The impact of skin grafting on the quality of life and self-esteem of patients with venous leg ulcers

A Comprehensive Review of Evaluating Donor Site Morbidity and Scar Outcomes in Skin Transfer Techniques

This comprehensive review delves into the intricacies of donor site morbidity and scar outcomes in skin transfer techniques central to the field of reconstructive surgery. The review synthesizes existing literature to illuminate the multifaceted factors influencing outcomes by surveying a broad spectrum of grafting methods, from traditional autografts to cutting-edge tissue engineering approaches. Key findings underscore the complex interplay of graft characteristics, surgical techniques, and patient-specific variables. The implications for clinical practice advocate for a nuanced, patient-centered approach, incorporating emerging minimally invasive procedures and adjuvant therapies. The review concludes with recommendations for future research, emphasizing the importance of longitudinal studies, comparative analyses, patient-reported outcomes, advanced imaging techniques, and exploration of tissue engineering innovations. This synthesis advances our understanding of donor site morbidity and scar outcomes. It provides a roadmap for refining clinical protocols, ultimately enhancing the delicate balance between therapeutic efficacy and patient well-being in reconstructive surgery.

Association of autologous punch grafting, TLC-NOSF dressing and multitype compression therapy to rapidly achieve wound closure in hard-to-heal venous leg ulcers

OBJECTIVE

To document the efficacy of a combined therapeutic strategy in achieving rapid wound healing in patients with long-standing ulcers.

MATERIALS AND METHODS

Outpatients with hard-to-heal venous leg ulcers were included in an interventional, prospective, single-arm, mono-centre study and treated with autologous punch grafting, TLC-NOSF dressing and multi-type compression therapy. The primary outcome was the percentage of healed wounds by week 12. Secondary outcomes included time-to-reach wound closure, wound area reduction, treatment acceptability and safety.

RESULTS

From November 2018 to October 2019, 42 patients with 51 ulcers were included (23 males, 70.6±40.8 years old, with multiple comorbidities). Despite poor wound healing prognosis at baseline (47% of recurrent ulcers, with a mean duration of 15 months and a mean area of 12.6cm²), wound healing was achieved in 47 ulcers (92%) after a mean period of treatment of 25±13 days. A relative wound area reduction>75% was also reached in three additional ulcers by the last evaluation visit. No adverse event related to the procedure was reported throughout the study period. The associated treatment were very well tolerated and accepted by the patients.

CONCLUSIONS

The evaluated procedure induced fast re-epithelisation of the treated ulcers. Based on our experience, this simple and successful reparative strategy may be considered as an interesting option in the treatment of venous leg ulcers of poor prognosis.

Unna boot therapy impact on wellbeing, hope and spirituality in venous leg ulcer patients: a prospective clinical trial

Objective:

To assess the impact of Unna boot therapy on subjective wellbeing, hope and spirituality in patients with venous leg ulcers (VLU).

Method:

This was a prospective, descriptive, analytical, multicentre clinical trial conducted in a nursing care and education centre, an outpatient wound care clinic and a primary health care unit in Brazil. Adult patients with VLUs took part in the study. Patients with diabetic foot ulcers and mixed ulcers were excluded. A questionnaire assessing sociodemographic and religious characteristics of patients, the Subjective Wellbeing Scale, the Spirituality Self-Rating Scale (SSRS), and the Herth Hope Index (HHI) were administered to all patients.

Results:

A total of 60 patients (63.3% female; 86.7% aged ≥60 years) participated. Before Unna boot therapy, 65%, 66.7% and 65% of patients reported a score of one on positive affect, negative affect and life satisfaction, respectively, indicating poor subjective wellbeing. After one month of compression therapy, 66.7%, 50.0%, and 80.0% of patients reported a score of three for each element positive affect, negative affect and life satisfaction, respectively, showing a significant improvement in subjective wellbeing (p=0.029). A significant increase in total SSRS scores (p=0.017) was found between baseline (mean: 9.77) and one month of treatment (mean: 25.47), indicating a significant increase in a sense of spirituality. There was also a significant increase in total HHI values (p=0.009) between baseline (mean: 15.68) and one month of compression therapy (mean: 39.38), suggesting a significant increase in hope among patients.

Conclusion:

Patients with VLUs treated with Unna boot therapy in this study showed significant improvement in subjective wellbeing, spirituality and hope for cure.

Mid- to Long-term Outcomes After Split-thickness Skin Graft vs. Skin Extension by Multiple Incisions

BACKGROUND/AIM

Skin extension by multiple incisions (SEMI) may be superior to split-thickness skin graft (STSG) for closure of large soft tissue defects.

MATERIALS AND METHODS

Twenty-six patients who had undergone STSG were compared to 29 patients who had undergone SEMI on the extremities. Patient and Observer Scar Assessment Scale (POSAS), Dermatology Life Quality Index, Wound QoL (Quality of Life) and Short Form Health Survey 36 were used. Elasticity, thickness and skin sensation were compared between the treated and contralateral extremity. Range of motion in adjacent joints was measured. Complication rates were compared.

RESULTS

A total of 55 patients with a mean follow-up of 5.5 years (range=2-9 years) were examined. Patients with STSG had significantly worse scores in POSAS. The scar was thinner, less elastic and did not provide intact sensibility. Other scores, ROM and complication rates did not differ significantly.

CONCLUSION

SEMI was superior to STSG regarding patient satisfaction and scar quality.

Impact of venous ulcers on patients' quality of life: an integrative review

OBJECTIVE

To analyze knowledge gathered about the impact of venous ulcers on patients' quality of life.

METHOD

Systematic bibliographic review study with an integrative approach. Databases of MEDLINE, LILACS, IBECS, CINAHL Complete, Web of Science, Scopus, and CUIDEN Plus were used for selection with the PICOT guiding criteria, through the DeCS and MeSH: adult, aged, varicose ulcer, and quality of life, in Portuguese, Spanish, and English. The inclusion criteria were: full original articles available in the databases selected with adherence to the theme in Portuguese, Spanish, and English, published from 2007 to 2016.

RESULTS

The sample included 14 national and international articles with different methodological approaches and investigative contexts, published from 2012 to 2016.

CONCLUSION

Chronic venous ulcers act on patients' bio-psycho-social-spiritual and socioeconomic spheres, having a negative impact on their quality of life.

Impact of non-adherent Ibuprofen foam dressing in the lives of patients with venous ulcers

Objective

to evaluate pain in patients with lower limb venous ulcer who used non-adherent Ibuprofen foam dressing (IFD).

Methods

we conducted a prospective study of patients with lower limb venous ulcers treated from April 2013 to August 2014. We used the Numerical Scale and McGill Pain Questionnaire, performing the assessments at the moment of inclusion of the patient in the study and every eight days thereafter, totaling five consultations. We divided the patients into two groups: 40 in the Study Group (SG), who were treated with IFD, and 40 in the Control Group (CG), treated with primary dressing, according to tissue type and exudate.

Results

at the first consultation, patients from both groups reported intense pain. On the fifth day, SG patients reported no pain and the majority of CG reported moderate pain. Regarding the McGill Pain Questionnaire, most patients of both groups reported sensations related to sensory, affective, evaluative and miscellaneous descriptors at the beginning of data collection; after the second assessment, there was slight improvement among the patients in the SG. After the third consultation, they no longer reported the mentioned descriptors. CG patients displayed all the sensations of these descriptors until the fifth visit.

Conclusion

non-adherent Ibuprofen foam dressing is effective in reducing the pain of patients with venous ulcers.

The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

OBJECTIVE

to evaluate pain in individuals with venous ulcers treated with elastic bandage and decongestant physical therapy.

METHODS

we studied 90 patients, divided into three groups with 30 patients each: a group treated with elastic bandage and decongestant physical therapy; a group treated with elastic bandage; and a group treated only with primary dressing according to tissue type and presence of exudate. We used the Pain Numerical Scale to quantify pain intensity and the McGill Pain Questionnaire for pain qualitative assessment.

RESULTS

in the first evaluation, all patients who participated in the study reported intense pain. In the fifth evaluation, the majority of patients treated with elastic bandaging and decongestant physical therapy did not report pain; the majority of patients in the elastic bandage group reported mild pain; and most patients treated only with primary dressing reported mild to moderate pain. During all five assessments using the McGill questionnaire, most patients in the elastic bandaging and primary dressing groups used descriptors of the sensory, affective, evaluative and miscellaneous groups to describe their pain. However, in the fourth and fifth evaluations, most patients who received decongestant physical therapy combined with elastic bandaging treatment did not use any of the descriptors.

CONCLUSION

patients treated with decongestant physical therapy and elastic bandage presented pain improvement from the third evaluation performed on.

Health-related quality of life and patient burden in patients with split-thickness skin graft donor site wounds

Split-thickness skin grafting is a common procedure to treat different kinds of wounds. This systematic, multicentre, observational, cross-sectional study of adult patients with split-thickness skin graft (STSG) donor site wounds was conducted to evaluate quality of life (QoL) impairments caused by donor site wounds following split-thickness skin grafting. Therefore, 112 patients from 12 wound centres in Germany were examined based on patient and physician questionnaires as well as a physical examination of the donor site wound. Most indications for skin grafting were postsurgical treatment (n = 51; 42.5%) and chronic wounds (n = 47; 39.2%). European QoL visual analoque scale (EQ VAS) averaged 64.7 ± 23.3, European QoL 5 dimensions (EQ-5D) averaged 77.4 ± 30.0. Wound-QoL (range: 0-4) was rated 0.8 ± 0.8 post-surgery and 0.4 ± 0.6 at the time of survey (on average 21 weeks between the time points). Compared to averaged Wound-QoL scores of chronic wounds donor site-related QoL impairments in split-thickness skin-graft patients were less pronounced. There were significant differences in patient burden immediately after surgery compared to the time of the survey, with medium effect sizes. This supports the hypothesis that faster healing of the donor site wound leads to more favourable patient-reported outcomes.

Development and validation of an algorithm for laser application in wound treatment

OBJECTIVE

To develop and validate an algorithm for laser wound therapy.

METHOD

Methodological study and literature review. For the development of the algorithm, a review was performed in the Health Sciences databases of the past ten years. The algorithm evaluation was performed by 24 participants, nurses, physiotherapists, and physicians. For data analysis, the Cronbach's alpha coefficient and the chi-square test for independence was used. The level of significance of the statistical test was established at 5% (p<0.05).

RESULTS

The professionals' responses regarding the facility to read the algorithm indicated: 41.70%, great; 41.70%, good; 16.70%, regular. With regard the algorithm being sufficient for supporting decisions related to wound evaluation and wound cleaning, 87.5% said yes to both questions. Regarding the participants' opinion that the algorithm contained enough information to support their decision regarding the choice of laser parameters, 91.7% said yes. The questionnaire presented reliability using the Cronbach's alpha coefficient test (α = 0.962).

CONCLUSION

The developed and validated algorithm showed reliability for evaluation, wound cleaning, and use of laser therapy in wounds.

Skin grafting for the treatment of chronic leg ulcers - a systematic review in evidence-based medicine

Skin grafting is one of the most common surgical procedures in the area of non-healing wounds by which skin or a skin substitute is placed over a wound to replace and regenerate the damaged skin. Chronic leg ulcers are an important problem and a major source of expense for Western countries and for which many different forms of treatment have been used. Skin grafting is a method of treatment that decreases the area of chronic leg ulcers or heals them completely, thus improving a patient's quality of life. Skin grafting is an old technique, rediscovered during the first and second world wars as the main treatment for wound closure. Nowadays, skin grafting has a pivotal role in the context of modern wound healing and tissue regeneration. The aim of this review was to track and to analyse the specific outcomes this technique achieved, especially in the last decade, in relation to venous, arterial, diabetic, rheumatoid and traumatic leg ulcers. Our main findings indicate that autologous split-thickness skin grafting still remains the gold standard in terms of safety and efficacy for chronic leg ulcers; skin grafting procedures have greater success rates in chronic venous leg ulcers compared to other types of chronic leg ulcers; skin tissue engineering, also supported by genetic manipulation, is quickly expanding and, in the near future, may provide even better outcomes in the area of treatments for long-lasting chronic wounds.

Epidermal skin grafting in patients with complex wounds: a case series

OBJECTIVE

Complex wounds are often difficult to close and sometimes require a split-thickness skin graft (STSG). However, epidermal skin grafts, which contain only an epidermal layer of skin, are a viable option for wound coverage in these challenging wounds. We report our experience using an automated epidermal harvesting tool to harvest epidermal skin grafts for the treatment of complex wounds.

METHOD

Epidermal skin grafts were harvested from the patient's thigh, which was first washed with isopropyl alcohol. After harvesting, they were transferred to the recipient site using a film dressing. A bolster dressing using gauze and a self-adherent wrap held the grafts in place.

RESULTS

We selected 34 patients with wounds that had been present from several weeks to over a year. Prior treatments, included skin substitutes, alginate dressings, Unna Boot, and collagen dressings. There were 17 female and 17 male patients with a mean age of 67.1 years (range: 37-103). Wound types were: traumatic wounds, diabetic foot ulcers, venous stasis ulcers, pressure ulcers, and surgical wounds. Patient comorbidities included hypertension, diabetes, congestive heart failure, and osteoarthritis. Mean epithelialisation rate at the recipient site was 7.0 weeks (range: 1-35 weeks). Wound complications included drainage, hypergranulation, and oedema. At follow-up 82.4% (28/34) of wounds were healed, 2.9% (1/34) wounds showed improved healing, 11.8% (4/34) of wounds did not heal, and 2.9% (1/34) were lost to follow-up. All donor sites healed without complications.

CONCLUSION

In our cohort, use of epidermal skin grafts in conjunction with bolster dressings resulted in full closure or wound improvement of a majority of patients. Epidermal grafting provides another treatment option to physicians when only the epidermal layer is needed.

DECLARATION OF INTEREST

Dr. Bhatia is a consultant for KCI, an Acelity company.

Epidermal Grafting for Chronic Complex Wounds in India: A Case Series

BACKGROUND : In India, the high cost of medical treatments and limited resources can deter patients from receiving available care, leading to the development of chronic wounds. We evaluated the use of epidermal grafting in patients with complex, long-term chronic wounds.

METHODS

Eighteen patients with complex wounds were treated with epidermal micrografts between September 2014 and March 2015 at a state-run, community health center in Mahe, Puducherry, India. Wound re-epithelialization was monitored for up to 14 weeks. RESULTS : Comorbidities in the patient group (nine females and nine males; mean age 54.1 ± 10.8 years, range 32-70 years) included diabetes mellitus, hypertension, obesity (body mass index (BMI) >30 kg/m(2)), and peripheral vascular disease. The wound types included diabetic and nondiabetic foot, pressure, and venous leg ulcers. The average wound age prior to treatment was 36.8 ± 48.5 months (range 2-180 months) in the majority of patients. All wounds measured less than 7 cm × 7 cm. The mean time to wound epithelialization was 3.7 ± 1.8 weeks (range 2-9 weeks). The majority of wounds healed following epidermal grafting (n=16, 88.9%). One patient developed infection following removal of the dressing under non-sterile conditions against the advice of the healthcare providers. Another patient developed wound hypergranulation after grafting. Both wounds healed completely after treatment with antibiotic therapy and tissue resection, respectively. All donor sites healed without complications. CONCLUSION : In patients with small- to medium-sized chronic wounds, epidermal grafting offered a viable wound closure option for wounds requiring only the epidermal layer. Additionally, epidermal grafting was performed in the clinic without anesthesia or a surgeon, making the procedure more accessible in resource-challenged regions.

Impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária

Objetivo: analisar o impacto das úlceras venosas (UV) na qualidade de vida (QV) das pessoas atendidas na atenção primária à saúde. Material e método: pesquisa quantitativa, descritiva e transversal, realizada com 101 usuários, atendidos em 42 serviços de saúde de Natal, Rio Grande do Norte, Brasil. Os dados foram coletados de fevereiro a setembro de 2014, por meio de um questionário sociodemográfico, clínico e de saúde, e do Charing Cross Venous Ulcer Questionnaire. Utilizou-se estatística descritiva e inferencial para a análise dos dados. Resultados: a QV esteve comprometida, principalmente, no estado emocional e estético, com pior média entre os indivíduos com mais de um ano de lesão. Identificou-se associação estatística significativa entre tempo de UV atual e estado emocional (p=0,008), com maior média (64,2) para aqueles com UV há mais de um ano. Conclusões: as pessoas com UV há mais de ano apresentam maior comprometimento da QV. Necessita-se de intervenções e ações de promoção à saúde dessa população.

Impact of compression therapy using Unna's boot on the self-esteem of patients with venous leg ulcers

OBJECTIVE

To assess self-esteem in patients with venous leg ulcers treated with Unna's boot. •

METHOD

A descriptive, analytic, clinical study was conducted from June 2010 to May 2011 in an outpatient wound care clinic in São Paulo, Brazil. Patients of both sexes, aged ≥18 years, who had had a venous leg ulcer for more than one year and a Doppler ankle brachial index ranging from 0.8-1.0 were consecutively selected for inclusion. Patients were treated with wound dressings and Unna's boot. Self-esteem was assessed using the Brazilian version of the Rosenberg Self-Esteem Scale (RSE) at inclusion (baseline) and after 4, 8, and 12 months of compression therapy using Unna's boot. The scale is reverse-scored; thus lower scores indicate higher levels of self-esteem. •

RESULTS

The patients showed a slight but significant improvement in self-esteem after 4 months of treatment (mean RSE score=17.12) compared with baseline (mean RSE score=24.90). However, a marked and significant improvement in self-esteem was observed after 8 months (mean RSE score=7.40) and 12 months (mean RSE score=2.10) of compression therapy using Unna's boot. •

CONCLUSION

Patients with venous leg ulcers treated with Unna's boot for 12 months showed a significant improvement in self-esteem •

DECLARATION OF INTEREST

All authors declare that no competing financial interests exist. There was no external funding for this study.