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Burton H, Iliadis AD, Jones N, Saini A, Bystrzonowski N, Vris A, Pafitanis G. Osteocutaneous Turn-Up Fillet Flaps: A Spare-Parts Orthoplastic Surgery Option for a Functional Posttraumatic Below-Knee Amputation. Arch Plast Surg 2023; 50:501-506. [PMID: 37808330 PMCID: PMC10556299 DOI: 10.1055/a-2033-5803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/12/2023] [Indexed: 02/13/2023] Open
Abstract
This article portrays the authors' experience with a complex lower limb bone and soft tissue defect, following chronic osteomyelitis and pathological fracture, which was managed by the multidisciplinary orthoplastic team. The decision for functional amputation versus limb salvage was deemed necessary, enhanced by the principles of "spare parts" in reconstructive microsurgery. This case describes the successful use of the osteocutaneous distal tibia turn-up fillet flap that allowed "lowering the level of the amputation" from a through knee to a below-knee amputation (BKA) to preserve the knee joint function. We comprehensibly review reports of turn-up flaps which effectively lower the level of amputation, also applying "spare-parts" surgery principles and explore how these concepts refine complex orthoplastic approaches when limb salvage is not possible to enhance function. The osteocutaneous distal tibia turn-up fillet flap is a robust technique for modified BKA reconstructions that provides sufficient bone length to achieve a tough, sensate stump and functional knee joint.
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Affiliation(s)
- Harry Burton
- London Reconstructive Microsurgery Unit, Emergency Care and Trauma Division, Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Alexios Dimitrios Iliadis
- Limb Reconstruction and Bone Infection Unit, Emergency Care and Trauma Division, Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Neil Jones
- Limb Reconstruction and Bone Infection Unit, Emergency Care and Trauma Division, Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Aaron Saini
- Trauma and Limb Reconstruction Unit, Department of Trauma and Orthopaedics, King's College Hospital Foundation Trust, London, United Kingdom
| | - Nicola Bystrzonowski
- Limb Reconstruction and Bone Infection Unit, Emergency Care and Trauma Division, Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Alexandros Vris
- Limb Reconstruction and Bone Infection Unit, Emergency Care and Trauma Division, Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Georgios Pafitanis
- London Reconstructive Microsurgery Unit, Emergency Care and Trauma Division, Department of Plastic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
- Limb Reconstruction and Bone Infection Unit, Emergency Care and Trauma Division, Department of Trauma and Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
- Department of Medical Sciences, Medical School, University of Cyprus, Nicosia, Cyprus
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2
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Hijazi Y, Elbaz A, Mutsago T, Bystrzonowski N, Berner JE, Pafitanis G. Fasciocutaneous perforator flap direct monitoring with a smartphone instant heart rate app. Microsurgery 2022; 42:522-523. [PMID: 35611642 DOI: 10.1002/micr.30922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/06/2022] [Accepted: 05/13/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Yasser Hijazi
- London Reconstructive Microsurgery Unit (LRMU), Department of Plastic Surgery, Emergency Care and Trauma Division (ECAT), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ahmed Elbaz
- London Reconstructive Microsurgery Unit (LRMU), Department of Plastic Surgery, Emergency Care and Trauma Division (ECAT), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Tonderai Mutsago
- London Reconstructive Microsurgery Unit (LRMU), Department of Plastic Surgery, Emergency Care and Trauma Division (ECAT), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Nicola Bystrzonowski
- London Reconstructive Microsurgery Unit (LRMU), Department of Plastic Surgery, Emergency Care and Trauma Division (ECAT), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Juan Enrique Berner
- London Reconstructive Microsurgery Unit (LRMU), Department of Plastic Surgery, Emergency Care and Trauma Division (ECAT), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Georgios Pafitanis
- London Reconstructive Microsurgery Unit (LRMU), Department of Plastic Surgery, Emergency Care and Trauma Division (ECAT), The Royal London Hospital, Barts Health NHS Trust, London, UK
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Abstract
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.
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Affiliation(s)
- Benjamin J Patel
- From the Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Patel B, Asher C, Bystrzonowski N, Healy C. 529 Safeguarding Skin Grafts: A 21st Century Algorithm for Fixation Techniques. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aim
Effective skin graft fixation is fundamental in preventing sheering forces, seroma and haematoma from compromising graft take. However, determining the ideal method of graft fixation remains a contentious subject. Currently, there is significant variation in fixation techniques used, based not only on clinical requirement, but also surgeon preference. Evidence-based recommendations are necessary to guide the decision-making process.
Method
We undertook a PRISMA-based assessment of the literature to define all fixation techniques and analyse their outcomes. Inclusion and exclusion criteria were composed. A search of Medline and Embase was performed, yielding 399 articles. After abstract screening, 96 were included for qualitative data analysis.
Results
Nine fixation techniques were identified: ‘tie over bolster’, ‘staple fixation’, ‘simple dressings’, ‘quilting sutures’, ‘re-look methods’, ‘foam sponge bolster’, ‘adhesive glues’, ‘negative pressure wound therapy’ and ‘less common techniques. We analyse the available evidence for each technique, identifying 13 studies with level I/II evidence. We summarise the research that underpins these nine categories, proposing an algorithm to facilitate technique selection based on anatomical and patient-specific factors.
Conclusions
An array of skin graft fixation techniques are used in plastic surgery, without clear guidelines. To our knowledge, this is the first time all fixation techniques have been defined. Our suggested algorithm is intended to aid surgeons in selecting an appropriate fixation technique and should be challenged by future research, particularly randomised control trials.
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Affiliation(s)
- B Patel
- Southmead Hospital, Bristol, United Kingdom
| | - C Asher
- St Thomas's Hospital, London, United Kingdom
| | | | - C Healy
- St Thomas's Hospital, London, United Kingdom
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5
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Abstract
Seven models for tendon repair simulation (urinary catheter, liquorice, fishing lure, dental rolls, drinking straw, silicone sealant and the authors' modification of silicone sealant with Micropore™ tape) were assessed for their performance in a number of domains. The silicone sealant and surgical tape model scored highest overall and for each individual domain. This was significantly higher than all other models with the exception of the silicone sealant alone. The lowest scoring model was the drinking straw model.
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Affiliation(s)
- Zak Vinnicombe
- Department of Plastic and Reconstructive Surgery, St. George's Hospital, London, UK
| | - Christian M Asher
- Department of Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital, London, UK
| | - Jonathan Super
- Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
| | - Nicola Bystrzonowski
- Department of Plastic and Reconstructive Surgery, The Royal London Hospital, London, UK
| | - Eufrossyni Katsarma
- Department of Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital, London, UK
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6
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Kanapathy M, Hachach-Haram N, Bystrzonowski N, Becker DL, Mosahebi A, Richards T. Epidermal graft encourages wound healing by down-regulation of gap junctional protein and activation of wound bed without graft integration as opposed to split-thickness skin graft. Int Wound J 2021; 18:332-341. [PMID: 33751815 PMCID: PMC8244016 DOI: 10.1111/iwj.13536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 01/07/2023] Open
Abstract
Wound coverage by split-thickness skin graft (SSG) and epidermal graft (EG) shortens healing time, with comparable outcomes. However, the healing mechanism of EG is not as well understood as SSG. The difference in the healing mechanisms of EG and SSG was investigated using gap junctional proteins, proliferative marker, and cytokeratin markers. Paired punch biopsies were taken from the wound edge and wound bed from patients undergoing EG and SSG at weeks 0 and 1 to investigate wound edge keratinocyte migratory activities (connexins 43, 30, and 26), wound bed activation (Ki67), and the presence of graft integration to the wound bed (cytokeratins 14 and 6). Twenty-four paired biopsies were taken at weeks 0 and 1 (EG, n = 12; SSG, n = 12). Wound edge biopsies demonstrated down-regulation of connexins 43 (P = .023) and 30 (P = .027) after EG, indicating accelerated healing from the wound edge. At week 1, increased expression of Ki67 (P < .05) was seen after EG, indicating activation of cells within the wound bed. Keratinocytes expressing cytokeratins 6 and 14 were observed on all wounds treated with SSG but were absent at week 1 after EG, indicating the absence of graft integration following EG. Despite EG and SSG both being autologous skin grafts, they demonstrate different mechanisms of wound healing. EG accelerates wound healing from the wound edges and activates the wound bed despite not integrating into the wound bed at week 1 post-grafting as opposed to SSG, hence demonstrating properties comparable with a bioactive dressing instead of a skin substitute.
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Affiliation(s)
- Muholan Kanapathy
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Nadine Hachach-Haram
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Nicola Bystrzonowski
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - David L Becker
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Institute of Medical Biology, A*Star, Immunos, Biomedical Grove, Singapore
| | - Afshin Mosahebi
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Toby Richards
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
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7
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Asher CM, Fleet M, Jivraj B, Bystrzonowski N. Cosmetic Tourism: a Costly Filler Within the National Health Service Budget or a Missed Financial Opportunity? A Local Cost Analysis and Examination of the Literature. Aesthetic Plast Surg 2020; 44:586-594. [PMID: 31832735 DOI: 10.1007/s00266-019-01571-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 11/30/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cosmetic tourism is a global commodity, but patients seeking treatment for complications of international cosmetic tourism appear to be on the rise. We calculate the financial burden to a single NHS trust and summarise the literature, reviewing the implications of cosmetic tourism and summarising available guidance to assist surgeons in this ethically challenging, but expanding, field. METHODS Hospital episodes for patients with complications from cosmetic tourism between January 2016 and March 2017 were retrieved using the patient management system. The coding department provided the episode costs. A literature search was conducted using Medline, EMBASE and HBE identifying 273 English abstracts. The abstracts were reviewed for relevance followed by assessment of the 48 selected full articles by all authors and 17 papers contained relevant, new information. RESULTS Eleven patients underwent management for complications of cosmetic surgery, most commonly infection, with a sum of 29 inpatient episodes and total cost of £259,732. DISCUSSION Our study illustrates the management of complications of cosmetic surgery carries a high cost. This is not an experience limited to just this trust in the UK. Internationally, healthcare systems are evolving to raise the safety profile for cosmetic tourists, some going the extra mile to accommodate healthcare tourists, reaping the financial reward. Following the examination of the literature, we query whether NHS trusts should heighten their presence as providers of private services on the international market, eliminating numerous medical-ethic concerns associated with substandard cosmetic tourism. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Affiliation(s)
- Christian M Asher
- Chelsea & Westminster NHS Trust, 369 Fulham Rd, Chelsea, London, SW10 9NH, UK.
| | - Malik Fleet
- Chelsea & Westminster NHS Trust, 369 Fulham Rd, Chelsea, London, SW10 9NH, UK
| | - Bejaan Jivraj
- Imperial College School of Medicine, Kensington, London, SW7 2DD, UK
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8
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Kanapathy M, Bystrzonowski N, Hachach-Haram N, Twyman L, Becker DL, Richards T, Mosahebi A. Lower donor site morbidity and higher patient satisfaction with epidermal grafting in comparison to split thickness skin grafting: A randomized controlled trial (EPIGRAAFT Trial). J Plast Reconstr Aesthet Surg 2020; 73:1556-1564. [PMID: 32532631 DOI: 10.1016/j.bjps.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/22/2020] [Accepted: 03/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Split thickness skin grafting (SSG) is an important modality for wound coverage; however, it leads to donor site morbidity. Epidermal grafting (EG) is a promising option for autologous skin grafting which offers minimal donor site morbidity, though it is not known if EG is an effective clinical alternative for SSG. This study compared the efficacy of EG as an alternative to SSG in terms of wound healing outcomes, donor site morbidity, patient satisfaction and adverse events. METHODS EPIGRAAFT is a Phase 2, randomized, open-label trial with two parallel groups: EG and SSG. Patients referred for skin grafting with a healthy granulating wound bed were included. The co-primary endpoints were the proportion of wounds healed and donor site healing time. The secondary endpoints include donor site morbidity measured using Vancouver Scar Scale, mean time for complete wound healing, patient satisfaction assessed using a validated skin grafting questionnaire and incidence of adverse events. RESULTS Of the 61 patients screened, 44 patients were randomized. There was no difference in the proportion of wounds healed at 6 weeks (p=0.366) and 3 months(p=0.24) as well as the mean time for wound healing (p=0.12). EG resulted in lower donor site morbidity (p=0.001), faster donor site healing time (EG: 4.86 days vs. SSG: 21.32 days) (p<0.0001), and higher overall satisfaction (p<0.001). There were no adverse events reported. CONCLUSION This study demonstrated that EG has superior donor site outcomes with faster donor site healing and lower morbidity compared to SSG, while having comparable wound healing outcomes. Patients receiving EG also experienced higher donor site satisfaction compared to SSG. ClinicalTrials.gov identifier: NCT02535481.
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Affiliation(s)
- Muholan Kanapathy
- Division of Surgery & Interventional Science, University College London, United Kingdom; Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
| | - Nicola Bystrzonowski
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
| | - Nadine Hachach-Haram
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
| | - Lucy Twyman
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
| | - David L Becker
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Institute of Medical Biology, A*Star, Immunos, Biomedical Grove, Singapore
| | - Toby Richards
- Division of Surgery & Interventional Science, University College London, United Kingdom; Faculty of Health and Medical Sciences, University of Western Australia.
| | - Afshin Mosahebi
- Division of Surgery & Interventional Science, University College London, United Kingdom; Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom
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9
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Rahman S, Langridge B, Hachach-Haram N, Hansen E, Bootle A, Bystrzonowski N, Hamilton S, Mosahebi A. Assessing the effects of changes in care commissioning guidelines at a tertiary centre in London on the provision of NHS-funded procedures of limited clinical effectiveness: an 11-year retrospective database analysis. BMJ Open 2017; 7:e015324. [PMID: 28756382 PMCID: PMC5642782 DOI: 10.1136/bmjopen-2016-015324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The main objective of this study was to assess the impact of changes in care commissioning policies on National Health Service (NHS)-funded cosmetic procedures over an 11-year period at our centre. SETTING The setting was a tertiary care hospital in London regulated by the North Central London Hospitals NHS Trust care commissioning group. PARTICIPANTS We included all patients logged on to our database at the time of the study which was 2087 but later excluded 61 from analysis due to insufficient information. PRIMARY AND SECONDARY OUTCOME MEASURES The main outcome measures were the results of tribunal assessment for different cosmetic surgeries which were either accepted, rejected or inconclusive based on the panel meeting. RESULTS There were a total of 2087 patient requests considered between 2004 and 2015, of which 715 (34%) were accepted, 1311 (63%) were declined and 61 (3%) had inconclusive results. The implementation of local care commissioning guidelines has reduced access to cosmetic surgeries. Within this period, the proportion of procedures accepted has fallen from 36% in 2004 to 21% in 2015 (χ2; p<0.05, 95% CI). CONCLUSION Local guidance on procedures of limited clinical effectiveness is a useful, although not evidence-based selection process to reduce access to cosmetic surgery in line with increasing financial constraints. However, patients with a physical impairment may not receive treatment in comparison to previous years, and this can have a negative impact on their quality of life.
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Affiliation(s)
- Shafiq Rahman
- Division of Surgery and Interventional Science, University College London, London, England
| | | | | | - Esther Hansen
- Department of Plastic Surgery, Royal Free Hospital, London, England
| | - Anna Bootle
- Department of Plastic Surgery, Royal Free Hospital, London, England
| | | | - Stephen Hamilton
- Department of Plastic Surgery, Royal Free Hospital, London, England
| | - Afshin Mosahebi
- Division of Surgery and Interventional Science, University College London, London, England
- Department of Plastic Surgery, Royal Free Hospital, London, England
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10
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Kanapathy M, Smith OJ, Hachach-Haram N, Bystrzonowski N, Mosahebi A, Richards T. Systematic review and meta-analysis of the efficacy of epidermal grafting for wound healing. Int Wound J 2017; 14:921-928. [PMID: 28198101 DOI: 10.1111/iwj.12729] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/26/2017] [Indexed: 02/02/2023] Open
Abstract
Autologous skin grafting is an important method for wound coverage; however, it is an invasive procedure and can cause donor site morbidity. Epidermal grafting (EG) enables epidermal transfer to wounds with minimal donor site morbidity. However, data to date have been heterogeneous. This study aims to synthesise the current evidence on EG for wound healing to establish the efficacy of this surgical technique. A comprehensive search in the MEDLINE, EMBASE and CENTRAL databases was conducted. The endpoints assessed were proportion of wounds healed and mean wound-healing time. This systematic review was conducted and reported according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We identified 1568 articles, of which seven articles were included in this review - a total of 209 wounds in 190 patients. The mean wound duration was 17·06 weeks (95% CI 8·57-25·55). Of these, 71·5% (95% CI 56·7-84·2) of the wounds achieved complete healing. Mean time for complete wound healing was 5·53 weeks (95% CI 3·18-7·88). The mean donor site healing time was 7·48 days (95% CI 4·83-10·13), with no reported donor site morbidity. The current data are small and lack level 1 evidence.
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Affiliation(s)
- Muholan Kanapathy
- Division of Surgery & Interventional Science, University College London, London, UK.,London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Oliver J Smith
- London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Nadine Hachach-Haram
- London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Nicola Bystrzonowski
- London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Afshin Mosahebi
- Division of Surgery & Interventional Science, University College London, London, UK.,London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Toby Richards
- Division of Surgery & Interventional Science, University College London, London, UK.,London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
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11
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Hendrickson S, Bystrzonowski N, Kokkinos C, Butler P. Necrotising fasciitis caused by metastatic endometrial cancer: a rare cause of a life-threatening condition. Ann R Coll Surg Engl 2017; 99:e72-e74. [PMID: 27869494 PMCID: PMC5392845 DOI: 10.1308/rcsann.2016.0341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2016] [Indexed: 12/18/2022] Open
Abstract
We report a case of necrotising fasciitis caused by metastatic endometrial adenocarcinoma. Metastases to the lumbar spine with local invasion to the iliopsoas muscle led to an iliopsoas abscess, which subsequently progressed to necrotising fasciitis of the flank. This patient lacked common risk factors for necrotising fasciitis. There are no previous reports in the literature of necrotising fasciitis with this aetiology. We discuss the available evidence for aetiology of and risk factors for necrotising fasciitis, and the relation of time to surgery with prognosis.
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Affiliation(s)
- S Hendrickson
- Plastic Surgery Department, Royal Free Hospital NHS Foundation Trust , London , UK
| | - N Bystrzonowski
- Plastic Surgery Department, Royal Free Hospital NHS Foundation Trust , London , UK
| | - C Kokkinos
- Plastic Surgery Department, Royal Free Hospital NHS Foundation Trust , London , UK
| | - P Butler
- Plastic Surgery Department, Royal Free Hospital NHS Foundation Trust , London , UK
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12
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Kanapathy M, Smith O, Hachach-Haram N, Bystrzonowski N, Richards T, Mosahebi A. Systematic review and meta-analysis of the efficacy of epidermal grafting for wound healing. Int J Surg 2016. [DOI: 10.1016/j.ijsu.2016.08.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Greenfield M, Smith O, Hachach-Haram N, Bystrzonowski N, Pucci A, Hashemi M, Mosahebi A. The effect of body contouring surgery on weight loss maintenance following bariatric surgery. Int J Surg 2016. [DOI: 10.1016/j.ijsu.2016.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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14
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Kanapathy M, Hachach-Haram N, Bystrzonowski N, Connelly JT, O'Toole EA, Becker DL, Mosahebi A, Richards T. Epidermal grafting for wound healing: a review on the harvesting systems, the ultrastructure of the graft and the mechanism of wound healing. Int Wound J 2016; 14:16-23. [PMID: 27785878 DOI: 10.1111/iwj.12686] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 10/07/2016] [Indexed: 12/13/2022] Open
Abstract
Epidermal grafting for wound healing involves the transfer of the epidermis from a healthy location to cover a wound. The structural difference of the epidermal graft in comparison to the split-thickness skin graft and full-thickness skin graft contributes to the mechanism of effect. While skin grafting is an epidermal transfer, little is known about the precise mechanism of wound healing by epidermal graft. This paper aims to explore the evolution of the epidermal graft harvesting system over the last five decades, the structural advantages of epidermal graft for wound healing and the current hypotheses on the mechanism of wound healing by epidermal graft. Three mechanisms are proposed: keratinocyte activation, growth factor secretion and reepithelialisation from the wound edge. We evaluate and explain how these processes work and integrate to promote wound healing based on the current in vivo and in vitro evidence. We also review the ongoing clinical trials evaluating the efficacy of epidermal graft for wound healing. The epidermal graft is a promising alternative to the more invasive conventional surgical techniques as it is simple, less expensive and reduces the surgical burden for patients in need of wound coverage.
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Affiliation(s)
- Muholan Kanapathy
- Division of Surgery & Interventional Science, University College London, London, UK.,London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Nadine Hachach-Haram
- London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Nicola Bystrzonowski
- London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - John T Connelly
- Centre for Cell Biology and Cutaneous Research, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Edel A O'Toole
- Centre for Cell Biology and Cutaneous Research, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - David L Becker
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Institute of Medical Biology, A*Star, Immunos, Biomedical Grove, Singapore, Singapore
| | - Afshin Mosahebi
- Division of Surgery & Interventional Science, University College London, London, UK.,London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Toby Richards
- Division of Surgery & Interventional Science, University College London, London, UK.,London Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
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Kanapathy M, Smith OJ, Hachach-Haram N, Bystrzonowski N, Mosahebi A, Richards T. Protocol for a systematic review of the efficacy of epidermal grafting for wound healing. Syst Rev 2016; 5:92. [PMID: 27255327 PMCID: PMC4891844 DOI: 10.1186/s13643-016-0268-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/23/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Autologous skin grafting is an important modality for wound coverage; however, it can result in donor site morbidity. Epidermal grafting is an emerging option to overcome this challenge. Furthermore, it can be done in an outpatient setting with minimal or no pain. To date, the evidence on the efficacy of this technique for wound healing has yet to be outlined. We aim to synthesise the current evidence on epidermal grafting for wound healing to establish the efficacy of this technique. METHODS/DESIGN We will conduct a comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases (up to May 2016) to identify studies on epidermal grafting for wound healing. We will include any primary studies (excluding case reports or case series lesser than three patients) or systematic reviews of such studies to assess the outcome of epidermal grafting for wound healing either on its own or compared to other methods. The expected primary outcome measures are the efficacy of epidermal grafting for wound healing (measured by the proportion of wounds healed at 6 weeks) and the mean wound-healing time (time for complete re-epithelialisation). Secondary outcome measures are the mean donor site-healing time, need for anaesthesia, costs associated with resource use, health-related quality of life, and proportion of patients with adverse event. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology. DISCUSSION This is a timely systematic review, and the finding of this systematic review is expected to guide research and clinical practice aimed at improving wound care. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016033051.
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Affiliation(s)
- Muholan Kanapathy
- Division of Surgery and Interventional Science, University College London, London, UK. .,Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK.
| | - Oliver J Smith
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
| | - Nadine Hachach-Haram
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
| | - Nicola Bystrzonowski
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
| | - Afshin Mosahebi
- Division of Surgery and Interventional Science, University College London, London, UK.,Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
| | - Toby Richards
- Division of Surgery and Interventional Science, University College London, London, UK.,Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
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16
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Kanapathy M, Hachach-Haram N, Bystrzonowski N, Harding K, Mosahebi A, Richards T. Epidermal grafting versus split-thickness skin grafting for wound healing (EPIGRAAFT): study protocol for a randomised controlled trial. Trials 2016; 17:245. [PMID: 27185033 PMCID: PMC4869340 DOI: 10.1186/s13063-016-1352-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 04/12/2016] [Indexed: 12/02/2022] Open
Abstract
Background Split-thickness skin grafting (SSG) is an important modality for wound closure. However, the donor site becomes a second, often painful wound, which may take more time to heal than the graft site itself and holds the risk of infection and scarring. Epidermal grafting (EG) is an alternative method of autologous skin grafting that harvests only the epidermal layer of the skin by applying continuous negative pressure on the normal skin to raise blisters. This procedure has minimal donor site morbidity and is relatively pain-free, allowing autologous skin grafting in an outpatient setting. We plan to compare EG to SSG and to further investigate the cellular mechanism by which each technique achieves wound healing. Methods/design EPIGRAAFT is a multicentre, randomised, controlled trial that compares the efficacy and wound-healing mechanism of EG with SSG for wound healing. The primary outcome measures are the proportion of wounds healed in 6 weeks and the donor site healing time. The secondary outcome measures include the mean time for complete wound healing, pain score, patient satisfaction, health care utilisation, cost analysis, and incidence of adverse events. Discussion This study is expected to define the efficacy of EG and promote further understanding of the mechanism of wound healing by EG compared to SSG. The results of this study can be used to inform the current best practise for wound care. Trial registration Clinicaltrials.gov identifier, NCT02535481. Registered on 11 August 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1352-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muholan Kanapathy
- Division of Surgery & Interventional Science, University College London, London, UK.,Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Nadine Hachach-Haram
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Nicola Bystrzonowski
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Keith Harding
- Cardiff University, Wound Healing Research Unit, School of Medicine, Heath Park, Cardiff, UK
| | - Afshin Mosahebi
- Division of Surgery & Interventional Science, University College London, London, UK. .,Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK.
| | - Toby Richards
- Division of Surgery & Interventional Science, University College London, London, UK.,Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
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Hachach-Haram N, Bystrzonowski N, Kanapathy M, Smith O, Harding K, Mosahebi A, Richards T. A prospective, multicentre study on the use of epidermal grafts to optimise outpatient wound management. Int Wound J 2016; 14:241-249. [PMID: 26997204 DOI: 10.1111/iwj.12595] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/24/2016] [Indexed: 11/29/2022] Open
Abstract
Current wound management through the use of a split-thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft-harvesting device (CelluTome) that allows pain-free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care.
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Affiliation(s)
- Nadine Hachach-Haram
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Nicola Bystrzonowski
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Muholan Kanapathy
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Oliver Smith
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Keith Harding
- Wound Healing Research Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Ash Mosahebi
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
| | - Toby Richards
- Royal Free Hospital Wound Healing Group, Department of Plastic and Reconstructive Surgery, The Royal Free Hospital, London, UK
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Hachach-Haram N, Bystrzonowski N, Kanapathy M, Edmondson SJ, Twyman L, Richards T, Mosahebi A. The use of epidermal grafting for the management of acute wounds in the outpatient setting. J Plast Reconstr Aesthet Surg 2015; 68:1317-8. [PMID: 26113275 DOI: 10.1016/j.bjps.2015.04.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/19/2015] [Accepted: 04/26/2015] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Muholan Kanapathy
- The Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom
| | | | - Lucy Twyman
- The Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom
| | - Toby Richards
- The Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom
| | - Afshin Mosahebi
- The Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom
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Bystrzonowski N, Gardiner M, Rice S, Kluk J, Swale V, Jemec B. Differences in outcome for patients referred to dermatology or plastic surgery with suspected skin cancer. Int J Surg 2013. [DOI: 10.1016/j.ijsu.2013.06.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Basson S, Bystrzonowski N, De Souza B. Paediatric Plastic Surgery Trauma – Are we Aware of the Service Needs? Int J Surg 2010. [DOI: 10.1016/j.ijsu.2010.07.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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