Role of B.A. Petrov in foundation and development of free flap skin transplantation problem

The article reviews the history of development of free-flap skin transplantation and basic role of acad. B.A. Petrov who was the first to show the role of dermatom skin transplantation in vast granulating wounds as the only method saving the life of patients with severe burns. He also suggested to solve an actual problem--deficiency of resources of donor skin--by repeated excision of skin flaps from previously used donor sites and use of cadaver skin. Very important is ales the role of B.A. Petrov in development of such particular questions as the role of patient's condition, wound bed am microbial flora of the wound in survival of skin transplants. In aspect of historical relationships the perspective of new approach to treatment of deep burns by transplantation of ceratinocytes, cultivated outside the patient's organism is shown.     

Adrenal hemangioma: review of the literature

Initially thought to act as tissue replacement, cultured epithelial allografts are now known to work by providing a potent stimulus for healing. In a similar fashion, we believe that traditional autografts may also provide a stimulus to help heal chronic wounds, thus acting as pharmacological agents for healing. We attempted to assess the possibility of augmenting the stimulatory properties of donor skin by initiating the healing process in the donor region prior to grafting. This was accomplished by pre-wounding the donor area 3 days prior to harvesting the donor skin. We compared these 'pre-wounded' grafts to those harvested immediately. Two patients underwent punch grafting for chronic leg ulceration. Half of the ulcer was grafted with donor skin harvested from an area that was pre-wounded and the other half from freshly harvested skin. We evaluated each for improvement of granulation tissue and degree of edge effect (migration of the previously dormant wound edges). All the grafts did well. There was marked improvement in granulation tissue in the ulcer bed after grafting, and the obvious presence of an edge effect. The edge effect was increased on the site where the pre-wounded grafts were placed. It may be possible to augment the growth stimulatory properties of donor skin. This may offer therapeutic options in patients with chronic wounds.     

Reconstruction for palmar skin defects of the digits and hand using plantar dermal grafting

The plantar skin is considered suitable for skin grafting onto the volar aspect of the digits and hand. However, this method is not widely used because it is associated with problems at the donor site. To solve these problems, a new method was developed in which two different layers of the plantar skin are harvested from the same site. In this method, a split-thickness skin graft of the upper layer including the corneal layer of epidermis and a dermal graft of the lower layer are harvested from the same plantar skin. The split-thickness skin graft is returned to the original donor site, whereas the dermal graft is used for the palmar skin defects on the digits and hand. To prevent drying, the dermal graft was covered with a wound-covering material to achieve good graft takes. Reconstruction was performed for 17 patients using this method, involving digit-only reconstruction in 8 patients, and wider reconstruction in the other 9. Excellent color and texture match of the graft and donor sites were obtained with no noticeable marginal scarring, and the durability of the skin was satisfactory. This method was useful for skin grafting to the digits and palms with minimal sacrifice to the donor site.     

Objectives, results and future prospects of burn treatment in 1997

When burn injuries to the skin are extensive, delays in wound closure contribute to multiple organ failure because the availability of donor sites does not allow early and permanent coverage of excised wounds. From 1991 to 1996, 30 patients with a mean burn size of 78% total body surface area (65% full-thickness) underwent skin grafting with autologous cultured epidermis (AEC) performed in the labs of Genzyme Tissue Repair Company. Twenty three were adults and seven children under 15 (mean age 29, range 2.5 to 70); 27 suffered inhalation injury; 3 presented with multiple trauma and 2 with blast injury. As soon as possible wound beds were excised and temporarily covered with allografts or with sandwich or meshed autografts; the mean surface covered with autografts was 28 +/- 12%. Keratinocytes grafts were applied to a mean of 37 +/- 16.5%, an average of 210 grafts of 25 to 30 cm2. Three patients died respectively at day 67, 81 and 90. At time of gaze backing removal, the mean percentage of culture engraftment was 69% (range 25 to 95); this engraftment was higher for children (74%) and very bad above 60 (25%). The mean length of hospitalisation was 114 +/- 30 days. The definitive coverage by AEC was evaluated through the percentage of secondary autografted area: 10 +/- 9.5% (range 0 to 46). The average cost by patient was 98,500$ or 16$ by cm2 of culture. The weakness of epithelialisation makes essential a dermal support to the keratinocytes cultures, allodermis is now currently used, perhaps the new skin substitutes will give the ideal missing piece.     

The distally based forearm island flap in hand reconstruction

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.     

A novel application of the infrared coagulator in hair transplantation. Significant reduction of width of the donor site wound

BACKGROUND: The infrared coagulator, a by-product of laser technology, has been used in dermatology in a variety of settings. During hair transplantation sessions, we observed a significant reduction of the donor ellipse width while performing hemostasis with the infrared coagulator. OBJECTIVE: Quantitative assessment of the donor wound width after infrared coagulator use, and correlation to the number of previous transplant sessions and patients' age. METHODS: Twenty-four patients (22 men, two women) underwent hair transplantation. The infrared coagulator was utilized for hemostasis with a pulse duration of 2.5 seconds. RESULTS: The infrared coagulator produced an average donor area decrease of 42%, while achieving rapid hemostasis. No correlation was demonstrated to number of previous transplant sessions or patients' age. CONCLUSIONS: The infrared coagulator significantly decreases the donor wound width while providing hemostasis. Advantages include the potential of larger donor strip harvest, minimal tissue manipulation, and less traumatic closure.     

Nursing management of skin grafts and donor sites

Skin grafting is one of the most commonly used techniques in plastic and reconstructive surgery. The patient undergoing split-thickness skin grafting may pose a variety of wound care problems for the nurse. The issues that may need to be addressed include: the reasons for grafting; type of graft used; preoperative and postoperative care of the recipient and donor sites; and the provision of general measures required to promote wound healing and successful graft take for the patient.     

Synthetic skin replacement for temporary wound coverage in eyelid surgery

BACKGROUND: Large uncovered defects of lid-skin which extend beyond the margin of the orbital rim frequently cause wound contracture and malposition of the lid. PATIENTS AND METHODS: Between April 1989 and October 1992 we have successfully used synthetic skin in severe cases of traumatic skin ablation (n = 3) and in complicated tumor surgery of the lids and of the medial canthal area (n = 14). Polyurethan foam material was used for temporary skin replacement (Epigard). RESULTS: The synthetic skin stimulated wound granulation and vascularization of the host area before final closure of the defect was achieved. No wound contracture occurred. CONCLUSION: Temporary bandage with synthetic skin is recommended if large skin defects can not be closed within 48 hours.     

Modified use of extremity tourniquets for burn wound debridement

A modified technique of tourniquet use for sequential burn wound debridement is described. With partial exsanguination of the extremity, intermittent release and rapid reinflation of the tourniquet will allow the surgeon to assess the adequacy of debridement and to decrease reactive hyperemia and blood loss during the excision. This controlled method to decrease blood loss in the upper extremities during debridement, in combination with epinephrine soaks and compressive wraps, can be mastered so that transfusion is not necessary during excisions of less than 12% total body surface area. Visible hemostasis is assessed with this method before final application of skin grafts to optimize skin graft revascularization and minimize wound hematomas.     

Y chromosome and spermatogenesis

The authors present two patients affected by scars resulting from burning of over 60 per cent of the total body area, in which the pre-expansion of a free flap has been used to increase the tissue surface useful for transfer from the only area of residual healthy skin (left forearm, left parascapular region). In both cases it was possible to transfer abundant healthy tissue into the desired areas, obtaining a rapid release of the region, which made possible an early physical rehabilitation of the patient starting after the second postoperative week. One of the main problems encountered, when facing surgical rehabilitation for the seriously burned patient, is the poor availability of skin donor areas suitable for reconstructive flaps. The pre-expansion of free flaps provides an advantage in that it allows the few integral residual areas to be used, improving vascularization and therefore increasing the available surface. Furthermore, as pre-expansion reduces tension on the margins, it allows for the easier closing of the donor area, with a minor risk of complications and a better scar outcome.     

Development of new wound dressing composed of spongy collagen sheet containing dibutyryl cyclic AMP

Although cyclic AMP has been considered to regulate cell proliferation, the mechanism of this function is largely unknown. Recent studies suggest that cyclic AMP promotes the proliferation of skin cells in a dose-dependent manner. An ointment containing dibutyryl cyclic AMP has been used in the treatment of skin ulcers and found to be effective in promoting tissue repair. To search more efficacious wound management, the authors developed a new wound dressing composed of a spongy atelo-collagen sheet containing dibutyryl cyclic AMP. This wound dressing was evaluated in two types of animal tests. One is the application of the wound dressing to a full-thickness skin defect in order to evaluate the granulation tissue formation and the wound size reduction. The wound dressing was found to promote the granulation tissue formation and naturally reduce the wound size. The other test was the application of the wound dressing to the full-thickness skin defect, leaving behind a skin island in a central portion, in order to evaluate the epithelialization. This skin island left in a full-thickness skin defect was extremely enlarged. The enlargement of the skin island seems to be related to the epithelialization from the margin of the skin island as well as by the expansion of a skin island induced by contraction of the developed granulation tissue in the surrounding wound area. These results suggest that an atelo-collagen spongy sheet containing dibutyryl cyclic AMP is effective in promoting the granulation tissue formation and epithelialization.     

The current possibilities for plastic repair with axial skin flaps on the lower extremity

Based on results of complex topographo-anatomical investigations in 187 lower extremities and experiences with performing 220 operations of free and non-free plasty with axial skin flaps formed in the femur, shin and foot, the authors consider the lower extremity as a donor site and a recipient field for such operations. Eight donor zones are selected on the lower extremity and 39 different flaps can be formed within their limits, 27 of them being tested in the clinic. Comparative characteristics of all donor zones are given. The present-day possibilities of the substitution of different wound defects using the axial skin flaps from the femur, shin and foot are shown.     

MRI of the intracerebral lesions at 0.5 Tesla: comparison of fast spin-echo and conventional spin-echo sequences

The purpose of this study was to identify the angiosome of the medial saphenous artery and vein and to evaluate the use of this cutaneous angiosome as a free skin flap in the dog. In phase 1 of this study, selective angiography of the medial saphenous artery performed in six canine cadavers showed that the skin covering the entire medial femorotibial area, the distal half of the caudal head of the sartorius muscle, and the gracilis muscle were perfused by the medial saphenous artery. In phase 2, a medial saphenous fasciocutaneous island flap was raised and sutured back to the skin edges of the donor wound in three dogs. One hundred percent survival of all of the flaps occurred. In phase 3, a medial saphenous fasciocutaneous microvascular free flap was transferred to a wound that was created over the dorsal metacarpal (n = 3) or metatarsal region (n = 3). The mean length +/- SD of the medial saphenous vascular pedicle was 80 +/- 13 mm (n = 5); the mean diameter +/- SD of the medial saphenous artery was 2.8 +/- 0.2 mm (n = 5) and the mean diameter +/- SD of the medial saphenous vein was 4.2 +/- 0.2 mm (n = 5). One hundred percent of all flaps survived (n = 6). Selective angiography or the distal cranial tibial artery (metatarsal wounds, n = 3) and the median artery (metacarpal wound, n = 3) was performed 3 weeks after surgery. All of the vascular anastomoses were patent and neovascularization of the wound beds was present. This free flap was found to be acceptable for cosmetic reconstruction of wounds located on the distal extremity.     

Micrografting in the treatment of severely burned patients

The micrografting technique, employed to treat patients with extensive TBSA burns and reduced areas of healthy donor skin, was assessed simultaneously with traditional mesh grafts (STSG) or Tiersch grafts in the treatment five severely burned subjects (average TBSA burned 35.6 per cent; average per cent of full thickness wounds 32.6 per cent). At the first clinical control on day 6 post-surgery, 93 per cent of the micrografted area was in situ and health; epithelialization of the wound sites was complete at day 21. Meshed STSG yielded 90 per cent attachment at day 6 post-surgery, with epithelialization complete at 12 +/- 2 days post-surgery. Functional results were equivalent no matter what technique was used, while aesthetic results were better in the areas where micrografting was carried out. Although the micrograft technique is labour-intensive, if the expansion needed is at least 1:6, the aesthetic and functional results obtained are comparable to, or better than, those with meshed grafts. Also, large segments of micrograft are not compromised if a small area of mesh becomes detached, and epithelialization is faster and more uniform, enabling a reduction in both infection and length of hospital stay.     

Clinical analysis of 15 patients with primary malignant melanoma in the genital tract

The penetrating wound of palm with the defect of tissues was usually caused by blunt crushing of gun-shot injury. It was difficult to treat clinically. In order to repair the skin defect of palm and dorsum in one operation, 2 kinds of dumbbell-shaped double-leaf flap were desigened. From February 1993 to March 1996, 5 cases with penetrating wound of palm were treated by this method in which the interosseous posterior artery flap in 4, and the superficial epigastric flap in 1. There were 4 males and 1 female with the ages ranging from 15 to 47 years old. The results were as follows: total survival of the flap in 4 cases and partial necrosis of skin margin of the distal leaf in 1 case. The appearance and function of the flap were satisfactory after a follow-up from 4 months to 3 years. It was concluded that the interosseous posterior artery flap had a long vascular pedicle with its constant anatomical distribution, and the 2nd stage of division of the pedicle of the flap was not necessary. It was a perfect flap in repairing the penetrating wound of the palm with small skin defect. The superficial epigastric flap was cumbersome in appearance and was necessary to divide the pedicle of the flap in 2nd staged operation. It was suitable in repairing the penetrating wound with large skin defect. Regarding the operative technique, a meticulous debridement and the appropriate flap area were required, and the blood vessel of the flap should not be compressed by the surrounding tissues. The advantages of this operation provided a simple method to handle, high rate of survival, and one-staged operation.     

Use of the scalp as a donor site for large burn wound coverage: review of 150 patients

The characteristics of rapid wound healing and multiple harvest capacity make the scalp an important donor site when dealing with large and deep burn wounds. This paper reports the results of a retrospective analysis of 150 patients treated for large burn wounds. The findings indicated that bleeding during graft skin harvest could be limited to 50 ml by intradermal injection of epinephrine (1:2,000,000), high-concentration epinephrine-soaked gauze compression (1:20,000), and temporary porcine skin coverage. Use of a scalp graft also carried a low risk of complications, with only four (2.7%) major complications including three cases (2.0%) of visible alopecia and one case (0.7%) of hair transplantation. There were no hypertrophic scars, even in the patient who had the largest number (11) of repeat harvests.     

Cultured autologous epithelium in patients with burns of ninety percent or more of the body surface

OBJECTIVE: The increasing survival of patients with very large burns has driven an interest in innovative permanent wound closure techniques, one of which is the use of cultured autologous epithelium (CAE). To document our ability to achieve wound closure with CAE in patients with very large burns, we report our 19-month experience with this technology in five patients with burns of 90% or more of the body surface. DESIGN: A retrospective review. MATERIALS AND METHODS: Over a 19-month period five patients with burns in excess of 90% of the body surface had skin biopsies taken for epithelial culture. The clinical course of these five patients was reviewed in detail. MEASUREMENTS AND MAIN RESULTS: These five patients had an average age of 11.5 years (range 7 months to 37 years), and an average total body surface area burn of 94% (range 90%-96%). Four of the five patients had inhalation injury. All wounds had vascularized allograft present at the time of CAE engraftment. Forty-five percent of the CAE was placed on vascularized allodermis and 55% on fascia (range on allodermis 20%-75%). Initial take of CAE was 51% (range 20%-80%). Delayed loss in percent of initial take averaged 60% (range 20%-100%). Delayed loss averaged 33% (range 20%-50%) when two patients who lost all of their CAE were excluded. Three patients had gram-negative bacteremia within 7 days of CAE placement, and two of these had 100% graft loss. Definitive closure rates with CAE averaged 7.5% (range 0%-15%) of the body surface, increasing to 12.5% (range 11.2%-15%) when two patients who lost all of their CAE are excluded. CONCLUSIONS: The initial enthusiasm for CAE has been tempered by demonstrations of low-initial engraftment rates, graft fragility, delayed graft loss, and cost. Such liabilities become more tolerable as usable donor site decreases below 5% to 10% of the body surface. CAE can materially contribute to wound closure in patients with very extensive burns, but gram-negative sepsis is associated with complete graft loss.     

Scalp autografts and hair transfer to the face in the burned child

Hair transfer from split-thickness skin grafts harvested from the scalp is not a widely reported problem. The authors present their experience with hair transfer from scalp autografts in a pediatric burn population, with particular emphasis on hair transfer to the face. They retrospectively reviewed 3307 acute and reconstructive pediatric burn admissions over a 4-year period at a single institution and identified 109 cases in which the scalp had been used as a donor site and in which the patient survived the acute burn period. Data from 73 male and 36 female patients were analyzed with respect to age, race, sex, percent total body surface area burned, graft thickness, number of scalp harvests and time between harvests, and presence of donor site alopecia. Eighteen of the 109 patients had noticeable hair growth from their scalp grafts (17 percent). Fourteen of 18 cases of hair growth involved face or neck grafts (13 percent); the remaining 4 patients had hair growth elsewhere on the body. There was no difference between the two groups (hair growth versus no hair growth) when compared by age, sex, or graft thickness. There was a correlation between larger burn size and greater incidence of hair growth. Those who had multiple harvests of the same scalp donor site were more than twice as likely to have hair transfer (9 of 34 versus 9 of 75 patients), although time between harvests was not a significant variable. Caucasian children represented 77 percent of the study population yet 100 percent of the cases of problem hair growth. Thirty-three percent of the hair growth group (6 of 18 patients) and 4 percent of the remaining patients (4 of 91) had some degree of donor site alopecia. The scalp is a reliable and valuable donor site for skin grafting in children, particularly for facial burns. The authors note a moderate incidence of hair transfer (17 percent) and propose both suggestions for prevention and recommendations for management.     

Changes in coronary risk profiles in employees after three years of multifactorial intervention

A mathematical model for computing stresses in sutured human skin wounds is presented. The model uses the incremental law of elasticity and elastic constants valid for in vivo orthotropic skin. The model is applied to compute the principal stress and displacements resulting from suturing small elliptical and circular wounds in a large flat sheet of skin, in order to determine the optimal suturing patterns. It is observed that the average stress index for a circular wound sutured toward the center is almost double that of a wound sutured transverse to the diameter. Thus, the latter type of suturing pattern is preferable. Similarly, suturing an elliptical wound transversely produces a lower average stress index than a circular wound of the same area. It is also found that the optimal ratio of semi-major to semi-minor axis of an elliptical wound is near 3 (for abdominal wounds), i.e., this ratio produces the most uniform stresses along the wound edges, where wound healing is slowest. Since high stresses have adverse effects on healing and blood flow, this work, depicting regions of high stresses, may be used along with other biological factors to help predict regions of slower healing in sutured wounds.