To Glue or Not to Glue? Analysis of Fibrin Glue for Split-thickness Skin Graft Fixation

Sticking to What Matters: A Matched Comparative Study of Fibrin Glue and Mechanical Fixation for Split-Thickness Skin Grafts in the Lower Extremity

Background: Split-thickness skin grafts (STSGs) remain a valuable tool in the reconstructive surgeons' armamentarium. Staple or suture mechanical fixation (MF) serves as the gold standard of care, though fibrin glue (FG) has gained popularity as a fixation modality. We compare STSG outcomes following application of FG versus MF through a study of lower extremity wounds. Methods: A retrospective review (2016-2019) of patients who underwent a STSG was performed. Two cohorts consisting of patients undergoing a STSG with FG or MF (suture or staple) were matched according to wound size, wound location, and body mass index. Results: A total of 67 patients with 79 wounds were included (FG: n = 30, wounds = 39; MF: n = 37; wounds = 40). There was no significant difference between groups regarding time to 100% graft take (FG: 39 days, MF: 35.1 days; P < .384) or 180-day graft complications (FG: 10.3%, MF: 15%; P < .737). Adjusted operative time for FG (51.8 min) was lower than for MF cases (67.5 min) at a level that approached significance (P < .094). FG patients were significantly less likely to require a postoperative wound vacuum-assisted closure (VAC) (FG: 16.7%; MF: 76.7%; P < .001) and required a significantly lower number of 30-day postoperative visits (FG: 1.5 ± .78 visits; MF: 2.5 ± .03 visits; P < .001). The MF group had higher mean aggregate charges ($211,090) compared with the FG group (mean: $149,907), although these were not statistically significant (P > .05). Conclusion: The use of FG for STSG shows comparable clinical outcomes to MF, with a significantly decreased need for postoperative wound VAC, the number of 30-day postoperative visits, and a lower wound-adjusted operative time.

An Outcome Analysis of Fibrin Sealant versus Staples for Fixation of Split-Thickness Skin Grafts

Background  Skin grafting plays a vital role in post-burn and post-traumatic wound management. Split-thickness skin grafts (STSG) are traditionally fixed using staples or sutures, which have tedious application and their removal necessitates painkillers, medical equipment, and human intervention. As an alternative, fibrin sealant is a biological tissue adhesive, composed of thrombin, calcium, and fibrinogen. Fibrin sealant promotes hemostasis and acts as a biological adherent. Objective  The aim of this study was to evaluate the outcomes (graft take, wound healing and complications) of fibrin sealant and staples for STSG fixation. Methods  It is a randomized controlled trial on 40 patients with wounds of minimum 400 cm 2 . Wound area was divided into equal halves and randomly allocated to the study group or control group. In the study group, 4 mL per 200 cm 2 of fibrin sealant was sprayed followed by STSG application. In the control group, STSG was fixed with only skin staples. Evaluation was done on postoperative days 3, 5, 15, and 30 for graft take, hematoma/seroma, infection, and complete wound healing. Results  The mean graft take was significantly higher ( p -value < 0.05) in the study group than in the control group (91 vs. 89%). No seroma or hematoma formation was seen in either group. Complete wound healing was seen in more patients in the study group, but the difference was statistically insignificant. Conclusion  Fibrin sealant is an excellent alternative to staples for skin grafting, with the advantage of better graft take and being free of pain that is incurred during staple removal.

Safeguarding Skin Grafts: An Evidence-Based Summary of Fixation Techniques

BACKGROUND

Effective skin graft fixation is vital in preventing sheering forces, seroma, and hematoma from compromising graft take. Yet, selecting the ideal technique for securing skin grafts remains a contentious subject, with significant variation in practice existing between surgeons. There is, therefore, benefit to be derived from assessing the literature for evidence-based recommendations to guide the decision-making process.

METHODS

A search of Medline and Embase was performed using appropriate key terms, yielding 419 articles. Reference lists were analyzed. Inclusion and exclusion criteria were composed. Level I to III studies, as defined by the Centre for Evidence-Based Medicine, that compared skin graft fixation methods were analyzed. Rayyan QCRI was used for abstract and title screening. After full text screening, 41 studies were included for qualitative analysis. All included randomized control trials (RCTs) were assessed for risk of bias using the Cochrane Risk-of-Bias 2 (ROB2) tool.

RESULTS

We identified 4 groups of fixation technique: "tie-over bolster" (TOB), "no TOB," "adhesive glues," and "negative pressure wound therapy" (NPWT). Twelve studies compared TOB with no TOB, with no difference in graft take demonstrated. Sixteen studies compared adhesive glues with traditional methods, with no difference in graft take demonstrated. Thirteen studies compared NPWT with traditional methods, with enhanced graft take demonstrated. Risk of bias was deemed low in 1 of 13 RCTs.

CONCLUSIONS

Based on the current evidence, only NPWT is associated with enhanced graft take. However, there is a scarcity of robust level I evidence comparing different fixation techniques, meaning that strong recommendations cannot be made. We propose examples of hypothesis-driven RCTs, in predetermined clinical settings, based on the theoretical benefits of the techniques that would add value to clinical practice.

Harnessing Multifaceted Next-Generation Technologies for Improved Skin Wound Healing

Dysregulation of sequential and synchronized events of skin regeneration often results in the impairment of chronic wounds. Conventional wound dressings fail to trigger the normal healing mechanism owing to the pathophysiological conditions. Tissue engineering approaches that deal with the fabrication of dressings using various biomaterials, growth factors, and stem cells have shown accelerated healing outcomes. However, most of these technologies are associated with difficulties in scalability and cost-effectiveness of the products. In this review, we survey the latest developments in wound healing strategies that have recently emerged through the multidisciplinary approaches of bioengineering, nanotechnology, 3D bioprinting, and similar cutting-edge technologies to overcome the limitations of conventional therapies. We also focus on the potential of wearable technology that supports complete monitoring of the changes occurring in the wound microenvironment. In addition, we review the role of advanced devices that can precisely enable the delivery of nanotherapeutics, oligonucleotides, and external stimuli in a controlled manner. These technological advancements offer the opportunity to actively influence the regeneration process to benefit the treatment regime further. Finally, the clinical relevance, trajectory, and prospects of this field have been discussed in brief that highlights their potential in providing a beneficial wound care solution at an affordable cost.

Dopamine based adhesive nano-coatings on extracellular matrix (ECM) based grafts for enhanced host-graft interfacing affinity

Interfacing affinity between grafts and host tissues is an urgent issue that needs to be addressed for the clinical translation of tissue engineered extracellular matrix (ECM) based grafts. Dopamine is known as a universal adhesive, the catechol groups on which could form chelating bonds with metal ions. Herein we developed an adhesive nano-coating on ECM based grafts which could crosslink in situ with ferric ions for fixation with surrounding tissues after implantation without affecting the porous structures of the grafts. Therefore, decellularized living hyaline cartilage graft (dLhCG), a model ECM-based graft, with dopamine based natural biological material adhesive coatings was manufactured to address the interfacing affinity issue between ECM-based grafts and cartilage. A macromolecule backbone was needed for the coating material to avoid the formation of a rigid crosslinking system and adverse effects caused by small molecules of dopamine. Chondroitin sulfate (CS), a cartilage derived sulfated GAG, was chosen as the backbone to fabricate dopamine modified CS (CSD) with no impurities introduced to the joint. Dopamine modified serum albumin (BCD) was also chosen for the favorable biocompatibility of albumin. Both dLhCG coated with CSD and dLhCG coated with BCD showed enhanced adhesive strength with cartilage after chelating with ferric ions in situ compared to dLhCG and further potential in improving the interfacing affinity of dLhCG with cartilage.

Percutaneous Debridement of and Fibrin Glue Injection Into a Pretibial Morel-Lavallée Lesion: A Case Report and Literature Review

ABSTRACT

The Morel-Lavallée lesion (MLL) is a posttraumatic close degloving injury, which is often underdiagnosed at first. Patients with MLLs usually present with tender and enlarging soft tissue swelling with fluctuation, decreased skin sensation, ecchymosis, or even skin necrosis hours to days after the inciting injury. The lesion can lead to intractable morbidity if it remains untreated. There is no consensus regarding the treatment for MLL at present. Here, we report an MLL in the pretibial region of a 43-year-old woman who experienced a low-energy contusion in a motorbike accident. The pretibial lesion was diagnosed using sonography and fine-needle aspiration. We successfully treated the patient by performing percutaneous debridement via a small incision and injections of fibrin after conservative treatment failed. The method we herein propose achieved the goal of open surgical debridement, providing faster recovery and a high degree of patient comfort. We reviewed the available pertinent literature and propose our own treatment protocol with the aim to establish common therapies ofMLL.