be sufficient to ensure successful translation into improving the function of those in the most need. Conversely, with a better understanding of regenerative medicine principals, rehabilitation researchers can better tailor rehabilitation efforts to accommodate and maximize the potential of regenerative approaches. Regenerative rehabilitative strategies can include activity-mediated plasticity, exercise dosing, electrical stimulation, and nutritional enhancers. Critical barriers in translating regenerative medicine techniques into humans may be difficult to overcome if preclinical studies do not consider outcomes that typically fall in the rehabilitation research domain, such as function, range of motion, sensation, and pain. The authors believe that encouraging clinicians and researchers from multiple disciplines to work collaboratively and synergistically will maximize restoration of function and quality of life for disabled and/or injured patients, including U.S. Veterans and Military Service Members (MSMs). Federal Government agencies have been investing in research and clinical care efforts focused on regenerative medicine (NIH, NSF, VA, and DoD), rehabilitation sciences (VA, NIH, NSF, DoD) and, more recently, regenerative rehabilitation (NIH and VA). As science advances and technology matures, researchers need to consider the integrative approach of regenerative rehabilitation to maximize the outcome to fully restore the function of patients.

Faciocervical Reconstruction Using a Large Expanded Forehead Island Flap Grafted Using a Microsurgical Technique for Burned Cicatricial Contracture Correction

Extrinsic cicatricial contracture is still one of the most common and frustrating complications in the faciocervical area after severe burns. Because of these contractured scars, patients not only suffer from aesthetic issues but also local dysfunction, especially when it comes to the faciocervical region. Esthetical and functional reconstruction of these regions remains a great challenge for reconstructive surgeons. This report presents a 28-year-old man with postburn mentocervical adhesion treated successfully with a large expanded forehead island flap. Cosmetic and functional results have been achieved in this patient during long-term follow-ups.

Use of a novel epidermal harvesting system in resource-poor countries

The 2010 earthquake in Port-au-Prince, Haiti, highlighted the need for wound care in resource-poor countries. Subsequently, the University of Miami in Florida established one of the first interprofessional wound care centers located at Bernard Mevs Hospital in the central portion of Port-au-Prince, caring for patients with acute and chronic wounds. In 2012, the authors used a novel epidermal harvesting system (CelluTome Epidermal Harvesting System; Kinetic Concepts Inc, San Antonio, Texas) to harvest epithelium to be grafted on 7 patients at the Mevs Hospital with longstanding wounds. Epidermal microblisters were obtained from each patient's thigh using the CelluTome Epidermal Harvesting System. After 35 minutes, microblisters were raised using the device harvester, and an adhesive dressing was inserted into the harvester for transfer to the wound site. In patients with lower-extremity wounds, a 2-layer compression dressing was placed over epidermal grafts. Six of the 7 wounds improved or achieved complete closure in 4 weeks. One of the patients with a 2-year-old thigh wound failed to demonstrate improvement; this may have been secondary to an inability to adequately secure the graft. All donor sites healed without any visible scarring. The authors were able to conclude that epidermal grafting may represent a viable reconstructive option for patients in resource-poor countries.

3D Volumetric Modeling and Microvascular Reconstruction of Irradiated Lumbosacral Defects after Oncologic Resection

Background

Locoregional flaps are sufficient in most sacral reconstructions. However, large sacral defects due to malignancy necessitate a different reconstructive approach, with local flaps compromised by radiation and regional flaps inadequate for broad surface areas or substantial volume obliteration. In this report, we present our experience using free muscle transfer for volumetric reconstruction, in such cases, and demonstrate three-dimensional (3D) haptic models of the sacral defect to aid preoperative planning.

Methods

Five consecutive patients with irradiated sacral defects secondary to oncologic resections were included, surface area ranging from 143–600 cm². Latissimus dorsi (LD)-based free flap sacral reconstruction was performed in each case, between 2005 and 2011. Where the superior gluteal artery was compromised, the subcostal artery (SA) was used as a recipient vessel. Microvascular technique, complications, and outcomes are reported. The use of volumetric analysis and 3D printing is also demonstrated, with imaging data converted to 3D images suitable for 3D printing with Osirix software (Pixmeo, Geneva, Switzerland). An office-based, desktop 3D printer was used to print 3D models of sacral defects, used to demonstrate surface area and contour and produce a volumetric print of the dead space needed for flap obliteration.

Results

The clinical series of LD free flap reconstructions is presented, with successful transfer in all cases, and adequate soft-tissue cover and volume obliteration achieved. The original use of the SA as a recipient vessel was successfully achieved. All wounds healed uneventfully. 3D printing is also demonstrated as a useful tool for 3D evaluation of volume and dead space.

Conclusion

Free flaps offer unique benefits in sacral reconstruction where local tissue is compromised by irradiation and tumor recurrence, and dead space requires accurate volumetric reconstruction. We describe for the first time the use of the SA as a recipient in free flap sacral reconstruction. 3D printing of haptic bio-models is a rapidly evolving field with a substantial role in preoperative planning.

Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature

INTRODUCTION

Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed.

MATERIALS AND METHODS

An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes".

RESULTS

A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review.

CONCLUSIONS

The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.

Epidermal skin grafting

Autologous skin grafts, such as full- and split-thickness, have long been part of the reconstructive ladder as an option to close skin defects. Although they are effective in providing coverage, they require the need for a trained surgeon, use of anaesthesia and operating room and creation of a wound at the donor site. These drawbacks can be overcome with the use of epidermal skin grafts (ESGs), which can be harvested without the use of anaesthesia in an office setting and with minimal to no scarring at the donor site. ESGs consist only of the epidermal layer and have emerged as an appealing alternative to other autologous grafts for the treatment of acute and chronic wounds. In this article, we provide an overview of epidermal grafting and its role in wound management.

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps

PURPOSE

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed.

METHODS

From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days.

RESULTS

All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery.

CONCLUSION

Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

Does negative pressure wound therapy applied to closed incisions following ventral hernia repair prevent wound complications and hernia recurrence? A systematic review and meta-analysis

Background

Despite advances in surgical technique, ventral hernia repair (VHR) remains associated with significant postoperative wound complications.

Objective

A systematic review and meta-analysis was performed to identify whether the application of negative pressure wound therapy to closed incisions (iNPWT) following VHR reduces the risk of postoperative wound complications and hernia recurrence.

Methods

The PubMed/MEDLINE, EMBASE and SCOPUS databases were searched for studies published through October 2015. Publications that met the following criteria were included: adult patients undergoing VHR; comparison of iNPWT with conventional dressings; and documentation of wound complications and/or hernia recurrence. The methodological quality of included studies was independently assessed using the Methodological Index for Non-Randomized Studies guidelines. Outcomes assessed included surgical site infection (SSI), wound dehiscence, seroma, and hernia recurrence. Meta-analysis was performed to obtain pooled ORs.

Results

Five retrospective cohort studies including 477 patients undergoing VHR were included in the final analysis. The use of iNPWT decreased SSI (OR 0.33 [95% CI 0.20 to 0.55]; P<0.0001), wound dehiscence (OR 0.21 [95% CI 0.08 to 0.55]; P=0.001) and ventral hernia recurrence (OR 0.24 [95% CI 0.08 to 0.75]; P=0.01). There was no statistically significant difference in the incidence of seroma formation (OR 0.59 [95% CI 0.27 to 1.27]; P=0.18).

Conclusion

For patients undergoing VHR, current evidence suggests a decreased incidence in wound complications using incisional NPWT compared with conventional dressings.

Orofacial Soft Tissue Reconstruction with Locoregional Flaps in a Health Resource-Depleted Environment: Experiences from Nigeria

Background

Reconstruction of orofacial soft tissue defects is often challenging due to functional and aesthetic demands. Despite advances in orofacial soft tissue defect reconstruction using free flaps, locoregional flaps still remain an important option, especially in health resource-depleted environments. This retrospective study highlights our experiences in oral and maxillofacial soft tissue reconstruction using locoregional flaps.

Methods

A twenty-three years retrospective analysis of all patients managed in our department was undertaken. Information was sourced from patients' case notes and operating theater records. Data was analyzed using SPSS ver. 16 (SPSS Inc.) and Microsoft Excel 2007 (Microsoft).

Results

A total of 77 patients underwent orofacial soft tissue defect reconstruction within the years reviewed. Males accounted for 55 (71.4%) cases and trauma was the main etiological factor in 45 (58.4%) of the patients treated. When sites of defect were considered, the lip, 27 (32.1%), was the most frequent site followed by the nose, 17 (20.2%). Forehead flap, 51 (59.3%), was the most commonly used flap. Complications noted were tumor recurrences at the recipient bed in 3 (3.9%) cases, tumor occurrence at the donor site in 1 (1.3%) case and postoperative infection in 11 (14.3%) cases.

Conclusions

Locoregional flaps still have an important role in the rehabilitation of patients with orofacial soft tissue defects. They remain a vital tool in the armamentarium of the reconstructive surgeon, especially in health resource-depleted environments where advanced reconstructive techniques may not be feasible.

Changing paradigms in lower extremity reconstruction in war-related injuries

BACKGROUND

Ballistic high-energy trauma has substantially increased the severity of non-fatal extremity injuries incurred in modern warfare. Expedient medical care, refinement in surgical techniques, and soft tissue coverage have brought about a paradigm shift in the management of lower extremity wounds during the last decade with an increased emphasis on limb salvage.

METHODS

A literature-based study was conducted to analyze reconstructive modalities based on the location, depth, and severity of wounds, as well as mechanism of injury, concomitant vascular injuries and open fractures, choice of flap, timing of definitive reconstruction, and complications.

RESULTS

Extremity injuries account for over 60 % of injuries in the recent conflicts in Iraq and Afghanistan, with the majority secondary to explosive devices. The severity of these injuries is profound compared with civilian registries, and conventional injury scoring systems have failed to accurately predict outcomes in combat trauma. The mainstay of treatment is serial debridement, negative pressure therapy, fracture stabilization, and treatment of concomitant injuries by the forward medical teams with subsequent definitive reconstruction after transport to an advanced military treatment facility. Autologous reconstruction with free tissue transfer and pedicled flaps remains the primary modality for soft tissue coverage in limb salvage. Adjunct innovative modalities, such as external tissue expansion, dermal substitutes, and regenerative matrices, have also been successfully utilized for limb salvage.

CONCLUSION

Lower extremity injuries account for the vast majority of injuries in modern warzones. Explosive devices represent the most common mechanism of injury, with blast impact leading to extensive soft tissue injuries necessitating complex reconstructive strategies. Serial debridement, negative pressure therapy, and autologous reconstruction with free tissue transfer and pedicled flaps remain the mainstay of treatment in recent conflicts.

Chronic Ulcer by Cutaneous GvHD After Bone Marrow Transplantation Treated With Skin Allograft From HLA-Identical Donor: Case Report and Literature Review

We present a successful split-thickness skin allograft for a chronic cutaneous graft-versus-host disease of the thigh in an immunosuppressed patient, treated for acute myeloid leukemia with allogenic bone marrow stem cells transplant.

Oncologic reconstruction: General principles and techniques

Halsted's principle of radical mastectomy influenced cancer treatment for decades. Randomized controlled trials resulted in a paradigm shift to less radical surgery and the use of adjuvant therapies. Oncologic reconstruction performed by plastic surgeons has evolved, ranging from skin grafts and local flaps for smaller defects to pedicled flaps and free flaps for larger and more complex defects. Immediate reconstruction facilitates resection is oncologically safe and contributes to meaningful improvements in quality of life. J. Surg. Oncol. 2016;113:852-864. © 2016 Wiley Periodicals, Inc.

Soft Tissue Coverage of the Lower Limb following Oncological Surgery

The treatment of lower limb tumors has been shifted by advancements in adjuvant treatment protocols and microsurgical reconstruction from limb amputation to limb salvage. Standard approaches include oncological surgery by a multidisciplinary team in terms of limb sparing followed by soft tissue reconstruction and adjuvant therapy when indicated. For the development of a comprehensive surgical plan, the identity of the tumor should first be determined by histology after biopsy. Then the surgical goal and comprehensive treatment concept should be developed by a multidisciplinary tumor board and combined with soft tissue reconstruction. In this article, plastic surgical reconstruction options for soft coverage of the lower extremity following oncological surgery will be described along with the five clinical cases.

Secondary Intention Healing and Purse-String Closures

BACKGROUND

Secondary intention healing and purse-string closures are simple but extremely useful methods for the dermatologic surgeon to master.

OBJECTIVE

To review the literature on the use of these two types of closures and offer recommendations based on our collective experiences.

METHODS

A literature review was performed using the terms "secondary intention healing" and "purse-string closure." The evidence and recommendations from the resultant references were summarized in our article and synthesized with our own experiences.

RESULTS

Twenty-eight sources were cited overall with fifteen related to secondary intention healing, eleven pertaining to purse-string closures, and one randomized, blind clinical trial comparing the two modalities.

CONCLUSION

The art of dermatologic surgery often requires a tailored approach to the patient and can involve a spectrum of closures, from the simplest to most complex. This variety not only provides more reconstruction options, but are also necessary to keep dermatologic surgery cost-effective. Certain locations or situations are more amenable for these two types of closures than others. The use of secondary intention healing, either alone or in conjunction with purse-string closures, should be in every dermatologic surgeon's armamentarium.

Reconstructive Management of Devastating Electrical Injuries to the Face

BACKGROUND

Devastating fourth-degree electrical injuries to the face and head pose significant reconstructive challenges. To date, there have been few peer-reviewed articles in the literature that describe those reconstructive challenges. The authors present the largest case series to date that describes the management of these injuries, including the incorporation of face transplantation.

METHODS

A retrospective case series was conducted of patients with devastating electrical injuries to the face who were managed at two level-1 trauma centers between 2007 and 2011. Data describing patient injuries, initial management, and reconstructive procedures were collected.

RESULTS

Five patients with devastating electrical injuries to the face were reviewed. After initial stabilization and treatment of life-threatening injuries, all five underwent burn excision and microsurgical reconstruction using distant flaps. Two of the patients eventually underwent face transplantation. The authors describe differences in management between the two trauma centers, one of which had the availability for composite tissue allotransplantation; the other did not. Also described is how initial attempts at traditional reconstruction affected the eventual face transplantation.

CONCLUSIONS

The care of patients with complex electrical burns must be conducted in a multidisciplinary fashion. As with all other trauma, the initial priority should be management of the airway, breathing, and circulation. Additional considerations include cardiac arrhythmias and renal impairment attributable to myoglobinuria. Before embarking on aggressive reconstruction attempts, it is advisable to determine early whether the patient is a candidate for face transplantation in order to avoid antigen sensitization, loss of a reconstructive "lifeboat," surgical plane disruption, and sacrifice of potential recipient vessels.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Exposed tibial bone after burns: Flap reconstruction versus dermal substitute

A 44 years old male patient had suffered extensive 3rd degree burns on both legs, undergoing thorough surgical debridement, resulting in both tibias being exposed. Approximately 5 months after the incident he was referred to the Department of Plastic and Reconstructive Surgery of the University Hospital Gent, Belgium, to undergo flap reconstruction. Free flap surgery was performed twice on both lower legs but failed on all four occasions. In between flap surgery, a dermal substitute (Integra(®)) was applied, attempting to cover the exposed tibias with a layer of soft tissue, but also without success. In order to promote the development of granulation tissue over the exposed bone, small holes were drilled in both tibias with removal of the outer layer of the anterior cortex causing the bone to bleed and subsequently negative pressure wound therapy (NPWT) was applied. The limited granulation tissue resulting from this procedure was then covered with a dermal substitute (Glyaderm(®)), consisting of acellular human dermis with an average thickness of 0.25mm. This dermal substitute was combined with a NPWT-dressing, and then served as an extracellular matrix (ECM), guiding the distribution of granulation tissue over the remaining areas of exposed tibial bone. Four days after initial application of Glyaderm(®) combined with NPWT both tibias were almost completely covered with a thin coating of soft tissue. In order to increase the thickness of this soft tissue cover two additional layers of Glyaderm(®) were applied at intervals of approximately 1 week. One week after the last Glyaderm(®) application both wounds were autografted. The combination of an acellular dermal substitute (Glyaderm(®)) with negative pressure wound therapy and skin grafting proved to be an efficient technique to cover a wider area of exposed tibial bone in a patient who was not a candidate for free flap surgery. An overview is also provided of newer and simpler techniques for coverage of exposed bone that could question the universal plastic surgery paradigm that flap surgery is the only way to cover these defects.

Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length

BACKGROUND

A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation.

METHODS

A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length.

RESULTS

Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers.

CONCLUSIONS

The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.

Simulation-Based Rhomboid Flap Skills Training During Medical Education

OBJECTIVE

To assess if the bench model fidelity interferes in the acquisition of rhomboid flap skills by medical students.

METHODS

Sixty novice medical students were randomly assigned to 5 practice conditions with instructor-directed Limberg rhomboid flap skills training: didactic materials (control group 1), low-fidelity rubberized line (group 2) or ethylene-vinyl acetate (group 3) bench models; high-fidelity chicken leg skin (group 4) or pig foot skin (group 5) bench models. Pretests and posttests were applied, and Global Rating Scale, effect size, and self-perceived confidence were used to evaluate all flap performances.

RESULTS

Medical students from groups 2 to 5 showed better flap performances based on the Global Rating Scale (all P < 0.05) and felt more confident to perform rhomboid flaps (all P < 0.05) compared to their peers from control group 1, regardless of bench model fidelity (all P > 0.05). The magnitude of the effect was considered large (>0.80) in all measurements.

CONCLUSION

There was acquisition of rhomboid flap skills regardless of bench model fidelity.

Defect closure with "8-shaped crisscross tensile suture" technique

BACKGROUND

Sutures and suturing techniques compose the basis of the surgery. Although many surgical methods such as the skin grafts or flaps has been described for the closure of large defects, proper primary suturing may sometimes yield very successful results and decrease the need of complicated procedures. In this article, a new combined skin-subcutaneous tissue suturing technique called as "8-shaped crisscross tensile suture (8CTS)" designed for the closure of large skin defects is presented.

PATIENTS AND METHODS

One hundred forty-nine patients with an age distribution between 14 and 65 y were operated for large skin defects by using the 8CTS technique. The most common etiology of the defects was free flap donor sites, and the most common defect localization was the anterolateral thigh region. The average defect width on the axis of primary closure was calculated as 14.6 cm. The 8CTS technique is a combination of both skin and subcutaneous layers suturation and may even involve deeper layers suturation according to the depth of the defect.

RESULTS

Eight complications including wound dehiscence, early recurrence of pilonidal sinus disease, seroma formation, skin-edge necrosis, and incisional hernia were observed. The wounds of 141 patients were treated successfully.

CONCLUSIONS

The 8CTS technique is a useful method for the closure of large defects eliminating the need of more complex procedures and providing acceptable cosmetic results while supporting both skin and subcutaneous tissue in one suture.

Recent advances in head and neck cancer reconstruction

Treatment of cancer is race against time! Following radical excision, breathing, speech, mastication and swallowing are hampered. Face is invariably involved. Beside functional normalcy, excellent cosmetic restoration is necessary for patient's life quality. Primary wound healing, quick resumption of adequate oral intake, prompt initiation of chemo-radiotherapy has direct bearing on cure. Primary reconstruction with pedicle or free flap is the choice of treatment in most protocols. Composite defects are requiring bone, muscle and skin restrict choice of donor site and may have shortfalls in aesthetic and functional requirements. To improve further newer, and newer modalities are being developed and used to give best aesthetic and functions. Navigation, use of three-dimensional imaging, stereo lithic model and custom made implant for reconstruction are recommended as they promise improvement in aesthetics. Robotic surgeries allow access for resection of tumours and reconstruction with free flap in deep oropharynx obviating need of doing mandibulotomy. Researchers in stem cell and tissue engineering are looking forward to regenerating tissues and avoid the need of autologous tissue flaps. Desired tissue combination across counter may be available in the future. Excellent immunosuppressant drugs have made it possible to reconstruct composite facial anatomical units with allotransplant in a single surgery, along sensory and motor recovery! Mythological heterogenic head transplant like clone Ganesha, will be a reality in the near future!!

Dermal skin substitutes for upper limb reconstruction: current status, indications, and contraindications

Dermal skin substitutes are a group of biologically engineered materials composed of collagen and glycosaminoglycans and are devoid of cellular structures. These biodegradable materials act as an artificial dermis to promote neovascularization and neodermis formation. Their applications in soft tissue reconstructions are rapidly expanding. In this article, the indications, advantages, and limitations of dermal skin substitutes for reconstruction of soft tissue defects of the upper extremity are reviewed.

Local and regional flaps for hand coverage

Hand surgeons are frequently challenged by the unique requirements of soft tissue coverage of the hand. Whereas many smaller soft tissue defects without involvement of deep structures are amenable to healing by secondary intention or skin grafting, larger lesions and those with exposed tendon, bone, or joint often require vascularized coverage that allows rapid healing without wound contraction. The purpose of this review was to present an overview of local and regional flaps commonly used for soft tissue reconstruction within the hand.

The role of plastic surgery for soft tissue coverage of the diabetic foot and ankle

The goal of wound healing is to obtain the best closure through the least morbid means. In the surgical treatment of the diabetic foot and ankle, the reconstructive foot and ankle surgeon is tasked with the challenge of repairing a variety of tissue defects. The decision for wound closure depends on the location of the wound and host factors. In order of increasing complexity, the clinician should consider the reconstruction decision ladder algorithm. Wound evaluation coupled with the knowledge of various closure techniques and their indications will arm the surgeon with the tools for a successful closure.

Current therapies for diabetic foot infections and osteomyelitis

Treatment of the patient with a diabetic foot infection and underlying osteomyelitis is currently an evolving process, often complicated by neuropathy, peripheral vascular disease, and renal insufficiency. Understanding which patients require hospitalization, intravenous antibiotic therapy, and urgent operative intervention may ultimately prevent the spread of infection or major limb amputation. The treating surgeon should focus on accurate and early diagnosis, proper antibiosis, and appropriate surgical debridement to eradicate infection while preserving function with a plantar-grade foot.

Complete horizontal skin cell resurfacing and delayed vertical cell infiltration into porcine reconstructive tissue matrix compared to bovine collagen matrix and human dermis

BACKGROUND

Xenogenous dermal matrices are used for hernia repair and breast reconstruction. Full-thickness skin replacement is needed after burn or degloving injuries with exposure of tendons or bones. The authors used a human skin organ culture model to study whether porcine reconstructive tissue matrix (Strattice) is effective as a dermal tissue replacement.

METHODS

Skin cells or split-thickness skin grafts were seeded onto human deepidermized dermis, Strattice, and Matriderm. Cellular resurfacing and matrix infiltration were monitored by live fluorescence imaging, histology, and electron microscopy. Proliferation, apoptosis, cell differentiation, and adhesion were analyzed by immunohistochemistry.

RESULTS

Epithelial resurfacing and vertical proliferation were reduced and delayed with both bioartificial matrices compared with deepidermized dermis; however, no differences in apoptosis, cell differentiation, or basement membrane formation were found. Vertical penetration was greatest on Matriderm, whereas no matrix infiltration was found on Strattice in the first 12 days. Uncompromised horizontal resurfacing was greatest with Strattice but was absent with Matriderm. Strattice showed no stimulatory effect on cellular inflammation.

CONCLUSIONS

Matrix texture and surface properties governed cellular performance on tissues. Although dense dermal compaction delayed vertical cellular ingrowth for Strattice, it allowed uncompromised horizontal resurfacing. Dense dermal compaction may slow matrix decomposition and result in prolonged biomechanical stability of the graft. Reconstructive surgeons should choose the adequate matrix substitute depending on biomechanical requirements at the recipient site. Strattice may be suitable as a dermal replacement at recipient sites with high mechanical load requirements.

Successful treatment of complex traumatic and surgical wounds with a foetal bovine dermal matrix

A foetal bovine dermal repair scaffold (PriMatrix, TEI Biosciences) was used to treat complex surgical or traumatic wounds where the clinical need was to avoid skin flaps and to build new tissue in the wound that could be reepithelialised from the wound margins or closed with a subsequent application of a split-thickness skin graft (STSG). Forty-three consecutive cases were reviewed having an average size of 79·3 cm(2) , 50% of which had exposed tendon and/or bone. In a subset of wounds (44·7%), the implantation of the foetal dermal collagen scaffold was also augmented with negative pressure wound therapy (NPWT). Complete wound healing was documented in over 80% of the wounds treated, whether the wound was treated with the foetal bovine dermal scaffold alone (95·2%) or when supplemented with NPWT (82·4%). The scaffold successfully incorporated into wounds with exposed tendon and/or bone to build vascularised, dermal-like tissue. The new tissue in the wound supported STSGs however, in the majority of the cases (88·3%); wound closure was achieved through reepithelialisation of the incorporated dermal scaffold by endogenous wound keratinocytes. The foetal bovine dermal repair scaffold was found to offer an effective alternative treatment strategy for definitive closure of challenging traumatic or surgical wounds on patients who were not suitable candidates for tissue flaps.

Free Tissue Transfer for Limb Salvage in High-Risk Patients: Worth the Risk

SIGNIFICANCE

Mircosurgical free tissue transfer is a powerful tool in the arsenal of reconstructive surgeons, oftentimes as the final option in limb salvage before amputation. Patients presenting for limb salvage frequently carry with them multiple co-morbidities such as diabetes mellitus, end-stage renal disease, and peripheral vascular disease. Surgeons are oftentimes hesitant to attempt free tissue tranfer in these medically complex individuals due to beliefs that the patient would not tolerate prolonged anesthesia, the surgery is doomed to fail, or the patient would be better off with an amputation. Because amputees actually demonstrate higher mortality rates, the decision to not to proceed with limb salvage should be made with great care.

RECENT ADVANCES

By reviewing the success rates with free tissue transfer for limb salvage in high-risk patients, the target articles have shown that this option is indeed viable even in this patient population. Specifically, reasonable success rates are presented for limb salvage using free tissue transfer in patients with end-stage renal disease, a single-vessel leg and critical limb ischemia.

CRITICAL ISSUES

The articles reviewed demonstrate that free tissue transfer for limb salvage in properly selected patients with end-stage renal disease or severe peripheral vascular disease is worth attempting. Before surgery, these patients must undergo a complete cardiac work-up regardless of previous cardiac history.

FUTURE DIRECTIONS

When necessary, free tissue transfer should be pursued by the reconstructive surgeon even in high-risk medically complex patients.

Scalp erosion in ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome): treatment with acellular dermal matrix

Ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome, also known as Hay-Wells syndrome) is an autosomal dominant disease caused by mutation in the p63 gene that is primarily characterized by facial clefting, presence of ankyloblepharon, ectodermal dysplasia, and scalp erosion. Scalp erosion is perhaps the most debilitating manifestation of AEC due to its problematic treatment that is fraught with failure given the underlying pathology of the p63 mutation causing dysfunctional wound healing. Management is often targeted in a stepwise fashion, beginning with daily baths, light debridement, and emollients and progressing to extensive skin excision. Skin grafting has limited success and, inevitably, infections requiring aggressive debridement and antibiotic therapy result from dysfunctional healing. The use of acellular dermal matrix for treatment of scalp erosion is a novel approach attempted in a patient with severe scalp disease. Here we report her case and the failure of treatment, along with possible explanations and suggestions for future therapy.

Body contouring

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. List patient selection factors for body lift surgery. 2. Describe operative approaches for brachioplasty, upper body lift, abdominoplasty, lower body lift, and thigh lift. 3. Identify complications and pitfalls related to body lifting and describe how to avoid them.

SUMMARY

The author discusses the preoperative assessment, surgical treatment plan, postoperative management, outcomes, and possible complications for a comprehensive spectrum of body-contouring surgical procedures. Preoperative planning includes medical history and physical examination, along with an open discussion with the patient. Surgical procedures for brachioplasty, upper back lift, abdominoplasty, lower back lift, gluteal augmentation and thigh lift are discussed. Postoperative management pearls are shared, as well as pitfalls to be avoided.

Tissue engineering for the management of chronic wounds: current concepts and future perspectives

Chronic wounds constitute a significant and growing biomedical burden. With the increasing growth of populations prone to dysfunctional wound healing, there is an urgent and unmet need for novel strategies to both prevent and treat these complications. Tissue engineering offers the potential to create functional skin, and the synergistic efforts of biomedical engineers, material scientists, and molecular and cell biologists have yielded promising therapies for non-healing wounds. However, traditional paradigms for wound healing focus largely on the role of inflammatory cells and fail to incorporate more recent research highlighting the importance of stem cells and matrix dynamics in skin repair. Approaches to chronic wound healing centred on inflammation alone are inadequate to guide the development of regenerative medicine-based technologies. As the molecular pathways and biologic defects underlying non-healing wounds are further elucidated, multifaceted bioengineering systems must advance in parallel to exploit this knowledge. In this viewpoint essay, we highlight the current concepts in tissue engineering for chronic wounds and speculate on areas for future research in this increasingly interdisciplinary field.