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.

Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Urethral carcinoma after skin substitution urethral reconstruction

Urethral cancer after urethral reconstruction is an under-recognized, uncommon disease associated with significant morbidity and mortality. The survival rates of patients with carcinoma of the bulbar urethra are as low as 20%-30%. Stricture recurrence and unrecognized malignant changes present prior to reconstruction are major risk factors for urethral cancer. Skin substitution urethroplasty is subjected to higher rates of recurrence, which lends to the potential for carcinogenesis. We present a case of a 59-year-old male who underwent multi-stage skin substitution urethroplasty who developed urethral carcinoma 20 years later.

Integra® Dermal Regeneration Template in Complex Scalp Reconstruction

Background/Objectives: The need for surgical reconstruction of scalp defects following the excision of cutaneous skin cancers is an increasingly common procedure. Particular challenges arise when considering options for reconstruction of large defects not amenable to local skin flap coverage. The use of skin grafts poses the risk of donor site morbidity. This paper investigates the emerging use of Integra®, a synthetic acellular dermal regeneration template, as an alternative or adjunct to skin grafting in scalp reconstruction. Methods: The study presents a retrospective analysis of 101 patients who underwent Integra®-based reconstruction of scalp defects. Demographics, procedure details, complications, need for further surgery, and time to healing were evaluated. Results: The overall success rate of the one-stage Integra®-only procedure was 95%, with a minor complication rate of 30.7%. Anticoagulation medication was identified as an independent risk factor for post-operative infection, while previous head and neck radiotherapy and increased defect depth were associated with the requirement for a second-stage skin graft. Conclusions: These findings support the consideration of Integra® as a safe and viable alternative for both partial and full thickness scalp defects in a select cohort of complex highly co-morbid patients, reducing complications and the need for additional procedures.

Efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids: A 13-year experience

BACKGROUND

Surgical excision combined with radiotherapy is considered an effective treatment for keloids, while the efficacy and safety of this regimen for huge keloids in patients who need reconstruction after excision is still unclear. Therefore, this study aimed to evaluate the efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids in a single center with 13 years of experience.

METHODS

All consecutive patients with huge keloids who underwent surgical excision and reconstruction combined with radiotherapy were identified. Demographic information, prior interventions for keloids, parameters and complications, and recurrence rates were documented.

RESULTS

Twenty-one patients (10 males; mean age, 43.19 ± 18.15 years) were included, 14 patients reconstructed with z-plasties, 5 with skin grafts, and 2 with skin flaps. During a mean follow-up of 75 months, one patient developed local necrosis without the need for revision surgery and two patients developed temporary hyperpigmentation. Two patients with the z-plasties suffered partial keloids recurrence, which was healed with corticosteroid injection. No wound infection, hematoma, telangiectasia, or new keloids at donor sites were observed. The overall appearance of reconstructed defects was aesthetically acceptable.

CONCLUSION

Surgical excision and reconstruction combined with radiotherapy may be safe and effective for huge keloids.

Recalcitrant Pyoderma Gangrenosum of the Face: A Case Report

Pyoderma gangrenosum (PG) is a rare autoinflammatory neutrophilic dermatosis. The ulcerative subtype presents with a tender nodule or pustule that progresses into a painful, necrotic ulcer.New lesions arise after minor trauma in one-third of patients, a phenomenon termed "pathergy." We present a 62-year-old Caucasian female with primary sclerosing cholangitis, hepatic cirrhosis, chronic hepatitis B, and severe PG. At the initial presentation, she had lesions on her face and four extremities. She had severe full-thickness ulcerations on the bilateral cheeks and underwent incision and drainage with washout of bilateral maxillary abscesses, left sinus curettage, and wound debridement. She has required multiple hospitalizations for severe flares. Treatment with steroids was complicated by spinal compression fractures. Steroid-sparring agents were ineffective. Her lesions involved bilateral cheeks, temples, temporal scalp, and eyelids with oroantral fistulae. Her facial ulcerations included a large septal perforation causing saddle nose deformity and eradication of a branch of the left facial nerve causing incomplete eye closure. She underwent bilateral facial wound irrigation with antibiotic irrigation and wound debridement. Due to social factors, she has been lost to follow-up and a definitive etiology of her PG has not yet been elucidated. Although rare, PG should remain a consideration in patients with ulcerative lesions on the head and neck. Wound debridement is typically discouraged given the risk of pathergy, but there may be a role for surgical intervention in adequately immunosuppressed patients.

Translational frontiers: insight from lymphatics in skin regeneration

The remarkable regenerative ability of the skin, governed by complex molecular mechanisms, offers profound insights into the skin repair processes and the pathogenesis of various dermatological conditions. This understanding, derived from studies in human skin and various model systems, has not only deepened our knowledge of skin regeneration but also facilitated the development of skin substitutes in clinical practice. Recent research highlights the crucial role of lymphatic vessels in skin regeneration. Traditionally associated with fluid dynamics and immune modulation, these vessels are now recognized for interacting with skin stem cells and coordinating regeneration. This Mini Review provides an overview of recent advancements in basic and translational research related to skin regeneration, focusing on the dynamic interplay between lymphatic vessels and skin biology. Key highlights include the critical role of stem cell-lymphatic vessel crosstalk in orchestrating skin regeneration, emerging translational approaches, and their implications for skin diseases. Additionally, the review identifies research gaps and proposes potential future directions, underscoring the significance of this rapidly evolving research arena.

Salvage of the cochlear implant in cases of skin breakdown over the receiver/stimulator in children

OBJECTIVE AND METHOD

Skin breakdown over receiver/stimulator (RS) after cochlear implantation poses a serious challenge. We report our experience using a one-stage reconstruction and implant salvage approach.

RESULTS

Between the years 2005 and 2017 five children, all females, with congenital- bilateral sensorineural hearing loss were identified. In all cases, a temporoparietal fascia flap (TPFF) and a large scalp flap were used to provide a two-layer coverage to the exposed RS. In the first three cases, a split-thickness skin graft was used to cover the donor site defect. In the latter two cases, a larger rotation flap was used, and a skin graft was not required. One case required revision due to the dehiscence of the wound and exposure of the RS. In another case, an accidental electrode array explantation occurred and the patient underwent a revision cochlear implantation. All patients had achieved complete healing and no change in hearing thresholds with the implants.

CONCLUSIONS

We demonstrate our one-stage salvage technique with TPFF that saves the implant and prevents a two-stage procedure. The success rate can be improved with special care at reconstruction and with better protection of the implant during the procedure.

A Comparative Analysis of the Outcomes of Various Graft Types in Burn Reconstruction Over the Past 24 Years: A Systematic Review

Burn injuries, a major global health concern, result in an estimated 180,000 fatalities annually. Despite tremendous progress in treatment methods over the years, the morbidity and mortality associated with burns remain significant. Autologous skin grafting, particularly split-thickness skin grafting (STSG), has been a cornerstone in burn reconstruction, and it has facilitated survival and functional recovery for total body surface area (TBSA) significantly. However, the requirement for primary closure at the donor site due to the constraints of full-thickness donor harvesting continues to pose challenges. The introduction of dermal regenerative templates (DRT) in the late 1970s marked a substantial step forward in tissue engineering, addressing the inadequacy of dermal replacement with STSGs. This systematic review aimed to compare the outcomes of different graft types - bioengineered, autografts, allografts, and xenografts - in burn reconstruction over the last 24 years. The review focused on the pros and cons of each graft type, offering clinical insights grounded in experience and evidence. The approach involved a systematic review of studies published in English from January 2000 to January 2024, covering randomized controlled trials (RCTs), cohort studies, case-control studies, and case series. The participants comprised individuals of all ages who underwent burn reconstruction with skin grafts, specifically split-thickness grafts, full-thickness grafts, composite grafts, and epidermal grafts (autografts, allografts, and xenografts) and bioengineered grafts. The primary outcomes were functional and cosmetic results, patient satisfaction, graft survival, and complications. The risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2), the Newcastle-Ottawa Scale (NOS) for non-randomized studies, and the Canada Institute for Health Economics (IHE) quality appraisal tool for case series. Our initial search yielded a total of 1,995 articles, out of which 10 studies were selected for final analysis. Among the four clinical trials assessed, 75% showed a high risk of bias. The studies reviewed involved various graft types, with six studies (60%) concentrating on allografts, three (30%) on autografts, and one (10%) on bioengineered skin grafts. The outcomes were varied, underlining the intricate nature of burn wound management. Our evaluation revealed promising results for autologous-engineered skin substitutes and allografts but also highlighted methodological disparities among the studies included. The dominance of observational studies and the diversity of outcome measures present obstacles to direct comparisons. Future research should address these limitations, employing well-structured RCTs, standardized outcome measures, and exploring long-term outcomes and patient-specific factors. The rapidly evolving field of regenerative medicine offers great potential for novel grafting methods. This systematic review provides valuable insights into the diverse outcomes of burn reconstruction using different graft types. Autologous-engineered skin substitutes and allografts seem to hold significant promise, suggesting a possible shift in grafting techniques. However, methodological inconsistencies and the lack of high-quality evidence underscore the necessity for further research to fine-tune burn care approaches.

Bednar's tumor at right shoulder in an adult male: a case report of a rare entity

Introduction and importance

Bednar tumor, a rare variant of dermatofibrosarcoma protuberans is a tumor with low malignant potential. Owing to limited studies, the pathogenesis and risk factor of this tumor are not clearly understood. The tumor extends from the epidermis to the dermal layers and even affects the surrounding bone. Here, the authors present a case of a 48-year-old male with a Bednar tumor, which was successfully managed by wide local excision and flap repair.

Case presentation

Our patient presented to the hospital after the reappearance of mass, 6 years after the excision of the previously misdiagnosed lipoma. Vitals and systematic examination were normal. Local examination revealed an oval-shaped mass with a glistening surface on the right shoulder. The patient underwent wide excision and skin flap surgery for the treatment, and the diagnosis was confirmed through histopathological examination and immunohistochemistry for the CD34 marker.

Clinical discussion

Bednar tumor is an infrequent skin tumor linked to genetic anomalies and is one of the rare variants [(<0.1%) of skin tumors]. Diagnosis can be done by histopathological examination and CD34 marker positivity via immunohistochemistry. This tumor is mistaken for lipoma, leading to recurrent growth postexcision. The tumor demands a broader resection due to the high chances of reoccurrence. Although Mohs micrographic surgery is the ideal approach, its limited availability in resource-constrained settings prompts alternative strategies.

Conclusion

This case highlights the challenges of diagnosis, the rarity of the condition, and the need for vigilant follow-up due to the tumor's propensity for recurrence.

Objective Non-Invasive Bio-Parametric Evaluation of Regenerated Skin: A Comparison of Two Acellular Dermal Substitutes

Several dermal substitutes are available on the market, but there is no precise indication that helps surgeons choose the proper one. Few studies have tried to compare different xenogeneic bioengineered products, but no objective bio-parametric comparison has been made yet. Fifteen patients who underwent skin reconstruction with Integra® or Pelnac® were retrospectively evaluated. After at least 12 months of follow-up, an objective and quantitative assessment of several skin biophysical properties, such as color, texture, elasticity, hydration, glossiness and trans-epidermal water loss, were measured with non-invasive skin measurement devices. The grafted skin showed a reduction of the superficial hydration level and a tendency to lower values of trans-epidermal water loss with both dermal substitutes. Melanic and hemoglobin pigmentation were higher in comparison to the donor site in both groups, while a melanic pigmentation increase versus the surrounding skin was seen just with Integra®. Finally, the skin was found to be more elastic when reconstructed with Integra®. The skin barrier appeared to be intact in both groups. Hence, these substitutes are valuable means of skin regeneration. Integra® seems to be more advantageous for reconstructing areas that need more skin flexibility.

Use of Integra® on avascular tissue

Integra® (Integra LifeSciences) is a well-known dermal regeneration template used in partial and full-thickness wound reconstruction. It can be applied directly on to vascular tissue to create a bed for a skin graft, which is often placed in a second surgery. We present our experience of its novel use in oral and maxillofacial surgery patients, using it directly on bone and cartilage (avascular tissue) without further skin grafting. Patients who required full-thickness excision of lesions down to bone or cartilage and who were treated using Integra® were included. After scalp or ear lesion resection, the collagenous dermal layer of Integra® was placed directly on to bone or cartilage and, along with its outer silicone epidermal layer, secured to the defect with absorbable sutures and a bolster dressing. The wounds were kept dry for 14 days, at which point the dressing and silicone were removed and patients continued regular wound care. Seventeen patients were included, 15 of whom had squamous cell carcinoma. One was lost to follow up. The rest achieved complete healing of the defect. Histology showed epidermis developing on the Integra® surface and at one year, the appearance of normal scarred skin. This novel approach could redefine the uses of Integra®, avoiding the need for free-flap surgery or skin grafting when reconstructing large defects. Further resection of close margins or recurrence is easier after reconstruction using dermal regeneration material than after reconstruction with a local or free flap.

Characterization and biological evaluation of a novel flavonoid-collagen antioxidant hydrogel with cytoprotective properties

Reactive oxygen species (ROS) play a critical and important role during wound healing but excess ROS at the wound site can lead to cellular damage and sub-optimal healing. Minimizing oxidative damage to the wound site and any supplemental therapeutic cells can be achieved by delivering exogenous antioxidants. Collagen hydrogels are ideal wound care materials due to their biocompatibility, high water content, and porous, three-dimensional architecture. Yet, they lack the inherent antioxidant activity that could help mitigate excess ROS at a wound site. This work formulates and evaluates the in vitro biocompatibility and antioxidant capabilities of collagen-fibroblast hydrogels combined with the polyphenolic antioxidant luteolin. Collagen solutions mixed with luteolin readily assembled into robust hydrogels with increasing gel strength due to increasing concentrations of luteolin. SEM images confirmed a mean pore size of 2.2 μm and a drastically different macromolecular ultrastructure with extensive fine crosslinking relative to collagen. Adequate cell viability and metabolic activity of dermal fibroblasts cultured within the gels were measured across all formulations, resulting in higher antioxidant activity and more than double the protection to cells from oxidative damage than traditional collagen hydrogels. Given these results, luteolin-collagen hydrogels demonstrate the potential for superior wound-healing properties when compared to collagen alone.

To Mesh or Not to Mesh: What Is the Ideal Meshing Ratio for Split Thickness Skin Grafting of the Lower Extremity?

Split-thickness skin grafts can provide effective autologous wound closure in patients with dysvascular comorbidities. Meshing the graft allows for reduced donor site morbidity and expanded coverage. This study directly compares outcomes across varying meshing ratios used to treat chronic lower extremity wounds. Patients who received split-thickness skin grafts to their lower extremity for chronic ulcers from December 2014 to December 2019 at a single center were retrospectively reviewed. Patients were stratified by meshing ratios: nonmeshed (including pie crusting), 1.5:1, and 3:1. The primary outcome was clinical "healing" as determined by surgeon discretion at 30 days, 60 days, and the latest follow-up. Secondary outcomes included postoperative complications, graft loss, ulcer recurrence, progression to amputation, and mortality. A total of 321 patients were identified. Wound sizes and location differed significantly, with 3:1 meshing applied to the largest wounds (187.8 ± 157.6 cm2; 1.5:1 meshed, 110.4 ± 103.9 cm2; nonmeshed 38.7 ± 55.5 cm2; p < .0001) mostly of the lower leg (n = 18, 75%; 1.5:1 meshed, n = 23, 43.4%; nonmeshed n = 62, 25.7%; p < .0001). Meshed grafts displayed a significantly higher proportion of healing at 30 and 60 days, but no differences persisted by the final follow-up (16.5 ± 20.5 months). Longitudinally, nonmeshed STSG was associated with most graft loss (46, 19.1%; p = .011) and ulcer recurrence (44, 18.3%; p = .011). Of the 3 meshing ratios, 3:1 exhibited the lowest rates of complications. Our results suggest that 3:1 meshing is a safe option for coverage of large lower extremity wounds to minimize donor site morbidity.

Strangulated penis in a prison inmate: Complete penile degloving and full-thickness skin graft

Introduction

Penile strangulation is a rare urological emergency that necessitates urgent management. The reasoning behind it may include sexual pleasure, erection reinforcement, or a psychiatric disorder.

Case presentation

Despite being an uncommon complication of penile strangulation, we report a 45-year-old prison inmate who presented with penile shaft necrosis secondary to using a non-metallic constriction object. The patient reported a 5-day history of progressive penile pain, edema, and skin injury but no urinary symptoms. The patient underwent complete penile skin degloving, circumcision, and insertion of a suprapubic catheter. Postoperatively, the penile tissue appeared healthy, and the wound was granulating. On the eleventh day following degloving, a full-thickness skin graft was taken from the groin area. The patient remained in the hospital for 20 days, during which he was clinically stable with clean, healing wounds.

Conclusion

Early management of penile strangulation is vital in order to prevent vascular and mechanical complications.

Fournier gangrene - would you KISS it?

Fournier gangrene is a disease characterized by necrotizing fasciitis of the perineal and genital region, resulting from synergistic polymicrobiotic infection. Most infections can be localized to a cutaneous, urethral, or rectal source and can culminate in a fulminant sepsis. Current state of the art is systemic broad-spectrum antibiotics and serial aggressive debridement which result in superficial perineal defect of wide dimensions. We compiled all the cases of Fournier gangrene that required reconstruction after debridement in Centro Hospitalar Universitário Lisboa Central from 2018 to 2022. Inclusion criteria were reconstruction for Fournier defects and patients' age 18 to 90 years old. Exclusion criteria were patients who didn't require reconstruction or didn't complete it due to death or transfer to another healthcare institution. Reconstructive procedures and complication rates are reported as whole numbers and percentages of total. The initial search yielded 32 patients. There were 2 (6.2%) patients with defects that healed by secondary intention, 6 (18.7%) with delayed primary closure, 4 (12.5%) with implantation of the testicle in a medial thigh pocket, 12 (37.5%) with skin grafts, 4 (12.5%) with scrotal advancement flaps, 2 (6.2%) with flaps, and 2 (6.2%) with flaps and skin grafts in combination. Four outcomes were evaluated: number of patients, defect size, method of reconstruction, and wound-healing complications. Most reconstructive techniques provide reliable coverage and protection of testicular function with an acceptable cosmetic result. The reconstructive options need to be patient tailored in order to achieve long lasting results with a minimum of postoperative morbidity.

Periorbital Facial Necrotizing Fasciitis in Adults: A Rare Severe Disease with Complex Diagnosis and Surgical Treatment-A New Case Report and Systematic Review

(1) Background: Necrotizing fasciitis (NF) is a severe and aggressive pathology with a rapid progression and high mortality risk. Periocular NF is a rare condition associated with a lower mortality risk but significantly higher disabling sequelae. (2) Methods: We present the case of a 67-year-old homeless patient, a victim of assault, with multiple untreated comorbidities (diabetes mellitus, cardiac conditions, and schizophrenia) and a delayed diagnosis of periocular necrotizing fasciitis. The condition showed a cyclical evolution influenced by the existing comorbidities, and the patient underwent both surgical and medical treatment with a multidisciplinary team. Additionally, we report a systematic review of cases from the literature. (3) Results: The patient's survival outcomes were favorable; however, the sequelae were disabling, not only concerning aesthetic aspects but also due to the loss of the affected eye globe. The systematic review revealed the rarity of such cases and the peculiarities of the presented case compared to those reported in the literature up to this point. (4) Conclusions: Understanding the signs, symptoms, and predisposing factors, as well as the potential rare localizations of NF, including the periocular region, can lead to the early diagnosis and treatment with good functional and aesthetic outcomes, minimizing significant disabilities.

Variations in Payer-Negotiated Prices for Head and Neck Reconstructive Surgery

OBJECTIVE

Little is known about pricing for reconstructive procedures of the head and neck. As of January 2021, the Centers for Medicare and Medicaid Services requires hospitals to disclose payer-negotiated prices for services, offering new insight into prices for privately insured patients.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Turquoise database.

METHODS

Payer-negotiated facility fees for 41 reconstructive surgeries were grouped by procedure type: primary closure, skin grafts, tissue rearrangement, locoregional flaps, or free flaps. Prices were normalized to account for local labor costs, then calculated as percent markup in excess of Medicare reimbursement. The mean percent markup between procedure groups was compared by the Kruskal-Wallis test. Subset analyses were performed to compare mean percent markup using a Student's t test. We also assessed price variation by calculating the ratio of 90th/10th percentile mean prices both across and within hospitals.

RESULTS

In total, 1324 hospitals (85% urban, 81% nonprofit, 49% teaching) were included. Median payer-negotiated fees showed an increasing trend with more complex procedures, ranging from $379.54 (interquartile range [IQR], $230.87-$656.96) for Current Procedural Terminology (CPT) code 12001 ("simple repair of superficial wounds ≤2.5 cm") to $5422.60 ($3983.55-$8169.41) for CPT code 20969 ("free osteocutaneous flap with microvascular anastomosis"). Median percent markup was highest for primary closure procedures (576.17% [IQR, 326.28%-1089.34%]) and lowest for free flaps (99.56% [37.86%-194.02%]). Higher mean percent markups were observed for rural, for-profit, non-Northeast, nonteaching, and smaller hospitals.

CONCLUSION

Wide variation in private payer-negotiated facility fees exists for head/neck reconstruction surgeries. Further research is necessary to better understand how pricing variation may correlate with out-of-pocket costs and quality of care.

Delayed skin grafting protocol following Integra™ application for non-radiated scalp reconstruction for decreased wound depth and improved contour

The clinical use of Integra™ has expanded to include scalp reconstruction since its FDA approval in 1996. Integra™, or dermal regeneration template, can be utilized in patients who are elderly with multiple medical comorbidities. Well-established Integra™ techniques utilize skin grafting 1-2 weeks following evidence of template vascularity. Most studies show the time to graft placement as <30 days, with almost all <52 days. No single article proposes a time frame for applying STSG after neodermis regeneration. Therefore, we aimed to describe our protocol to define a time frame for delaying scalp reconstruction with STSG following dermal regeneration. Over the last several years, the senior author has utilized a delayed reconstruction with skin grafting method where-in Integra™ is applied to either debrided bone or exposed pericranium in selected patients, and allowed to mature for ~6 weeks before performing skin grafting. The results have been predictable, reproducible, and have yielded high levels of patient and provider satisfaction due to the improved contour cosmesis. In this pictorial essay, the authors' novel protocol is detailed.

Establishment and validation of a nomogram to predict the neck contracture after skin grafting in burn patients: A multicentre cohort study

Cervical burn contracture is one of the burn contractures with the highest incidence and severity, and there is no effective method to predict the risk of neck contracture. This study aimed to investigate the effect of combined cervicothoracic skin grafting on the risk of neck contracture in burn patients and to develop a nomogram to predict the risk of neck contracture after skin grafting in burn patients. Data from 212 patients with burns who underwent neck skin grafting were collected from three hospitals, and the patients were randomly divided into training and validation sets. Independent predictors were identified through univariate and multivariate logistic regression analyses and incorporated into a prognostic nomogram. Its performance was assessed using the receiver operating characteristic area under the curve, calibration curve, and decision curve analysis. Burn depth, combined cervicothoracic skin grafting, graft thickness, and neck graft size were significantly associated with neck contractures. In the training cohort, the nomogram had an area under the curve of 0.894. The calibration curve and decision curve analysis indicated good clinical applicability of the nomogram. The results were tested using a validation dataset. Combined cervicothoracic skin grafting is an independent risk factor for neck contracture. Our nomogram demonstrated excellent performance in predicting neck contracture risk.

Meek Micrografting Technique for Reconstruction of Extensive Necrotizing Fasciitis of the Anterior Abdomen and Bilateral Femoral Region: A Case Report

Necrotizing fasciitis is an uncommon yet fatal soft tissue infection. Current recommended treatment includes antibiotics with repeat surgical exploration and wound debridement followed by reconstruction. In burn patients, the Meek micrograft has demonstrated a higher true expansion ratio, faster reepithelialization rate, more resilient toward infection, and reduced risk of graft failure as compared with meshed graft. To our best knowledge, the use of Meek micrografting technique in reconstruction of postdebridement wounds of necrotizing fasciitis has not been reported. Hereby, we present a case of a 57-year-old gentleman who was referred to us for wound reconstruction after surgical debridement of Fournier's gangrene and extensive necrotizing fasciitis involving the anterior abdomen and bilateral femoral region. Meek micrografting technique was used to reconstruct the anterior abdomen as the wound bed was large. Although the graft was complicated with a small area of localized infection, it did not spread across the entire graft and was successfully treated with topical antibiotics and regular wound dressing. In our case, wound reconstruction using Meek micrografting technique in a patient with extensive necrotizing fasciitis was successful and showed positive outcome. Therefore, we suggest further studies to be conducted to investigate the applications and outcomes of the Meek micrografting technique, especially in patients with extensive wound bed and limited donor site availability.

The Mastoid Skin Graft: A Fast, Efficient Donor Site for Auricle Reconstruction After Mohs Surgery

BACKGROUND

Mohs micrographic surgery has been considered the gold standard for treating nonmelanoma skin cancers. Approximately 8% to 10% of skin cancers requiring Mohs surgery occur on the auricle. Skin grafts can be used to achieve optimal functional and cosmetic results.

OBJECTIVES

To describe a skin graft technique using the mastoid area as a donor site for auricular reconstruction following Mohs micrographic surgery, to achieve optimal esthetic results in functionally important areas.

METHODS

This retrospective study assessed the outcomes of patients who underwent MMS in an out-patient Mohs surgery clinic from 2010 to 2021. All patients had MMS of the auricle with reconstruction using a split thickness skin graft harvested from the mastoid area.

RESULTS

A total of 154 patients were included. The average lesion diameter was 13.7 mm (range 5-30 mm), excised in an average of 1.9 rounds of MMS. Skin graft success rate was 96%. Complications included one patient with a hypertrophic scar. The cosmetic appearance of the recipient site was rated as excellent by 87.5% of patients. All patients rated the cosmetic appearance of the donor area as excellent and well-concealed.

CONCLUSIONS

Split thickness skin grafts harvested from the mastoid area are a quick and efficient reconstruction method for post-Mohs auricular defects.

Functional and aesthetic recovery of the second toe defect using a wrap-around pedicled flap from the great toe

We report the results of using a fibula-sided digital artery pedicled flap from the great toe to cover the second toe free flap donor site, which avoids delayed wound healing, and prevents pain and skin ulceration. This study included 15 patients who had second toe wrap-around free flaps to reconstruct thumb and finger defects. All 15 pedicled flaps used to cover the defect healed uneventfully. All patients were able to stand and walk and were satisfied with the postoperative aesthetic outcome at the 6-month follow-up. We conclude that this an effective procedure for preventing donor site defects after second toe wrap-around free flap transfer.Level of evidence: IV.

Reconstruction methods for and cosmetic evaluation of external nasal tumour resections: flap versus graft

Nose reconstruction is challenging given the three-dimensional structure and free edge, and various methods have been reported. In general, local flaps provide cosmetic outcomes that are better than those following skin grafts, but there are no published comparative studies on Asians. To determine whether local flaps or skin grafts may optimally be used to reconstruct external nasal defects among Asians. We retrospectively collected data on patients who underwent external nasal tumour resection and reconstruction by 14 plastic surgeons in eight Japanese institutes from 2009 to 2021. The cosmetic results were scored by 14 surgeons using anonymized preoperative and six-month postoperative photographs. Scores for each reconstruction method were statistically evaluated. In total, 86 cases were enrolled; 57 received local flaps and 29 received skin grafts. Most local flaps showed better outcomes compared to skin grafts, but this was not the case for nasolabial and forehead flaps. Notably, local flaps placed in the nasal ala tended to be less successful than flaps placed elsewhere; only the bilobed flap scored better than skin grafts. The defect site did not affect the results of skin grafts. For Asians requiring nasal reconstruction, local flaps provide better cosmetic outcomes than skin grafts, except for those in the nasal ala. Skin grafts may be a good alternative when the bilobed flap is unavailable for the nasal ala.

Perspectives on the Current State of Bioprinted Skin Substitutes for Wound Healing

Human skin is particularly vulnerable to external damaging influences such as irradiation, extreme temperatures, chemical trauma, and certain systemic diseases, which reduce the skin's capacity for regeneration and restoration and can possibly lead to large-scale skin defects. To restore skin continuity in severe cases, surgical interventions such as the transplantation of autologous tissue are needed. Nevertheless, the coverage of larger skin defects caused by severe third-grade burns or extensive irradiation therapy is limited due to the depletion of uninjured autologous tissue. In such cases, many of the patient's epidermal cells can become available using biofabricated skin grafts, thereby restoring the skin's vital functions. Given the limited availability of autologous skin grafts for restoring integrity in large-scale defects, using bioprinted constructs as skin graft substitutes could offer an encouraging therapeutic alternative to conventional therapies for large-scale wounds, such as the transplantation of autologous tissue. Using layer-by-layer aggregation or volumetric bioprinting, inkjet bioprinting, laser-assisted bioprinting, or extrusion-based bioprinting, skin cells are deposited in a desired pattern. The resulting constructs may be used as skin graft substitutes to accelerate wound healing and reconstitute the physiological functions of the skin. In this review, we aimed to elucidate the current state of bioprinting within the context of skin tissue engineering and introduce and discuss different bioprinting techniques, possible approaches and materials, commonly used cell types, and strategies for graft vascularization for the production of bioprinted constructs for use as skin graft substitutes.

Comparing Anatomical and Functional Outcomes of Two Neovaginoplasty Techniques for Mayer-Rokitansky-Küster-Hauser Syndrome: A Ten-Year Retrospective Study with Swine Small Intestinal Submucosa and Homologous Skin Grafts

Objective

This study aimed to compare the anatomical and functional outcomes of the modified McIndoe vaginoplasty for Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome using swine small intestinal submucosa (SIS) graft or homologous skin grafts.

Methods

A total of 115 patients with MRKHs who underwent neovaginoplasty between January 2012 and December 2021 were included in the study. Among them, 84 patients received vaginal reconstruction with SIS graft, whereas 31 neovaginoplasty underwent a skin graft procedure. The length and width of the neovagina were measured, and sexual satisfaction was evaluated using the Female Sexual Function Index (FSFI). The operation details, cost, and complications were also assessed.

Results

The SIS graft group had a significantly shorter mean operation time (61.13±7.17min) and less bleeding during the operation (38.57±9.46mL) compared to the skin graft group (92.1±9.47min and 55.81±8.28mL, respectively). The mean length and width of the neovagina in the SIS group were comparable to the skin graft group at 6 months follow-up (7.73±0.57 cm versus 7.6±0.62cm, P=0.32). The SIS group had a higher total FSFI index than the skin graft group (27.44±1.58 versus 25.33±2.16, P=0.001).

Conclusion

The modified McIndoe neovaginoplasty using SIS graft is a safe and effective alternative to homologous skin grafts. It results in comparable anatomical outcomes and superior sexual and functional outcomes. Overall, these results suggest that the modified McIndoe neovaginoplasty using SIS graft is preferred for MRKH patients who require vaginal reconstruction.

Role of Sentinel Lymph Node Biopsy for Skin Cancer Based on Clinical Studies

The sentinel lymph node is the first lymph node from the primary tumor. Sentinel lymph node biopsy (SLNB) is a surgical procedure that can detect occult nodal metastasis with relatively low morbidity. It may also have a therapeutic effect via regional disease control. The Multicenter Selective Lymphadenectomy-I (MSLT-I) trial revealed a prognostic benefit from SLNB in melanoma patients. However, it remains unclear whether there is a prognostic benefit from SLNB in patients with nonmelanoma skin cancer owing to a lack of randomized prospective studies. Nevertheless, SLNB provides important information about nodal status, which is one of the strongest factors to predict prognosis and may guide additional nodal treatment. Currently, SLNB is widely used in the management of not only patients with melanoma but also those with nonmelanoma skin cancer. However, the utilization and outcomes of SLNB differ among skin cancers. In addition, SLNB is not recommended for routine use in all patients with skin cancer. In this review, we provide a summary of the role of SLNB and of the indications for SLNB in each skin cancer based on previously published articles.

Estimation of wound surface area: an evaluation of medical professionals' assessment in a plastic surgery unit

The percentage of skin graft take following the resurfacing of burn injuries is routinely calculated in a subjective fashion, in order to make management decisions. Given the gravity of decisions made based on this clinical assessment of graft check, it is notable that limited research has been carried out on this subject. No standardised subjective assessment tools exist to measure surface area of graft take in a manner similar to that of Wallace's Rule of Nines or Lund and Browder. This study set out to examine the accuracy of visual assessments of graft take within the multidisciplinary team regularly making assessments of newly grafted burn wounds. A total of 15 digitally drawn images were used to assess 36 staff members' estimations of percentage of surface area. The results showed a wide variation in estimation in all staff types, including senior burns surgeons, who were found to underestimate surface area by as much as 30%. The British Burns Association has removed 'healing time' as an outcome measurement from its guidance, as it recognises how hard it is to make a standardised assessment of wound healing. This study demonstrates the difficulty in subjectively assessing surface area and makes some suggestions for further research and clinical applications of technology to aid assessment.

The Incident of Multiple Skin Necrosis and Unilateral Vision Loss Post Liposuction: A Case Report

For many years, people with excess weight around specific body parts who wanted to improve their shape or establish symmetry to achieve their ideal body image chose liposuction. As with any intervention, there is a chance of complications and unfavorable outcomes with liposuction. As a late result of the procedure, skin necrosis, infection, and hematoma are some of the known complications of such a procedure. Other known complications include damage to surrounding structures like nerves, vasculature, or perforating body viscera. This study aimed to report an eventful and unwanted result of a common and relatively safe cosmetic procedure. A 31-year-old Saudi female presented to the emergency room (ER) with right unilateral vision loss, bruises, and burning pain involving the upper limbs, thighs, abdomen, back, and flanks after having liposuction and rhinoplasty two weeks ago in a private clinic overseas. Multiple investigations were obtained to investigate her blindness, which showed a right upper branch of retinal vein occlusion. She was treated conservatively with daily wound dressings and analgesics. After five days, the patient returned with infected wounds and clinical deterioration, necessitating multiple excisions, debridement, and grafting. She eventually recovered and was discharged in good health. Herein, we report a rare case of unilateral blindness and multiple skin necrosis following liposuction of the abdomen and thigh. Debridement and skin grafting were the ideal treatment strategies.

Naringenin Impedes the Differentiation of Mouse Hematopoietic Stem Cells Derived from Bone Marrow into Mature Dendritic Cells, thereby Prolonging Allograft Survival

BACKGROUND

The use of immature dendritic cells (imDCs) to induce donor-specific immunotolerance following in vivo stimulation is limited by their low rate of induction and their tendency to undergo maturation. We derived imDCs from bone marrow hematopoietic stem cells (HSCs-imDCs). We then tested the ability of naringenin (Nar) to impede the maturation of HSCs-imDCs for inducing transplantation immune tolerance.

METHODS

HSCs derived from bone marrow were collected and induced to differentiate into imDCs by treating with Nar (Nar-HSCs-imDCs). Flow cytometry was used to evaluate DC surface markers, apoptosis, and endocytic ability. The ability of DCs to influence the in vitro proliferation of T cells and of regulatory T cells (Tregs) was analyzed by mixed lymphocyte reaction assays. Enzyme-linked immunoassays were used to quantify cytokine levels in supernatants from co-cultured DCs and Tregs, as well as in the serum of experimental animals. The level of immunotolerance induced by Nar-HSCs-imDCs was evaluated by skin grafting in recipient Balb/c mice, while the Kaplan-Meier method was used to statistically evaluate graft survival.

RESULTS

Compared with HSC-imDCs, Nar-HSCs-imDCs showed higher expression of cluster of differentiation 11c (CD11c), but lower expression levels of CD80, CD86, and major histocompatibility complex class II. Nar-HSCs-imDCs also showed stronger inhibition of T cells and higher Treg cell proliferation. Interleukin 2 (IL-2) and interferon gamma levels were downregulated in Nar-HSCs-imDCs, whereas IL-4, IL-10, and transforming growth factor beta levels were upregulated. The rate of apoptosis and endocytic capacity of Nar-HSCs-DCs increased significantly after treatment with lipopolysaccharide. HSCs-imDCs or Nar-HSCs-imDCs were injected into Balb/c mice via the tail vein 7 days before skin grafting. Significantly reduced donor-specific CD4+ T cells and induced proliferation of CD4+CD25+FoxP3+ Treg cells were observed in the spleen of mice from the Nar-HSCs-imDCs group, especially at a dose of 106 Nar-HSCs-imDCs. The latter group also showed significantly prolonged survival of skin grafts.

CONCLUSIONS

Nar-HSCs-imDCs markedly improved the acceptance of organ allografts, offering a potentially new strategy for inducing immune tolerance in transplantation.

Chitosan-collagen-fibrinogen uncrosslinked scaffolds possessing skin regeneration and vascularization potential

Clinical success of regenerative medicine for treating deep-tissue skin injuries depends on the availability of skin grafts. Though bioengineered constructs are tested clinically, lack of neovascularization provide only superficial healing. Thus constructs, which promotes wound healing and supports vascularization has gained priority in tissue engineering. In this study, chitosan-collagen-fibrinogen (CCF) scaffold was fabricated using freeze-drying method without using any chemical crosslinkers. CCF scaffolds proved cytocompatibility and faster healing in in vitro scratch assay of primary human adult dermal fibroblasts cells with progressively increasing vascular endothelial growth factor-A and reducing vascular endothelial growth factor receptor 1 expressions. Skin regeneration evaluated on in vivo full thickness wound model confirmed faster remodeling with angiogenic signatures in CCF scaffold-implanted mice. Histopathological observations corroborated with stereo-zoom and SS-optical coherence tomography images of wound sites to prove the maturation of healing-bed, after 12 days of CCF implantation. Therefore, it is concluded that CCF scaffolds are promising for skin tissue regeneration and demonstrates pro-angiogenic potential.

Polycaprolactone Electrospun Nanofiber Membrane with Skin Graft Containing Collagen and Bandage Containing MgO Nanoparticles for Wound Healing Applications

The objective of this study was to create a nanofiber-based skin graft with an antimicrobial bandage that could accelerate the healing of an open wound while minimizing infection. To this end, we prepared a bi-layer construct where the top layer acts as bandage, and the bottom layer acts as a dermal equivalent graft. A collagen (CG) gel was combined without and with an electrospun polycaprolactone (PCL) membrane to prepare CG and CG-PCL dermal equivalent constructs. The antibacterial properties of PCL with and without an antibacterial agent (MgO nanoparticles) against Staphylococcus aureus (ATCC 6538) was also examined. Human dermal fibroblasts were cultured in each construct to make the dermal equivalent grafts. After culturing, keratinocytes were plated on top of the tissues to allow growth of an epidermis. Rheological and durability tests were conducted on in vitro dermal and skin equivalent cultures, and we found that PCL significantly affects CG-PCL graft biological and mechanical strength (rheology and durability). PCL presence in the dermal equivalent allowed sufficient tension generation to activate fibroblasts and myofibroblasts in the presence of transforming growth factor-beta. During culture of the skin equivalents, optical coherence tomography (OCT) showed layers corresponding to dermal and epidermal compartments in the presence or absence of PCL; this was confirmed after fixed specimens were histologically sectioned and stained. MgO added to PCL showed antibacterial activity against S. aureus. In vivo animal studies using a rat skin model showed that a polycaprolactone nanofiber bandage containing a type I collagen skin graft has potential for wound healing applications.

Efficacy of bioabsorbable dressing combined with antibacterial spray for treatment of third-degree burns

OBJECTIVE

To evaluate the clinical efficacy of a bioabsorbable dressing in combination with antibacterial spray in treating third-degree burns.

METHOD

Patients with third-degree burns in our hospital from February 2019 to February 2020 were enrolled and divided into an experimental group and a control group. In all patients, two wound repair surgeries were performed. During the first surgery, bioabsorbable dressing (PELNAC, Gunze Medical Equipment (Shenzhen) Co. Ltd., China) was used for wound treatment. During the second surgery, autologous split-thickness skin graft was performed. For patients in the experimental group, bioabsorbable dressings (PELNAC) were uniformly applied with antibacterial spray during the operation and during postoperative dressing. For patients in the control group, antibacterial spray was not used.

RESULTS

A total of 68 patients took part in the study (experimental group n=36; control group n=32). Infection rate in the experimental group was significantly lower than that in the control group (2.8% versus 21.9%, respectively; p<0.05). The mean wound healing time in the experimental group was shorter by 3.2 days and the wound healing rate of the experimental group was significantly higher than that in the control group (p<0.05). Vancouver Scar Scale (VSS) scores at specific postoperative time intervals were significantly reduced in the experimental group compared with those in the control group (p<0.05).

CONCLUSION

Bioabsorbable dressing combined with antibacterial spray could reduce infection rate, shorten wound healing time and reduce scar formation in repairing third-degree burns.

Epidermolysis in a newborn of a mother affected by covid-19 in the 3rd trimester of pregnancy

Covid-19, caused by severe respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently a pandemic. Although this infection primarily presents with respiratory symptoms, the number of reported extrapulmonary manifestations, including dermatological, is also increasing. A group of pregnant women is particularly susceptible to respiratory diseases, but with regard to covid-19, there is still limited data on the course of infection in pregnancy in relation to the possibility of vertical transmission. We present the case of a 30-year-old unvaccinated patient with a history of overcoming covid-19 infections in the 7th month of pregnancy, and with persistent skin lesions. The patient gave birth to a mature newborn with epidermolytic lesions on a bullous base. In the differential dia-gnostic process, Staphylococcal scalded skin syndrome and epidermolysis bullosa were ruled out in the newborn. Considering the clinical findings and epidemiological history of the mother, we assume a possible vertical transmission of covid-19 with skin manifestation of the disease in the newborn.

Acquired atresia of the external auditory canal and canaloplasty with Thiersch graft reconstruction: Outcomes and complications

Acquired atresia of the external auditory canal (EAC) is a rare disease characterized by otorrhea and progressive hearing loss. Clinically, it is differentiated into two stages: the wet stage and the dry stage. The dry stage does not respond to pharmacological treatment and has to be treated surgically. One surgical option is canaloplasty of the EAC with Thiersch graft reconstruction. This study aimed to report the follow-up outcomes (otomicroscopic signs and pure tone audiometry [PTA]) in patients with acquired atresia treated with this technique. Eighteen adult patients surgically treated for acquired atresia of the EAC between 2010 and 2020 were enrolled. All underwent canaloplasty with Thiersch graft reconstruction by one senior surgeon. Otomicroscopy and PTA results were evaluated before and after surgery. Postsurgical follow-up was performed at 1-3-6-12 months and then annually. Presurgical otomicroscopic examination revealed stenosis that occluded more than 75% of the EAC in all patients, and preoperative PTA showed conductive hearing loss in 89% of patients. However, postsurgical otomicroscopic examination showed that 94% of patients had a normal EAC diameter after one year, and only one patient had anterior blunting and recurrent atresia. In addition, postsurgical PTA evidenced a normal range in 89% of patients after one year. In conclusion, acquired atresia of the EAC is a troublesome disease usually associated with hearing loss. Therefore, treatment is chosen to resolve its symptoms. The results demonstrate evidence that canaloplasty with Thirsch graft may be a suitable surgical method considering the lower incidence of recurrence and the excellent hearing outcomes.

Understanding the mechanisms of spontaneous and skin-grafted wound repair: the path to engineered skin grafts

Spontaneous wound repair is a complex process that involves overlapping phases of inflammation, proliferation and remodelling, co-ordinated by growth factors and proteases. In extensive wounds such as burns, the repair process would not be achieved in a timely fashion unless grafted. Although spontaneous wound repair has been extensively described, the processes by which wound repair mechanisms mediate graft take are yet to be fully explored. This review describes engraftment stages and summarises current understanding of molecular mechanisms which regulate autologous skin graft healing, with the goal of directing innovation in permanent wound closure with skin substitutes. Graftability and vascularisation of various skin substitutes that are either in the market or in development phase are discussed. In doing so, we cast a spotlight on the paucity of scientific information available as to how skin grafts (both autologous and engineered) heal a wound bed. Better understanding of these processes may assist in developing novel methods of wound management and treatments.

A Comparison of Skin Graft Techniques with and without Plaster Back Slab Dressing in Reducing Donor Site Morbidity in Radial Forearm Free Flap Surgery - A Retrospective Study

Introduction

The radial forearm free flap (RFFF) is a commonly used free flap for the reconstruction of orofacial defects because of its versatility and reliability. The donor site is closed with either split or full-thickness skin graft, and one of the common donor site morbidities is skin graft failure. Various techniques to minimise skin graft failure were reported, and we compared the skin graft techniques with and without plaster back slab dressing in the radial forearm donor site.

Materials and Methods

This is a retrospective study of 75 patients who had RFFF for reconstruction of oral cavity cancer at two different tertiary teaching hospitals in the United Kingdom between April 2015 and March 2020. Thirty-nine patients from Hospital one had volar back slap, bolster dressing and crepe bandage. In contrast, 36 patients from Hospital two had only pressure dressing without a back slab.

Results

The mean age of the study population was 60.65 (P = 0.274). In both groups, two patients had donor site complications. However, there was no significant difference in the donor site skin graft complications with a P = 0.662.

Discussion

There was no evidence in the literature to support an ideal bandage for skin graft at the RFFF donor site. Our comparison of two techniques of skin graft dressings with and without back slap did not show any difference in the skin graft take, and the volar back slab did not add any additional benefits. The simple use of foam as a bolster dressing without a back slab is ideal for the radial forearm free flap donor site.

Skin grafting on amputated lower limb, norepinephrine-induced ischemic limb necrosis - case report

Ischemic limb necrosis due to high dose of norepinephrine (NE) in a patient with septic shock is uncommon. Unfortunately, amputation of necrotic parts is the only available treatment. Reconstruction with skin autografts for defects resulting from the amputation of the lower limbs is challenging. Herein we report a case of digit necrosis in the upper and lower limbs after administration of a high dose of NE > 1 μcg/kg/min in a patient with septic shock. The source of infection that led to septic shock was not detected. Surgical amputation was performed as it was impossible to repair impaired vasculature and patients' life was endangered. Large defects were covered with skin autografts from the patient's thighs. The included figures demonstrate the extremities' appearance before, after amputation, during and after skin graft transplantation.

Evidence for the in vivo existence and mobilisation of myeloid angiogenic cells and pericyte-like cells in wound patients after skin grafting

Myeloid angiogenic cells (MACs) and pericyte-like cells, derived from peripheral blood mononuclear cells (MNCs) by in vitro culturing, are suggested as relevant cell types for angiogenesis and tissue repair. However, the in vivo existence and relevance of these cells has so far remained unknown. Our aim was thus to study, if MACs and pericyte-like cells exist in circulation during the wound healing of skin graft patients, and to evaluate the cellular features of wound repair. MNCs were isolated from blood samples of healthy controls (n = 4) and patients with a traumatic full thickness skin defect (n = 4) before skin grafting and on postoperative days 1 and 6. The numbers of circulating CD14⁺ CD45⁺ CD31⁺ CD34^- MACs and CD14⁺ CD45⁺ NG2⁺ pericyte-like cells were assessed by flow cytometry, and gene expression of various pro-angiogenic factors was analysed by qPCR. Wound bed biopsies were taken on postoperative days 6 and 14, and MAC (CD31, CD14 and CD45) and pericyte-related markers (NG2 and PDGFRβ) were histologically studied. MACs and pericyte-like cells were detected in both healthy controls and in patients. Before reconstruction, on average 18% of all circulating MNCs represented MACs and 2% pericyte-like cells in wound patients. Number of MACs significantly increased 1.1-1.7-fold in all patients 1 day after skin grafting (p < 0.01). In addition, histological analysis demonstrated effective vascularization of skin grafts, as well as presence of pericytes, and CD14 and CD45 expressing myeloid cells during wound healing. In conclusion, our data shows, for the first time, the presence and mobilisation of MACs and pericyte-like cells in human circulation.

Comparison of propeller flaps versus skin grafts for coverage of osteocutaneous fibula free flap donor site defects

BACKGROUND

Authors compare use of propeller flaps versus skin grafts in defect coverage after fibula flap harvest.

MATERIALS AND METHODS

Retrospective review of patients who received either PFPF or STSG. Primary predictor variable was technique, and secondary predictor variables were comorbidities. Primary outcome variable was flap/graft healing, and secondary outcome variables were cosmesis, adverse events, effect on activities of daily living (ADLs), pain, additional procedures, and cost. Statistical analysis performed via independent sample t tests, ANOVA, and χ² tests. Logistic regression analysis was performed.

RESULTS

Study sample was 50 patients. PFPFs showed higher rates of success, while STSG showed increased complications and adverse events. Pain and ADLs significantly affected in STSG group. Cosmesis was better in the PFPF group, and overall cost was significantly higher in STSG group.

CONCLUSION

PFPFs show greater success rates, fewer complications, improved cosmesis, less pain, reduced cost compared to STSG for wound coverage after fibula flap harvest.

Management of an extensive form of verrucous hemangioma with staged skin grafting: A case report

A 20-year-old male presented with large and extensive lesions of verrucous hemangioma involving the left lower extremity. The lesions were excised in the supra-fascial plane. After 10 days, the split-thickness skin graft was applied over the raw area resulting in good graft take.

The Effects of Zataria multiflora Cream on Split-Thickness Skin Graft Donor-Site Management: A Randomized, Blinded, Placebo-Controlled Study

Purpose: The wound healing process involves a complex series of biological events. Skin grafts have several uses as a reconstructive method. There are several dressings for the skin graft donor site, but the optimum dressing agents that provide all the requirements at the same time are unclear. This prospective, randomized, placebo-controlled clinical trial aimed to evaluate the therapeutic effect of Zataria multiflora cream in the wound healing process of partial-thickness skin graft donor sites and compared it with a placebo. Materials and Methods: This clinical trial study was performed on patients who underwent split-thickness skin grafts. Enrolled patients applied Z. multiflora cream and placebo controlled (petrolatum ointment) twice a day, from the day of intervention at the skin graft donor sites in two parts, separately. On 7, 14, 21, and 28 days after surgery, the wound healing process was evaluated, photographed, and scored according to the Bates-Jensen assessment tool. Evidence of infection was evaluated. The main agent and placebo were compared during the wound healing process. Results: Decreases in wound surface area and total score were significantly greater in the Z. multiflora group (p < 0.05). The wounds of 30% of patients in the second week and 90% of patients in the third week were completely epithelialized in the Z. multiflora group. These values were 3.3% and 36.7% for the control group, respectively, and so, the healing rate was ∼9-fold in the second week and 2.45-fold in the third week in the Z. multiflora group compared with the control group (p < 0.05). Conclusion: Wound healing and reepithelialization accelerated significantly in the first, second, third, and fourth week after intervention in the Z. multiflora treatment group, due to modulating the inflammatory phase and improving the proliferative phase. Clinical Trial Registration Number: IRCT20210624051695N1.

Evaluation of the surgical and functional outcomes of secondary vaginoplasties with free skin mesh graft in patients following transfeminine genital reconstructive surgery

Background

Gender-affirming surgery is classically done using the penile inversion vaginoplasty technique, however in some patients it may not promote adequate depth. In patients whose vaginal conduits became short or stenotic, we propose to perform a secondary vaginoplasty using an abdominal free skin mesh graft. In this study, we present ours results of a series of cases using this technique.

Methods

A retrospective review of patients undergoing secondary vaginoplasty with free skin mesh graft from 2000 to 2017 at our hospital was performed. Demographic data, surgical characteristics, complications, personal satisfaction and neovagina functionality (defined as the ability to have satisfactory sexual intercourse) were evaluated.

Results

Of 186 patients who were submitted to primary vaginoplasty, 36 patients (19.3%) were then submitted to secondary vaginoplasty. This study sample included 35 patients. The average age of patients was 41.0 years (37.0 to 50.5) and the average time between gender affirmation surgery and secondary vaginoplasty was 6 months (4-24). Ten patients (28.6%) developed postoperative complication, the most frequent being: neovagina introitus stenosis (22.9%), rectal fistula (8.6%), tissue dehiscence (2.9%), and urethral fistula (2.9%). Subjective personal satisfaction and neovagina functionality of patients was reported by 77.1% of the sample.

Conclusions

Our study demonstrates that secondary vaginoplasty surgery using a free skin mesh graft has good results and is a functional option with low complexity and low rate of serious complications.

Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer

Simple Summary

Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Abstract

Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Crescent-shaped skin paddle for a fibular flap: Avoiding skin grafting at the donor site

A fibular osteocutaneous flap is the mainstay of oromandibular reconstruction. This report aimed to present a crescent-shaped skin paddle, a novel fibular skin paddle designed to achieve both sufficient intraoral lining and primary closure of the donor site. A 3-5-cm-wide crescent-shaped skin paddle was harvested according to the locations of the distal septocutaneous perforators on preoperative color Doppler sonography. This narrow skin paddle fits well morphologically into the mucosal defect, enabling a reliable intraoral lining. This advantage becomes more evident when the mandibular defect crosses the midline or extends posteriorly to the maxillary tuberosity as the shape of the mucosal defect becomes arcuate. Primary closure of the donor site is easier to achieve because the required width of the crescent-shaped skin paddle is minimized. This method reduces donor-site morbidity associated with skin grafting while ensuring safe intraoral closure with a fibular osteocutaneous flap.

One-Stage Coverage of Leg Region Defects with STSG Combined with VAC Dressing Improves Early Patient Mobilisation and Graft Take: A Comparative Study

Lower limb skin defects are very common and can result from a wide range of aetiologies. Split thickness skin graft (STSG) is a widely used method to address these problems. The role of postoperative dressing is primary as it permits one to apply a uniform pressure over the grafted area and promote adherence. Focusing on lower limb reconstruction, our clinical study compares the application of V.A.C. (Vacuum Assisted Closure) Therapy vs. conventional dressing in the immediate postoperative period following skin grafting. We included in the study all patients who received skin grafts on the leg region between January 2015 and December 2018, despite the aetiology of the defect. Only reconstructions with complete preoperative and postoperative follow-up data were included in the study. Patients were divided into two groups depending on if they received a traditional compressive dressing or a VAC dressing in the immediate postoperative period. We could retain 92 patients, 23 in the No VAC group and 69 in the VAC group. The patients included in the VAC group showed a statistically significant higher rate of graft take together with a lower immobilisation time (p < 0.05). Moreover, a lower rate of postoperative infection was recorded in the VAC group. This study represents the largest in the literature to report in detail surgical outcomes comparing the use of VAC therapy vs. conventional dressing after STSG in the postoperative management of lower limb reconstruction using skin grafts. VAC therapy was used to secure the grafts in the leg region, increasing the early graft take rate while at the same time improving patient mobilisation.